Right-sided valvular endocarditis: etiology, diagnosis, and an approach to therapy

Pulmonary Valve Endocarditis With Tetralogy of Fallot: A Comprehensive Exploration

Infective endocarditis, a fatal infection with rising morbidity and mortality rates among infants and children, is characterized by microbial infection within the endocardium, the inner lining of the heart including heart valves. The heightened susceptibility to infection in children is attributed to pre-existing pathologies, structural defects, and comorbidities. This report details a case of a one-year-old child with tetralogy of Fallot, showcasing isolated pulmonary valve vegetations as a distinctive manifestation of infective endocarditis.

Right ventricular mural infective endocarditis after traumatic tricuspid valve regurgitation in a 40-year-old man: A case report

As the clinical manifestations of traumatic tricuspid valve regurgitation vary according to the extent of tricuspid valve injury, this condition can often go unnoticed and be incidentally discovered. Here, we report the case of a 40-year-old man with patent foramen ovale, in which severe tricuspid regurgitation due to tricuspid valve prolapse was incidentally discovered following blunt chest trauma. Further examination revealed that the prolapse had also caused active right ventricular mural infective endocarditis. The patient had no relevant past medical history of chronic debilitating disease or immunosuppression. After evaluation by the cardiology team, emergent surgical tricuspid valvular repair was successfully performed.

Learning objective

Tricuspid valve prolapses resulting from chest trauma may occasionally lead to severe tricuspid regurgitation. Furthermore, this may cause active right ventricular infective endocarditis. In the present case, Staphylococcus aureus was detected in blood cultures, which is usually rapidly progressive and often leads to devastating consequences. Early surgical approach should be considered in cases of infection in the left atrium via patent foramen ovale.

Isolated pulmonary valve endocarditis with rapid progression: a case report and literature review

BACKGROUND

Isolated pulmonary valve endocarditis (IPE) is rare, accounting for 1.5-2% of all cases of infective endocarditis. Herein, we describe a case of isolated pulmonary valve endocarditis with rapid progression in a 28-year-old male. Unlike most patients reported previously who were cured with only anti-infective therapy, without surgery at an early stage, multiple complications occurred in this patient in less than 2 weeks.

CASE PRESENTATION

The patient was diagnosed with pulmonary valve endocarditis with blood cultures showing Staphylococcus aureus and echocardiography revealing 2 masses (measuring 14*13 mm、11*16 mm in size). Only 12 days later, acute massive pulmonary embolism occurred. Then, repeated echocardiography revealed multiple masses attached to the pulmonary valve with severe pulmonary insufficiency and the possibility of pulmonary valve destruction. Finally, pulmonary valve replacement, vegetation removal, and right pulmonary thromboendarterectomy together with resection of the middle and lower lobes of the right lung were performed.

CONCLUSIONS

The role of surgery at an early stage might need to be reconsidered, and it may be viable to combine medical and surgical approaches.

Septic perimyocarditis due to a right-sided infective endocarditis of atypical morphology in a 33-year-old woman

Perimyocarditis should be considered in patients with endocarditis not improving with conventional therapy and without typical valvular abnormalities. Vegetations can be sited anywhere in the atrium or ventricle and exhibit multiple shapes.

A rare case of right-sided infective endocarditis caused by group B Streptococcus complicated with septic knee arthritis and subcutaneous abscess in the lower extremity

Background

Several reports have assessed group B Streptococcus (GBS) infections in non‐pregnant cohorts, especially in immunocompromised hosts and patients with severe disease, including diabetes mellitus.

Case presentation

We report a rare case of large GBS‐associated tricuspid valve infective endocarditis (IE) complicated with septic knee arthritis and s.c. abscess formation in the lower extremity of a non‐i.v. drug user. After confirming the absence of vegetation on transthoracic echocardiography (TTE) at admission, the lower extremity was irrigated, and antibiotic therapy was initiated. One week later, the causes of persistent fever were reinvestigated. The TTE detected a large mass around the tricuspid valve. The cultured GBS was penicillin sensitive. The vegetation completely disappeared without surgery within 4 weeks.

Conclusion

When patients with untreated diabetes mellitus have persistent fever and s.c. abscess or septic arthritis, IE is a possible differential diagnosis. Repetitive evaluation by TTE is warranted to avoid this fatal complication.

