Uncorrected Ebstein's anomaly with atrial septal defect complicated by brain abscess in an adult patient.

: We report the case of a 56-year-old male patient affected by a severe form of Ebstein's anomaly (type C of Carpentier classification) with secundum atrial septal defect, who presented to the emergency department with impaired consciousness, seizures, and trismus. The brain computed tomography scan showed evidence of a mass located in the frontal lobe, confirmed by brain MRI consistent with brain abscess. Both echocardiography and cardiac MRI showed no evidence of valvular vegetation. This case shows how the combination of increased atrial pressure and bidirectional shunt through atrial septal defect may lead to paradoxical embolization.

Septic pulmonary and systemic embolism in tricuspid endocarditis.

A 28-year-old woman presenting with fever was referred to our hospital and diagnosed as septic pulmonary embolism secondary to tricuspid valve endocarditis. Although antibiotic therapy was initiated, she further showed multiple complications including Janeway lesions and cerebral infarctions, suggestive of septic systemic embolism. Transoesophageal echocardiography detected a right-to-left shunt through a patent foramen ovale (PFO). The patient was successfully treated with surgical tricuspid valvuloplasty and PFO closure. Paradoxical systemic embolism may occur in patients with septic pulmonary embolism through the PFO.

Paradoxical brain embolism induced by Mycoplasma pneumoniae infection with deep venous thrombus.

A 21-year-old man had sudden-onset right hemiplegia and aphasia with respiratory infection. A chest X-ray disclosed consolidation in both lungs and magnetic resonance imaging showed an embolism in the left middle cerebral artery. A pelvic computed tomography scan revealed deep venous thrombus in both femoral veins. Patent foramen ovale was detected by transesophageal echocardiogram. Antibodies to M. pneumoniae were highly elevated, and hypercoagulability was subsequently detected. This case suggests that the possible pathogenic mechanism for M. pneumoniae infection-related stroke might be paradoxical brain embolism with deep venous thrombus as a consequence of the hypercoagulability related to this infection.

Brain abscess caused by paradoxical embolization in Ebstein's anomaly.

A 25-year-old woman presented with Streptococcus milleri brain abscess. Previous cardiac history was unremarkable. In search for a source of embolism echocardiography was performed and revealed a previous undiagnosed Ebstein's anomaly of moderate severity with apical displacement of the septal leaflet of the tricuspid valve and a secundum atrial septal defect (ASD) with left to right shunt. The combination of increased right atrial pressure caused by Ebstein's and an ASD with possibility of transient right to left shunt predispose for paradoxical embolization. The most likely reason for development of a brain abscess in this patient is septic embolization from an infectious focus outside the heart. Ebstein's anomaly can remain undiagnosed until adulthood if the right ventricle, in spite of the smaller size, is haemodynamically well functioning.

Percutaneous PFO closure for the prevention of recurrent brain abscess.

A patent foramen ovale (PFO) can act as a conduit between the venous and arterial circulations, allowing right-to-left shunting and bypass of the pulmonary circulation. Brain abscess may develop as a result of paradoxical embolism of organisms through a PFO. In this small series, we report on the closure of PFO for the prevention of recurrent brain abscess. Only prospective, randomized trials comparing PFO closure to conservative therapy could provide a definitive answer as to the optimal strategy for preventing recurrent cerebral abscess.