Fatal mural endocarditis and cutaneous botryomycosis after heart transplantation

Fatal mural endocarditis and botryomycosis occurred concurrently in a 62-year-old women 4 months after orthotopic heart transplantation. Subsequent to mild mitral regurgitation, infection developed on a left atrial thrombus and was complicated by cerebral embolization. Simultaneously, skin nodules manifested on both forearms. Histologic examination revealed typical aspects of early evolving botryomycosis with massive infiltration of the dermis and hypodermis by necrotic granulomas framed by grains of Gram-positive coccoid forms. Bacteria were decorated by a nonspecific polyclonal antibody to Mycobacterium bovis.