Delayed diagnosis of right-sided valve endocarditis causing recurrent pulmonary abscesses: a case report

BACKGROUND

Pulmonary valve infective endocarditis is a rare diagnosis that is usually associated with immunocompromised states or structurally abnormal hearts. It is unusual for it to occur in structurally normal hearts or to cause recurrent symptoms after targeted antibiotics. Although guidelines suggest follow-up with repeat echocardiography and inflammatory marker surveillance, this case demonstrates that these are not always useful investigations, and instead imaging of the chest may be more appropriate.

CASE PRESENTATION

We describe a case of a 74-year-old man who presented with respiratory symptoms and was originally misdiagnosed with pneumonia but later found to have a large pulmonary valve vegetation caused by Streptococcus mitis. Despite initially responding to antibiotic therapy, the vegetation continued to cause pulmonary emboli and cavitating lung abscesses months later, necessitating pulmonary valve replacement.

CONCLUSIONS

This case demonstrates that pulmonary valve endocarditis can present atypically with recurrent respiratory symptoms, and in such cases, echocardiography should be considered to investigate for right-sided infective endocarditis. In addition, despite correct treatment, with normalization of inflammatory markers and improvement in vegetation size, infective endocarditis can continue to cause systemic symptoms. Finally, clinicians should consider chest computed tomography routinely as part of right-sided infective endocarditis follow-up.

Nature's balancing act: Infective endocarditis of pulmonary valve with ventricular septal defect in fifth decade; a rare and unusual presentation

It is unusual for a moderate-size ventricular septal defect (VSD) to remain asymptomatic and complication-free until the age of 45 years. Similarly, infective endocarditis of anatomically normal pulmonary valve is also rare. Here we report a case in which nature created a protection for VSD, i.e. right ventricular outflow tract (RVOT) obstruction, which led to a complication, i.e. pulmonary valve endocarditis. A 45-year-old sick-looking man presented in medical emergency with fever and progressively increasing breathlessness for the previous 2 weeks. He had no significant past history. The patient was febrile and on cardiovascular (CVS) examination, ejection systolic murmur in left upper parasternal region was heard, suggesting a diagnosis of infective endocarditis. Echocardiography revealed subaortic VSD of 1.2 cm size with left to right shunt. There was moderator band hypertrophy in sub-infundibular right ventricle (RVOT obstruction) creating obstruction to blood flow, thus preventing development of pulmonary artery hypertension. There were two large vegetations (4 × 3 mm) on each leaflet of pulmonary valve. High speed turbulent jet of blood generated from right ventricle obstruction was striking the pulmonary valve leaflets which led to injury and subsequent development of infective endocarditis of pulmonary valve. The patient improved on intravenous antibiotics. The plan was to give 6 weeks of antibiotics followed by surgical closure of VSD and resection of moderator band. <Learning objective: It is rare for a moderate size ventricular septal defect to remain asymptomatic and complication-free until the age of 45 years. Sometimes nature creates a barrier in the form of moderator band hypertrophy in sub infundibular right ventricle i.e. RVOT obstruction, leading to obstruction to blood flow and preventing development of pulmonary hypertension.>.

A chronic hemodialysis patient with isolated pulmonary valve infective endocarditis caused by non-albicans Candida: a rare case and literature review

BACKGROUND

Isolated pulmonary valve infective endocarditis caused by Candida is rare in chronic hemodialysis patients. The 2009 Infectious Diseases Society of America guidelines suggest the combined use of surgery and antibiotics to treat candidiasis; however, successful nonsurgical treatment of Candida endocarditis has been reported.

CASE PRESENTATION

A 63-year-old woman with end-stage kidney disease was admitted to our hospital after experiencing disorientation for 5 days. The patient was permanently bedridden because of depression, and denied active intravenous drug use. She received maintenance hemodialysis through a tunneled-cuffed catheter. An initial blood culture grew Candida guilliermondii without other bacteria. Subsequent blood cultures and tip culture of tunneled-cuffed catheter also grew C. guilliermondii, even after caspofungin replaced fluconazole. A 1.2-cm mobile mass was observed on the pulmonary valve. Surgical intervention was suggested, but the family of the patient declined because of her multiple comorbidities. The patient was discharged with a prescription of fluconazole, but she died soon after.

CONCLUSION

Our patient is the first case with isolated pulmonary valve endocarditis caused by C. guilliermondii in patients with uremia. Hematologic disorders, in addition to long-term central venous catheter use, prolonged antibiotic intravenous injection, and congenital cardiac anomaly, predispose to the condition. The diagnosis "isolated" pulmonary IE is difficult, and combing surgery with antifungal antibiotics is the appropriate therapeutic management for Candida related pulmonary IE.

