B49-47 Extracorporeal Rescue of Fulminant Bacterial Endocarditis With Aortic Root Abscess in an HIV-positive Young Woman

Abstract Introduction Aortic valve abscess is a rare and life threatening complication of infective endocarditis, especially in young adults. When combined with acute respiratory distress syndrome and recent HIV diagnosis, management becomes particularly complex. This case highlights the multidisciplinary care required in such presentations, including mechanical support and emergent cardiac surgery. Description A 34 year old female with asthma and newly diagnosed HIV on Biktarvy presented with fever, severe back pain, and progressive respiratory distress. Exam revealed lumbar spine tenderness, left leg weakness, and signs of systemic illness. Initial labs showed leukocytosis, elevated inflammatory markers, and Streptococcus pneumoniae bacteremia. MRI spine indicated possible myositis and epidural phlegmon. She was initially started on empiric antibiotics. Her respiratory status declined rapidly, requiring escalation from high-flow oxygen to BiPAP. Imaging revealed bilateral infiltrates and pulmonary edema. Despite supportive measures, she developed ARDS and was intubated, with continued decline requiring VV ECMO. TransThoracic Echocardiography showed moderate aortic regurgitation and pericardial effusion. TEE identified a bicuspid aortic valve with an abscess, aortic root infection, and mitral valve involvement. She underwent an emergent Bentall procedure with aortic root replacement and mitral valve repair. Postoperatively, she required renal replacement therapy, prolonged mechanical ventilation, anticoagulation, and broad-spectrum antibiotics. As she stabilized, she was weaned from ECMO and ventilatory support, and later discharged to a rehabilitation facility on IV Rocephin, Coumadin, and her antiretroviral regimen. Discussion This case shows the importance of early recognition and aggressive management of bacterial endocarditis in immunocompromised hosts. HIV infection and sepsis amplify endothelial injury and immune dysregulation, predisposing to invasive infection and rapid hemodynamic decline. Pneumococcal endocarditis remains rare but is associated with high mortality when complicated by abscess formation. The timely use of ECMO provided critical cardiopulmonary support, bridging the patient to definitive surgical intervention and recovery. This case highlights the essential role of serial imaging and multidisciplinary coordination in detecting complex structural complications of endocarditis. Awareness of such fulminant presentations in young immunocompromised patients is vital, as early mechanical support and emergent surgery can convert an otherwise fatal course into a survivable outcome. This abstract is funded by: none