A Case with Patent Ductus Arteriosus Complicated by Pulmonary Artery Endarteritis

Case A 49-year-old woman, with no history of heart disease, was admitted to the hospital with a febrile sensation, fatigue, and weight loss (2 kg). Three months ago, she was diagnosed as having a stricture of the pulmonary artery and suspicious pneumonia. So, the patient was treated empirically with antibiotics at another hospital. However the symptoms did not improve. No further information was obtained from the past medical and family history. On physical examination, the blood pressure was 130/80 mmHg, the heart rate was 68 beats/min and regular, and the body temperature was 38。C. On inspection, the conjunctivae were anemic. Cardiac auscultation revealed a continuous murmur (grade III) at the left parasternal border. Laboratory investigations revealed a normocystic, normochromic anemia (Hemoglobin 9.66 g/dL). The white cell count, C-reactive protein and erythrocyte sedimentation rate were 5,960×10/L, 6.52 mg/dL and 21 mm/h, respectively. The renal and liver function tests were normal. The chest X-ray revealed cardiomegaly (C/T ratio=0.6). The chest CT showed a dilated pulmonary artery and thombus in the proximal side of left main pulmonary artery. An electrocardiogram demonstrated sinus rhythm and the minimal voltage criteria for left ventricular hypertrophy. Transthoracic echocardiography (TTE) showed a 0.5 cm defect between the descending thoracic aorta and the main pulmonary artery and a 3.4×1.0 cm hypoechogenic movable vegetation attached to the wall of the main pulmonary artery (Fig. 1). The left atrium was enlarged (4.26 cm). However, the diameter of left ventricle was normal. TTE showed a diastolic filling pattern of impaired relaxation (E/E’=12.3). Transesophageal echocardiography (TEE) showed a 0.9 cm patent ductus arteriosus (PDA) and a left to right shunt