A Retrospective Review: Significance of Vegetation Size in Injection Drug Users with Right-Sided Infective Endocarditis

BACKGROUND

Previously described prognostic markers in right-sided infective endocarditis (RSIE) include vegetation size ≥1cm, fever for more than three weeks, cardiac failure and severe sepsis. This study aimed to evaluate effectiveness of medical therapy for vegetations ≥1cm and explore determinants of outcome in a representative population of intravenous drug users (IDUs) at a metropolitan Australian health service.

METHODS

Retrospective review of consecutive IDUs presenting to our institution with native-valve RSIE (by modified Duke criteria) over seven years (2005-2011). Data recorded included echocardiographic estimation of maximal vegetation diameter (classified as < or ≥1cm). Relationships between vegetation size and specified outcomes of death, septic shock, recurrence and relapse were examined by Chi-squared testing.

RESULTS

Of 49 episodes five (10%) were managed surgically and a further four (8%) were lost to follow-up and excluded from the analysis. Of the remaining 40 evaluable medically treated patients (median age 28, range 20-55), 37 (93%) cultured methicillin-sensitive S. aureus and all had tricuspid valve involvement. Of 24 with vegetations ≥1cm, three died (mortality 13%) compared with one (6%) in 16 medically treated patients with vegetations <1cm (p=0.63). A Pittsburgh (PITT) bacteraemia score of ≥4 at presentation was associated with a mortality of 24% (four of 17 patients died) compared with 0 in 23 patients with PITT scores <4 (p=0.026).

CONCLUSION

Medical therapy alone can be effective for RSIE when large vegetations are present. However a high sepsis score at presentation may increase risk of death. Larger studies are required to determine optimal indications for early surgical intervention.

Intracardiac abscess with cutaneous fistula secondary to ventricular septal defect repair simulating sternal wound infection

Cutaneous fistula as a clinical presentation of intracardiac abscess of the right side is such an unusual occurrence that it has not until now been reported in the English-language medical literature. We present a rare case of right-sided infective endocarditis caused by Achromobacter xylosoxidans in which recurrent infection presented as sternal wound discharge. The infection was found to have an intracardiac origin and was successfully managed by radical débridement on cardiopulmonary bypass.

Giant vegetation mimicking cardiac tumor in tricuspid valve endocarditis after catheter ablation

A 33-year-old man suffered from fever of unknown origin and developed right-sided heart failure. A transeshophageal echocardiogram revealed an progressive enlarging mass in the right atrium mainly attached to the tricuspid valve and a previous ablation site, which mimicked a cardiogenic tumor. He was operated on to remove the mass and intraoperative pathology showed it was large vegetation and secondary granulation due to tricuspid endocarditis. Tricuspid valve replacement was performed combined with reconstruction of the right atrial wall.

Current outcomes for tricuspid valve infective endocarditis surgery in North America

BACKGROUND

Tricuspid valve (TV) infective endocarditis (IE) accounts for 15% of IE cases and usually is treated medically. Surgical intervention is rare, and understanding of treatment options is based on small series of patients. The purpose of this study was to describe the population and outcomes for isolated TV IE using The Society of Thoracic Surgeons Adult Cardiac Database.

METHODS

Between 2002 and 2009, 910 operations for TV IE were performed. Procedures included replacement, repair, and valvectomy. Healed IE was present in 31.4% (n = 286), and active IE, in 68.5% (n = 624). Baseline patient characteristics as well as operative mortality and morbidity were analyzed, and univariate statistical differences were evaluated by Kruskal-Wallis test and stratum-adjusted Mantel-Haenszel χ(2) tests.

RESULTS

The median age was 40 years, with 50.6% male. Replacement of the TV was the most common procedure (n = 490; 53.8%), followed by TV repair (n = 354; 38.9%) and valvectomy (n = 66; 7.2%). Overall operative mortality was 7.3%, with no significant difference in mortality among valvectomy 12%, repair 7.6%, and replacement 6.3% (p = 0.34). Compared with the active group, healed patients experienced a trend toward lower operative mortality (4.2% versus 8.6%; p = 0.06), lower complication rates (35.6% versus 51.4%; p = 0.0004), and shorter overall length of stay (12 versus 22 days; p < 0.0001).

CONCLUSIONS

Isolated TV operation for IE is a rare clinical entity with a similar operative mortality to left-sided IE operations. Repair and replacement of the TV had similar perioperative mortality. Patients in the healed TV IE group demonstrated lower complication rates, length of stay, and a trend toward decreased mortality.

