This patient is a 31 year old female with a history of AIDS who presents with shortness of breath, cough and fever. Vitals: 120/80 95 19 102.5 91%RA.
Answer: Redundant Chordae
Chordae tendinae are the fibrous cords that connect the papillary muscles to the tricuspid and mitral valve.
Given history and echo findings, there was concern for infective endocarditis (IE) this is an important component of the differential diagnosis, however there are some clues that can help differentiate the two.
Common False Positives for IE1
Lambl’s excrescences – filiform fronds that occur at sites of valvular closure
Redundant chordae (our patient’s diagnosis)
Chordal insertion into normal mitral valve
Sutures from implanted prosthetics
False positive IE
Gray, similar appearance to myocardium
White, similar appearance to pericardium
Upstream side of valve, in path of jet, prolapse into upstream chamber
Downstream surface of valve
Hair or string-like with narrow attachment,
Chaotic, orbiting, independent of valve motion
Moves in concert with valve, No turbulent flow or regurgitation
In general, TTE has a sensitivity of 50% for detecting IE. If clinical suspicion remains high, TEE has sensitivity in the range of 90 – 100%.2, 3
Remember to consider IE in patients with a history of injection drug use, prosthetic valves, or fever coupled with vascular phenomena (embolic pathology).
Our patient was ultimately diagnosed with pneumonia and admitted for IV antibiotics.
Kim MJ, Jung HO. Anatomic variants mimicking pathology on echocardiography: differential diagnosis. Journal of cardiovascular ultrasound. 21(3):103-12. 2013. [pubmed]
Evangelista A. Echocardiography in infective endocarditis. Heart. 90(6):614-617. 2004. [article]
Shively BK, Gurule FT, Roldan CA, Leggett JH, Schiller NB. Diagnostic value of transesophageal compared with transthoracic echocardiography in infective endocarditis. Journal of the American College of Cardiology. 18(2):391-7. 1991. [pubmed]