Vol. 8, Issue 1, Part A (2026)

Rheumatic heart disease (RHD) remains a significant cause of valvular pathology, often presenting with severe mitral regurgitation (MR). Atypical presentations combining RHD, complex neurological symptoms (chorea, stiffness, depressive symptoms), and severe systemic infection by a multidrug-resistant (MDR) organism pose major diagnostic and therapeutic challenges.
Case Presentation: A 20-year-old male presented with an 8-month history of whole-body stiffness, persistent depressive symptoms, chorea-like movements, constant headache, and acute dyspnea over the preceding 4-5 days. Physical examination revealed a high-pitched pansystolic murmur at the apex, suggestive of severe MR. Laboratory investigations showed microcytic hypochromic anemia (Hb 7.82 gm%), markedly elevated inflammatory markers (ESR 63 mm/hr), and elevated cardiac biomarkers (Troponin I 0.428 ng/mL; NT-proBNP 1751 pg/mL). Echocardiography confirmed RHD with severe eccentric mitral regurgitation, thickening/prolapse of the anterior mitral leaflet (AML), and a dilated left atrium (LA). Magnetic Resonance Imaging (MRI) of the brain revealed irregular lesions in the right frontotemporal and left parietal regions exhibiting diffusion restriction, suggestive of an acute/subacute infarct with hemorrhagic transformation. Multiple areas of susceptibility blooming were also noted in both cerebral and cerebellar lobes, consistent with old degraded blood products or microhemorrhages. Crucially, blood culture performed on April 1, 2025, grew Gram Negative Bacilli, subsequently identified as Achromobacter denitrificans. Susceptibility testing showed resistance (R) to a wide array of antibiotics, including Piperacillin/Tazobactam, Cefepime, Amikacin, Gentamicin, Ciprofloxacin, Colistin, Cefrtiaxone, Cefoperazone/sulbactam, Intermediate resistance (I) to Imipenem and Meropenem and susceptibility (S) to Trimethoprim/Sulfamethoxazole. The patient was managed with guideline-directed heart failure therapy, blood transfusion, and culture-directed antibiotics (Meropenem and Gentamycin ordered later, despite documented resistance to both), leading to clinical stabilization and partial improvement in neurological symptoms.
Conclusion: This case underscores the complexity of RHD, which can manifest with cardioembolic stroke and neurological sequelae in young adults. The superimposed bacteremia caused by MDR A. denitrificans, resistant to all 8 tested antibiotics, represents an extremely rare and high-risk complication requiring integrated cardiac, neurological, and infectious disease management.