Isolated pulmonary valve endocarditis in a patient with aplastic anaemia

A 42-year-old female patient of aplastic anaemia on maintenance blood transfusion presented with a 3-week history of fever, cough, dyspnoea and pedal oedema. Upon examination she  was found to have severe pallor, temperature of 101°F, tachycardia, bilateral pitting pedal oedema, raised jugular venous pressure, ejection systolic murmur (grade 2/6) in pulmonary area and petechiae over extensor aspect of both lower limbs. Blood investigations revealed low haemoglobin, thrombocytopaenia and mild increase in serum creatine. Chest x-ray was normal. Initial 2D trans thoracic echocardiography performed after hospital admission was normal. Antibiotics were started empirically to treat a possible underlying infection. Subsequently, three sets of blood cultures grew Enterococcus faecalis. Upon searching for the source, repeat echocardiograph done showed 2×0.5 cm vegetation on both pulmonary leaflets with severe pulmonary regurgitation, all other valves were free of vegetations. She was treated with intravenous antibiotics for the endocarditis and improved.

Complicated Community-Acquired Staphylococcus Endocarditis and Multiple Lung Abscesses: Case Report and Review of Literature

Background. Isolated tricuspid valve endocarditis in the absence of risk factors in the community setting is very rare and can be easily missed in patients with hitherto normal valves. Case Presentation. We present a case of a 49 year old gentleman who presented with generalized body aches, fever, and jaundice and was initial diagnosed as hepatitis. He subsequently developed recurrent episodes of panic attacks and shortness of breath and later multiple skin abscesses. Further investigations excluded pulmonary embolism but revealed multiple abscesses in the body including the lungs. Blood cultures and culture from abscesses grew S. aureus. An initial transthoracic echocardiogram was normal. A transesophageal echocardiogram subsequently confirmed endocarditis on a normal natural tricuspid valve and multiple lung abscesses. He was successfully treated with appropriate antibiotics. Conclusion. We discuss the pathogenesis of this patient's presentation highlight the need for assessment and proper evaluation of patients with unexplained bacteremia.

Endocarditis caused by Staphylococcus aureus: A reappraisal of the epidemiologic, clinical, and pathologic manifestations with analysis of factors determining outcome

Staphylococcus aureus is the leading cause of infectious endocarditis and its mortality has remained high despite better diagnostic and therapeutic procedures over time. We conducted a retrospective review of 133 cases of definite S. aureus endocarditis seen at a single tertiary care hospital over 22 years to assess changes in the epidemiology and incidence of the infection, manifestations, outcome, risk factors for mortality, and impact of cardiac surgery on prognosis.Patients were classified into 2 groups: 1) right-sided endocarditis (64 patients) and 2) left-sided endocarditis (69 patients). While the number of cases of left-sided endocarditis remained steady at 1-3 cases per 10,000 admissions, the incidence of right-sided endocarditis, after a peak in the early 1990s, declined to almost disappear in 2001. Among the cases of right-sided endocarditis, we found 2 subsets of patients with different clinical features and prognosis: the first subset comprised 53 intravenous drug abusers, and the second subset comprised 11 patients with catheter-associated S. aureus bacteremia and endocarditis. Fifty-one patients were human immunodeficiency virus (HIV)-positive drug abusers, most of whom (80.3%) had right-sided endocarditis. We did not find differences in mortality between HIV-positive and HIV-negative individuals; mortality seemed to depend more on the site of the heart involved than on HIV status.Among the cases of left-sided endocarditis, the mitral valve was more commonly involved than the aortic valve (61% vs. 30%). Overall, 74% of patients with left-sided endocarditis developed 1 or more cardiac or extracardiac complication. In comparison, only 23.4% of patients with right-sided endocarditis developed complications.Prosthetic valve endocarditis (PVE) was hospital-acquired more frequently than native valve endocarditis (NVE). Patients with PVE had a shorter duration of symptoms until diagnosis and presented with or developed cardiac murmurs less frequently than patients with NVE. Cardiac failure (49%), renal failure (43%) and central nervous system (CNS) events (35%) were frequently observed in patients with both PVE and NVE. Valve replacement was more frequently needed and more rapidly performed in patients with PVE than in their counterparts with NVE.The overall mortality of patients with right-sided endocarditis was 17%. While the mortality of right-sided endocarditis in injection drug users was 3.7%, the mortality of patients with right-sided endocarditis associated with infected intravenous catheters was 82% (odds ratio [OR], 0.01; 95% confidence interval [CI], 0.001-0.07). For left-sided endocarditis mortality was 38% and was not significantly different in patients with NVE or PVE (OR, 0.65; 95% CI, 0.23-1.87). CNS complications were associated with mortality in both NVE (OR, 6.55; 95% CI, 1.78-24.04) and PVE (OR, 32; 95% CI, 2.63-465.40). Development of 2 or 3 complications was associated with an increased risk of mortality (OR, 5.59; 95% CI, 1.08-28.80 and OR, 9.25; 95% CI, 1.36-62.72 for 2 vs. 1 complication and for 3 vs. 2 complications, respectively).Surgical treatment did not significantly influence mortality in cases of NVE, (OR, 3.19; 95% CI, 0.76-13.38) but significantly improved the prognosis of patients with PVE (OR, 69; 95% CI, 2.89-1647.18).S. aureus endocarditis is an aggressive, often fatal, infection. The results of the current study suggest that valve replacement will improve the outcome of infection, particularly in patients with PVE.

