An Unusual Case of Aortic Leaflet Aneurysm

A 45-year-old female who was a known case of rheumatoid arthritis (RA) on irregular treatment presented with recent onset fever, breathlessness, and clinical features of aortic regurgitation. Echocardiography revealed an aneurysm involving the noncoronary cusp (NCC) of the aortic valve (AV) with probable vegetation attached to the NCC. Repeated fungal and bacterial blood cultures were negative, and the patient continued to have a fever despite empirical antibiotics and antifungals. There was a clinical improvement with steroids; however, in view of recurrent heart failure, she was proposed for AV replacement. Intraoperatively, pericardial layers were noted to be thickened and adherent; thus, she underwent pericardiectomy, followed by AV replacement. Histopathology and microbiological evaluation of the excised specimen showed features compatible with RA as a cause for cardiac involvement. Culture-negative endocarditis needs meticulous evaluation to rule out fastidious bacteria, fungi and rare pathogens, as well as noninfective causes. RA occasionally mimics infective endocarditis and can cause significant cardiac structural derangements.