Mitral valve infective endocarditis following device occlusion of a coronary artery fistula

A three year old girl, with a right coronary artery fistula and signs of a hyperdynamic circulation, underwent uncomplicated closure of the fistula using an occluding device introduced via the femoral arterial route and covered with appropriate antibiotics. Two months later she presented with a persistent fever, signs of infective endocarditis (IE) and embolic phenomena in the left lower limb. Mitral valve endocarditis was confirmed immediately and treated effectively. However, initial ultrasound and doppler did not show the femoral artery thrombo-occlusion that was only confirmed on magnetic resonance angiography (MRA) one month later. This case highlights the usefulness of MRA in diagnosing suspected vessel occlusion in young children, and is in keeping with the latest NICE guidelines that suggest that prophylactic antibiotics do not always prevent IE. Parent and patient education on ‘what to look out for’, combined with careful clinical vigilance is paramount in the early detection of IE with a consequent reduction in morbidity and mortality.