Pulmonary valve endocarditis caused by right ventricular outflow obstruction in association with sinus of valsalva aneurysm: a case report

Background

Right-sided infective endocarditis is uncommon. This is primarily seen in patients with intravenous drug use, pacemaker or central venous lines, or congenital heart disease. The vast majority of cases involve the tricuspid valve. Isolated pulmonary valve endocarditis is extremely rare. We report the first case of a pulmonary valve nonbacterial thrombotic endocarditis caused by right ventricular outlflow tract (RVOT) obstruction in association with a large sinus of Valsalva aneurysm.

Case presentation

A 60-year-old man with a six-week history of fever, initially treated as pneumonia and sinusitis with levofloxacin, was admitted to the hospital with a new onset of a heart murmur. An echocardiogram showed thickening of the pulmonary valve suggestive of valve vegetation. A dilated aortic root and sinus of Valsalva aneurysm measuring at least 6.4 cm were also identified. The patient was empirically treated for infective endocarditis with vancomycin and gentamycin for 28 days. Four months later, the patient underwent resection of a large aortic root aneurysm and exploration of the pulmonary valve. During the surgery, vegetation of the pulmonary valve was confirmed. Microscopic pathological examination revealed fibrinous debris with acute inflammation and organizing fibrosis with chronic inflammation, compatible with a vegetation. Special stains were negative for bacteria and fungi.

Conclusion

This is the first case report of a pulmonary valve nonbacterial endocarditis caused by RVOT obstruction in association with a sinus of Valsalva aneurysm. We speculate that jets created by the RVOT obstruction and large sinus of Valsalva aneurysm hitting against endothelium of the pulmonary valve is the etiology of this rare nonbacterial thrombotic endocarditis.

Infective endocarditis of the tricuspid valve caused by Staphylococcus aureus after ear piercing

Right-sided endocarditis usually involves the tricuspid valve, predominantly in intravenous drug abusers, in patients with anti-arrhythmic devices or central venous lines, and in patients with skin or genitourinary infection and with congenital heart disease 1. We describe a case of a 15-y-old patient, who had tricuspid valve endocarditis in a morphologically normal valve after having his ear pierced, without history of parenteral drug addiction and vascular catheter use. Progression of vegetation size and development of tricuspid valve regurgitation in spite of the intensive antibiotic treatment eventually required surgical intervention.

A case of isolated tricuspid valve infective endocarditis caused by Abiotrophia defectiva

A 17-year-old man with a history of dental caries was admitted to our hospital because of 1-week high fever. There was no history of previous cardiac disease. He denied drug abuse. Blood culture was positive for Abiotrophia defectiva. Echocardiography demonstrated large vegetation attached to the anterior cusp of the tricuspid valve with moderate regurgitation. Although he was treated with antibiotics for more than 3 weeks, he had chest pain due to septic pulmonary emboli on chest computed tomography. Surgical resection of the vegetation was performed. The postoperative course was uneventful and he is doing well at the time of follow-up.

Visceral leishmaniasis complicated by fungal pulmonary valve endocarditis

We present a rare neglected case of fungal pulmonary valve endocarditis which presented with typical extra cardiac manifestations after repeated injections for treatment of visceral leishmaniasis. Surgical intervention to replace the pulmonary valve was the only option to manage the patient in spite of extensive medical treatment.

Analysis of mortality and risk factors associated with native valve endocarditis in drug users: the importance of vegetation size

BACKGROUND

Native valve endocarditis in drug-user patients had a microbiology, a frequency of involvement of different cardiac valves, and a prognosis that differ from those in non-drug users. A retrospective study of native valve endocarditis cases in intravenous drug users diagnosed from 1985 to 1999 in our institution was performed to analyze the inhospital mortality of drug users with native valve endocarditis and to identify factors predictive of mortality.

