Data Availability Statement: The data supporting the findings of this case report are fully presented within the article.Funding Statement: This case report received no specific funding from public, commercial, or not-for-profit agencies.Conflict of Interest Disclosure: The authors declare no conflicts of interest regarding the publication of this case report.Ethics Approval Statement: According to international and institutional regulations, no ethical approval was needed for case reports. However, we ensured that all relevant ethical guidelines were followed.Patient Consent Statement: The patient gave written informed consent to the publication of this case report and any accompanying images.Permission to Reproduce Material from Other Sources: No materials from other sources are included in this case report.Abstract:Introduction:  The sinus of Valsalva consists of three spaces at the base of the aorta, which is crucial for cardiac function because it ensures proper closure of the aortic valve during diastole. Sinus of Valsalva aneurysms (SVAs), though rare (0.1-3% of congenital heart defects), can lead to serious complications when ruptured. This case report presents a unique instance of a ruptured SVA in a 24-year-old male, highlighting atypical symptomatology and diagnostic challenges.Case Presentation:  A previously healthy 24-year-old male presented with palpitations and fatigue, lacking classic symptoms such as chest pain. His medical history included epilepsy managed with carbamazepine. Initial transthoracic echocardiography revealed severe aortic insufficiency and rupture of the sinus of Valsalva to the right atrium(RA). Transesophageal echocardiography (TEE ) was performed and confirmed a ruptured aneurysm from the non-coronary cusp (NCC) into the right atrium and severe Aortic insufficiency due to protrusion of NCC to Left ventricular outflow tract (LVOT). These findings were confirmed by CT angiography.Surgical Intervention and Outcomes:  Cardiac Surgery consultation recommended surgical closure of the sinus of Valsalva rupture and aortic valve repair. However, the patient refused to undergo surgery due to the subtlety of his symptoms. He has remained stable upon follow-ups.Conclusion:  This case emphasizes the need for heightened clinical suspicion of SVA in patients presenting with non-specific symptoms, particularly those on medications like carbamazepine that may mask typical presentations.Introduction:The sinus of Valsalva refers to the three spaces located at the base of the aorta, just above the aortic valve. These sinuses play a crucial role in cardiac function by facilitating the proper closure of the aortic valve during diastole, thereby preventing blood backflow into the left ventricle. Their structural integrity is significant for maintaining normal hemodynamics; abnormalities can lead to serious cardiovascular complications.(1)A sinus of Valsalva aneurysm (SVA) is characterized by an abnormal dilation of one or more of these sinuses, which can lead to rupture and subsequent complications.(1) Although SVAs are rare, their incidence is estimated to be approximately 0.1-3% of all congenital heart defects, with a higher prevalence in males.(2). The etiologies of SVAs can be congenital, stemming from defects in the elastic lamina, or acquired due to conditions such as hypertension, atherosclerosis, or trauma.(1)Patients with an SVA may remain asymptomatic for extended periods; however, when symptoms do occur—often due to rupture—they can include acute chest pain, syncope, palpitations, and signs of heart failure. The presentation can be atypical, especially in younger patients or those with underlying conditions that may mask classic symptoms.(3)This case report highlights a unique instance involving a 24-year-old male who presented with subtle symptoms—palpitations and fatigue—despite having a ruptured SVA. This atypical presentation underscores the importance of high clinical suspicion for SVA in patients with non-specific symptoms. Additionally, we hypothesize that the patient’s use of carbamazepine may have contributed to the masking of his symptoms, emphasizing the need for careful evaluation in similar cases. The findings from this case not only contribute to the understanding of SVA presentations but also raise awareness about potential diagnostic challenges associated with pharmacological treatment.Case history/examination:A 24-year-old man without any known history of congenital heart disease presented to a cardiologist with palpitations, fatigue, and occasional shortness of breath during physical activity over the past few days. He reported no chest pain, nausea, vomiting, fever, or cold sweat. During the cardiology visit, the patient underwent transthoracic echocardiography, which revealed severe aortic insufficiency (AI). Given this finding, he was referred to our center for further evaluation and management. His medical history was significant for epilepsy since childhood, for which he was currently taking carbamazepine. He reported no use of alcohol, drugs, or tobacco and did not mention any family history of cardiovascular disease.During the initial evaluation, the patient appeared well-nourished and in no acute respiratory distress, such as using accessory muscles or cyanosis. He was not tachypneic, exhibiting a normal respiratory rate of 16 breaths per minute and a comfortable breathing pattern. His vital signs were: a heart rate of 103 beats per minute, blood pressure of 120/80 mmHg, oxygen saturation at 96%, and a normal body temperature of 98.6°F (37°C). He was alert and oriented. His posture was relaxed, and he maintained good eye contact throughout the interaction. The patient’s skin was warm and dry, with no signs of pallor or cyanosis.We found no abnormal findings in his head and neck examination, including jugular venous distention. Heart sounds were significant for a holo-diastolic murmur at the aortic area with radiation to the apex and continuous murmur at the Right sternal border. Respiratory sounds were heard clearly and symmetrically without wheezing or crackles. His abdomen was non-distended and without tenderness and organomegaly. Upon examination of his upper and lower extremities, his radial and dorsalis pedis pulses were palpated bilaterally and were symmetrical and regular. His veins were symmetric without focal distention. Figure 1 shows the patient’s EKG upon his first visit.

IntroductionGranulomatosis with polyangiitis (GPA) is a chronic condition characterized by granulomatous inflammation of blood vessels, leading to damage in various organs, including the lungs, kidneys, and sinuses. This pattern of involvement can complicate the diagnosis of coexisting conditions, especially those involving granulomatous inflammation, like tuberculosis (TB). Its treatment typically involves the use of immunosuppressants, which can further complicate the diagnosis of infectious conditions. (1) Cardiac tuberculosis (TB) is a rare but clinically significant extrapulmonary manifestation of tuberculosis, often presenting substantial diagnostic challenges due to its nonspecific symptoms. Timely diagnosis and management are crucial as TB’s involvement in cardiac tissues can result in severe complications such as tuberculous pericarditis and cardiac tamponade. (2) Patients may exhibit symptoms like fatigue, weight loss, dyspnea, and chest pain, which can easily mimic other cardiac conditions, complicating both diagnosis and management. The prevalence of cardiac TB varies geographically, with notably higher rates observed in regions where TB is endemic. (2) In addition to cardiac TB, mitral-aortic intervalvular abscesses represent another rare yet critical complication associated with infective endocarditis, particularly in patients with pre-existing cardiovascular disease. This anatomical region, known as the mitral-aortic intervalvular fibrosa (MAIVF), consists of fibrous and avascular tissue that is particularly vulnerable to infections and trauma. These abscesses occur in less than 1% of endocarditis cases and can lead to severe sequelae, such as valvular dysfunction and heart failure, if not diagnosed and treated promptly. (3, 4)The primary causative agents are often bacterial infections, particularly from organisms like Staphylococcus aureus. These infections can invade the fibrous tissue following surgical interventions or arise in the context of chronic conditions that predispose patients to endocarditis.(5, 6) The co-occurrence of tuberculosis (TB) and granulomatosis with polyangiitis (GPA) presents a significant clinical challenge, especially among immunocompromised patients. This case report details a 45-year-old woman with end-stage renal disease secondary to GPA who developed an MAIVF abscess with necrotizing granulomatosis inflammation and a positive tissue PCR for TB. Understanding the interplay between these two conditions is critical for guiding distinct therapeutic approaches, given that both involve granulomatous inflammation.