A 54-year-old man comes to the physician with fatigue and decreased exercise tolerance over the last 6 months. He denies cough, chest pain, syncope, or weight loss. He had aortic valve replacement with a mechanical valve due to bicuspid aortic valve stenosis 7 years ago. Coronary angiography prior to surgery showed no evidence of coronary artery disease. His medications include warfarin and antacids for occasional heartburn.
His blood pressure is 122/70 mm Hg and pulse is 89/min and regular. Jugular venous pressure is estimated at 9 cm H₂O. A faint early diastolic murmur is heard at the left sternal border. Lungs are clear on auscultation. The liver span is 9 cm, and the tip of the spleen is not palpable. There is no edema of the lower extremities.
Laboratory results are as follows:

Which of the following is the most likely diagnosis?

Question

A 54-year-old man comes to the physician with fatigue and decreased exercise tolerance over the last 6 months. He denies cough, chest pain, syncope, or weight loss. He had aortic valve replacement with a mechanical valve due to bicuspid aortic valve stenosis 7 years ago. Coronary angiography prior to surgery showed no evidence of coronary artery disease. His medications include warfarin and antacids for occasional heartburn.
His blood pressure is 122/70 mm Hg and pulse is 89/min and regular. Jugular venous pressure is estimated at 9 cm H₂O. A faint early diastolic murmur is heard at the left sternal border. Lungs are clear on auscultation. The liver span is 9 cm, and the tip of the spleen is not palpable. There is no edema of the lower extremities.
Laboratory results are as follows:

Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This patient's early diastolic murmur is likely due to aortic regurgitation, which could be from structural failure of a mechanical valve or infective endocarditis. He also has anemia with elevated LDH, suggesting a hemolytic process. Hemolytic anemia is due to destruction of erythrocytes by malfunctioning valve and is more common with prosthetic mechanical valves than bioprosthetic valves. Patients often present with fatigue, jaundice, dark urine, and a new or changing heart murmur. Anemia, indirect hyperbilirubinemia, and elevated serum lactate dehydrogenase are present. Peripheral smear shows schistocytes. Anemia is often mild and is treated with oral iron or periodic blood transfusions. In certain cases of paravalvular leak, the valve may need to be replaced. (Choice A) Colonic angiodysplasia is a common cause of lower GI bleed and is sometimes found in patients with aortic stenosis. In most patients, bleeding improves after valve replacement. This patient's normal MCV and markedly elevated LDH make iron deficiency anemia from GI bleeding unlikely. (Choice C) This patient has no symptoms of large-vessel vasculitis (eg, giant cell or Takayasu) such as fever, weight loss, headache, or jaw/arm claudication. (Choice D) Patients with lymphoma usually present with lymphadenopathy, hepatosplenomegaly, B symptoms (fever, weight loss, night sweats), and possibly a rapidly growing mass. Although lymphoma can cause elevated LDH, this patient does not have these other symptoms. (Choice E) While infective endocarditis can result in valve failure, this patient has no fever, leukocytosis, or signs of embolic phenomena. Educational objective: Hemolytic anemia is a complication of prosthetic heart valves. Treatment involves oral iron or blood transfusion. Patients with paravalvular leak or valve failure may need valve replacement. __________ References: Hemolysis associated with prosthetic heart valves: a review. (http://www.ncbi.nlm.nih.gov/pubmed/19384085)

A 54-Year-Old Man Comes to the Physician with Fatigue and Decreased