METHODS

All patients fulfilled the Duke's criteria for definite or probable endocarditis. Analysis of predictors of inhospital mortality was restricted to right-sided infective endocarditis (IE) with definite diagnosis and echocardiographic data. The following variables were analyzed: sex, HIV serostatus, CD4 cell count < 200/mm3, time of IE diagnosis (before 1993 or after 1993), previous valvulopathy, polymicrobial IE, fungal etiology (mixed or alone), neurological complication, arterial emboli, pulmonary emboli, congestive heart failure, vegetation size (VS) > 2 cm, and inhospital cardiac surgery. Logistic regression was used in a multivariate model to identify factors independently associated with mortality. Adjusted odds ratios (OR) and 95% CIs were examined.

RESULTS

Four hundred ninety-three cases of IE were diagnosed in this period. Two hundred twenty cases of native valve endocarditis in intravenous drug users were identified. Fourteen cases in this group died (6%). Mean time from diagnosis to death was 18.5 +/- 15 days (range, 3-52). Vegetation size was available in 111 cases. Univariate analysis identified the following variables associated with inhospital mortality in right-sided cases: VS > 2 cm and fungal etiology. In multivariate analysis, the variables associated with mortality that achieved statistical significance were size of vegetation > 2 cm (P = .014, OR 10.2, 95% CI 1.6-78.0) and fungal etiology (P = .009, OR 46.2, 95% CI 2.4-1100.9).

CONCLUSIONS

The main prognostic factors of inhospital mortality in right-sided IE in drug users in our series were VS > 2 cm and fungal etiology. The role of early surgery in these patients should be reevaluated.

Infective tricuspid valve endocarditis with pulmonary emboli caused by Campylobacter fetus after tooth extraction

We describe a case of infective endocarditis caused by Campylobacter fetus accompanied by pulmonary emboli. A 52-year-old man was referred to our hospital due to febrile temperatures with a history of dental treatment followed by eating raw meat. Computed tomography revealed multiple infiltrations and a nodule with low attenuation area and feeding vessels. A mobile mass, possible vegetation, attached to the tricuspid valve was detected by transthoracic echocardiography. Two blood cultures disclosed Campylobacter fetus. Long-term antibiotic therapy was given, curing the infection with valvuloplasty. We presented the possibility that infective Campylobacter fetus endocarditis after dental treatment was caused by eating raw meat.

A rare localization in right-sided endocarditis diagnosed by echocardiography: a case report

BACKGROUND

Right-sided endocarditis occurs predominantly in intravenous drug users, patients with pacemakers or central venous lines and with congenital heart diseases. The vast majority of cases involve the tricuspid valve.

CASE PRESENTATION

A case of a 31-year-old woman with intravenous drug abuse who had a right-sided vegetation attached to the muscular bundle of the right ventricle is presented. Transthoracic echocardiography revealed a vegetation in the right ventricular outflow tract. Transesophageal echocardiography clearly showed that the 1.8 cm vegetation was not adherent to the pulmonary valve but attached to a muscular bundle.

CONCLUSIONS

Our case points to an unusual location of right-sided endocarditis in intravenous drug users. It confirms that TTE remains an easy and highly sensitive first-line examination for the diagnosis of right-sided endocarditis.

Unexpected death due to right-sided infective endocarditis in a methamphetamine abuser

A case of unexpected death due to right-sided infective endocarditis (IE) in a 44-year-old female methamphethamine abuser is presented. The woman was taken to a hospital by ambulance with a high fever having almost lost consciousness. She died about 6 h after admission. Autopsy revealed IE of the tricuspid valve. Septic thrombi from the lung were seen in other organs, and accordingly she was considered to have already been in a septic state on admission. Right-sided IE is relatively rare among the overall cases of IE, and is considered to result in good prognosis. It is also considered that right-sided IE occurs commonly among addictive drug abusers. We should therefore bear in mind that the presence of right-sided IE may be a predicting factor of drug abuse even if the injection site is not clearly visible, and for this reason, a toxicological analysis of the addictive drugs should be carried out.

