Introduction Myxomatous degeneration is a common aetiology of mitral valve prolapse. It may lead to potential complication such as mitral regurgitation and may resemble other clinical pathologies such as vegetations or cardiac masses.

Case Presentation A 58-year-old man presented with recurrent exertional dyspnoea, reduced effort tolerance and low-grade fever for a year duration. He was not in respiratory distress and the JVP was normal. Peripheral stigmata of infective endocarditis were absent. Cardiovascular examination revealed S1S2 with systolic murmur over mitral region. Chest X-ray portrayed cardiomegaly, ECG showed left ventricular hypertrophy and full blood count showed leucocytosis. The CRP, ESR and procalcitonin were not elevated and there was no growth on the blood culture. Transthoracic and transoesophageal echocardiogram revealed LVEF of 52%. The LVIDs was 5.26cm and LVIDd was 6.49cm. There was severe MR and severely prolapsed AMVL A2 as well as ruptured chordae. Suspicious vegetative lesion was seen at the tip of AML of mitral valve. Coronary angiogram was normal. He was empirically treated as infective endocarditis and referred to cardiothoracic team in view of no improvement in the suspicious mass after two weeks of antibiotics. He underwent mechanical mitral valve replacement. Intraoperatively, thickened mitral valve with prolapsed AMVL and ruptured chordae tendineae at A2 were seen. Histopathological report revealed fibrocartilaginous tissues with myxoid changes over leaflets without evidence of vegetations. The antibiotics were stopped since then. Three months later, his EF improved to 63% with absence of regional wall motion abnormalities. There was no further episode of admission afterwards.

Discussion Mitral valve prolapse is a complication of myxomatous valve disease. The myxomatous process reduce the tensile strength of chordae which lead to its rupture at the point of maximal stress, typically near the attachment of the chordae to the valve leaflets or the papillary muscles. Anterior leaflet is an uncommon location of myxomatous mitral valve. The presence of myxomatous valve may exacerbate incidence of infective endocarditis due to its structural abnormalities and possible nidus of infection.

Conclusion This case report showed the complexities in managing cardiac mass cases, which necessitates a multidisciplinary approach in order to reach accurate diagnosis and optimal management with the best possible outcome.