Candida Tricuspid Endocarditis in a Non-addict

Isolated native non-rheumatic fungal tricuspid valve endocarditis is rarely described in the absence of intravenous drug addiction or use of intracardiac catheters or concomitant cardiac anomalies. Herein, we report a case of tricuspid valve endocarditis in a non-addict, which was successfully treated with valve replacement. The cultures of blood and vegetations revealed Candida Pichia Etschelsii. Candida tricuspid endocarditis must be considered in any patient with tricuspid vegetation, regardless of predisposing factors. </hea

Citrobacter diversus endocarditis

Citrobacter species are motile Gram-negative bacilli that cause disease in humans, such as urinary tract infection, pneumonia, superficial and deep wound infections, gastroenteritis, meningitis, bacteremia, and rarely endocarditis. In those cases of endocarditis, intravenous drug use has been associated with Citrobacter species. Gram-negative organisms are present in less than 10% of cases of endocarditis in intravenous drug users. We present a case of tricuspid valve endocarditis in an intravenous drug user caused by Citrobacter diversus alone.

Right-side endocarditis in injection drug users: review of proposed mechanisms of pathogenesis

Infective endocarditis of the right-side heart valves occurs commonly in injection drug users. Although a variety of hypotheses have been put forward to explain this clinical observation, no single hypothesis is adequate. In this article, basic scientific, clinical, and microbiological data on this topic are presented. It is apparent that no clear unifying mechanism emerges to explain the well-documented clinical predilection for the infection of the right-side heart valves in this population. Further investigation of this topic utilizing large international clinical registries may help to clarify matters further.

Eustachian Valve Endocarditis in an Elderly Woman

We describe the transesophageal echocardiographic findings in Eustachian valve endocarditis for a 73-year-old woman with a previous history of mitral valve disease. After a 4-week treatment with antibiotics, follow-up echocardiographic examination showed a smaller vegetation.

Native tricuspid valve endocarditis in a young woman

Images

[Three cases of right-sided active endocarditis with multiple pulmonary infarction]

We have experienced three patients with right-sided active endocarditis combined with multiple pulmonary infarction. Ventricular septal defect (VSD), aortic regurgitation (AR), tricuspid regurgitation (TR) and congestive heart failure were present in case 1. TR was present in case 2. VSD, TR and patent ductus arteriosus were present in case 3. alpha-Streptococcus caused endocarditis in case 1 and 3; Candida albicans caused endocarditis in case 2. Antibotic therapy had no effect in case 2 and 3. Case 1 and 3 developed pulmonary hemorrhage, which resolved before the operation in case 1, but not in case 3. Our three patients underwent surgery and recovered successfully. They were discharged on the 43th, 58th and 32th postoperative day and are presently free of clinical symptoms. These experiences suggest surgery should be undertaken in the following situations: 1. antibiotic therapy has no effect on the infection, 2. hemodynamics are worsening, and 3, pulmonary infarction and pulmonary hemorrhage occur repeatedly.

[Tricuspid valve endocarditis. Demonstration of a rare disease exemplified with 3 case reports]

BACKGROUND

Endocarditis of the tricuspid valve is a rare form of valvular endocarditis and occurs mainly in patients with special risk factors.

CASE REPORTS

The three case reports demonstrate 3 young patients (age 30 to 37 years, 2 female and 1 male) with a typical history of those risk factors. The two women were intravenous drug addicts and one of them had suffered already an episode of tricuspid valve endocarditis several years ago. The man developed his infection after implantation of a pacemaker. In all of the three patients the endocarditis was due to infection with staphylococci twice staphylococcus epidermidis and once staphylococcus aureus. In two of the three patients the endocarditis could not be cured by intravenous antibiotics alone and these patients had to undergo cardiac valvular surgery. All patients left the hospital after several weeks without signs of infection.

CONCLUSION

In clinical praxis the introduction of a special endocarditis service, a small team which has to be consulted in every suspected case of endocarditis, seems to be beneficial as well as the use of the Duke criteria for diagnosis in those cases.

Issues in surgical treatment of endocarditis including intraoperative and postoperative management

Patients with infective endocarditis who require surgical intervention can be divided into four separate groups, in order of incidence: (1) patients with underlying acquired or congenital cardiac lesions or valvar abnormalities, (2) patients with preexisting prosthetic valves, (3) patients with nosocomial infections who are immunosuppressed, and (4) older patients with infection risk or patients with indwelling deep venous catheters. The surgical management for these individual groups and for specific valve lesions is discussed, along with illustrative case studies.

Right-sided endocarditis in the non-drug addict

Fifteen patients with right-sided infective endocarditis during a 5 year period (1985-1990) were retrospectively reviewed. Isolated tricuspid valve involvement occurred in nine patients. Staphylococcus aureus was the causative organism in seven cases; four were culture negative. The diagnosis was established by two-dimensional echocardiography in 11 patients and at postmortem in the remaining four patients who succumbed shortly after admission. Fever, tachypnoea and pneumonia were universal features. A successful outcome ensued in eight patients with medical therapy alone and in two patients who were submitted to valve replacement. Five patients died, two from uncontrolled infection with repeated pulmonary emboli. Right-sided infective endocarditis should be suspected in any pneumonic illness that complicates post-abortal infection or other inadequately treated sepsis. Two-dimensional echocardiography is important in diagnosis since cardiac signs are minimal at presentation.

Cardiovascular complications of parenteral nutrition

During a 3 year period, 1987-1989, we encountered three major complications associated with parenteral nutrition leading to congestive cardiac failure--acute beriberi, right atrial and superior vena caval thrombosis, and fungal endocarditis. Unrecognized, these are invariably fatal. Persistent vomiting from intestinal obstruction led to the development of thiamine deficiency in the patient with beriberi. Recurrent catheter tip sepsis probably accounted for thrombosis and endocarditis in the second and third cases, respectively. These conditions are preventable with careful attention to nutritional replenishment and aseptic technique. In patients with catheter-related sepsis early, repeated blood culture is of diagnostic value. Patients with Staphylococcus aureus catheter-associated bacteraemia require at least 4 weeks of appropriate antibiotic therapy. Recurrent sepsis, especially when associated with pulmonary embolic phenomena, is an indication for echocardiography.

Spectrum of right-sided infective endocarditis: an Indian experience

We studied retrospectively 23 consecutive patients seen at our centre with right heart endocarditis. None of the patients had a history of intravenous drug abuse. All patients were found to have underlying congenital heart disease as a predisposing factor, of which ventricular septal defect (26%) and Fallot's tetralogy (26%) were the commonest. Postoperative endocarditis (26%) also constituted an important clinical subset. Fever (100%) and predominant pulmonary symptoms (69.5%) were the important presenting features. Congestive heart failure was present in 15 patients (65.2%) and predicted an adverse in-hospital outcome. Both the pulmonary and the tricuspid valves were affected equally with presence of vegetations at multiple sites in 10 patients (43.4%). Seven patients (30%) also had concomitant left-sided endocarditis. Medical therapy alone was successful in 15 patients (68.1%) with an overall in-hospital mortality of 31.8%. Five of 6 patients with postoperative endocarditis died, signifying an ominous prognosis of this subgroup when treated medically. The clinical spectrum of right-sided endocarditis in our country differs from the West. The frequent presence of underlying congenital heart disease, the rarity of drug abuse as a predisposing factor, equal involvement of the tricuspid and pulmonary valves and a greater incidence of congestive heart failure are some of these differences.

Seven-pathogen tricuspid endocarditis in an intravenous drug abuser. Pitfalls in laboratory diagnosis

Polymicrobial endocarditis is being reported with increasing frequency in drug abusers. However, the full extent of infection may be unrecognized with routine blood culture techniques because of the overgrowth of more fastidious organisms by other pathogens. This report documents an intravenous drug abuser with the first reported case of tricuspid valve endocarditis involving seven pathogens, discusses pitfalls of routine blood cultures and examines the role of the laboratory in microbiologic diagnosis.

Right-sided valvular endocarditis supported by an unexpected intracardiac foreign body

One case of tricuspid valve endocarditis due to a catheter fragment inside the right chambers of the heart is described. The symptoms were fever, cardiac failure, splenomegaly and relapsing pneumonia. Blood culture was positive, revealing Staphylococcus aureus. A two-dimensional echocardiogram demonstrated a large vegetation on the tricuspid valve. The percutaneous removal of the foreign body allowed complete recovery in a few weeks.

Septic pulmonary arteriovenous fistula. An unusual conduit for systemic embolization in right-sided valvular endocarditis

Right-sided valvular (tricuspid, pulmonic) endocarditis is frequently complicated by septic pulmonary embolization. Systemic embolization may also rarely occur due to associated left-sided endocarditis or right-to-left shunting in patients with septal defects. This report documents the occurrence of systemic embolization causing a cerebrovascular accident in an intravenous drug abuser with recurrent tricuspid valve endocarditis due to an isolated peripheral septic pulmonary arteriovenous fistula. Noninvasive diagnosis of the fistula by cardiac auscultation, contrast echocardiography, and nuclear magnetic resonance imaging was confirmed by selective pulmonary angiography. Subselective balloon embolization of the pulmonary arteries feeding this fistula was accomplished.