Isolated Pulmonic Valve Endocarditis: Case Report and Review of Existing Literature on Diagnosis and Therapy

Pulmonary Valve Endocarditis during and beyond Euro ENDO Registry: A Single Center Case Series

Background: Pulmonary valve infective endocarditis (PVIE) is a rare form of infective endocarditis (IE) and is associated with high mortality and severe complications. Guidelines for treatment of this form of IE are scarce and based on general recommendations. We report a case series of PVE. Detailed Case Description: Case 1-A 36-year-old female with congenital pulmonary artery stenosis, dyspnea and leg edema symptoms for 2 months. Blood cultures yielded Staphylococcus spp. and Corynebacterium sp., and echocardiography revealed multiple floating vegetation at the pulmonic valve and surrounding structures. The clinical course was complicated with sepsis and multi-organ failure. Urgent surgery with pulmonary homograft implantation resulted in successful five-year outcome. Case 2-In a 38-year-old male with previous tetralogy of Fallot correction and symptoms of fatigue, fever, myalgia, and photophobia, echocardiography was suggestive of PVIE. The clinical course was complicated with septic shock, multi-organ failure, ischemic stroke with hemorrhagic transformation and death on the 12th day of hospitalization. Case 3-A 41-year-old male without previous medical history was hospitalized due to prolonged fatigue, fever, dyspnea, and leg edema. He was diagnosed with multi-valve infective endocarditis, affecting the aortic, tricuspid, and pulmonary valve. Acute heart failure and hemodynamic instability indicated urgent surgery with aortic valve replacement and reconstruction of the tricuspid and pulmonary valves. At four-year follow up he was doing well. Conclusion: Symptoms in PVIE may be versatile, and diagnosis is often delayed. High level of suspicion, early recognition, and echocardiography are cornerstones in diagnostics. Despite the standpoint that medical therapy is first-line, the role of surgery needs to be advocated in particular cases.

Pneumonia, Arthritis, and Liver Injury: A Cardiac Diagnostic Conundrum

A 40-year-old intravenous cocaine user presented with non-specific symptoms, including fever, headache, myalgias, and fatigue. After being provisionally diagnosed with rhinosinusitis and discharged on antibiotics, the patient returned with shortness of breath, dry cough, and persistent high-grade fevers. Initial workup showed multifocal pneumonia, acute liver injury, and septic arthritis. Blood cultures were positive for methicillin-sensitive staphylococcus aureus (MSSA) which led to the evaluation of endocarditis with a transthoracic echocardiogram (TTE) and transesophageal echocardiogram (TEE). TEE was performed as the initial diagnostic imaging test, and it did not show any evidence of valvular vegetation. However, given the persistence of the patient's symptoms and clinical suspicion of infective endocarditis, TTE was performed which showed a 3.2 cm vegetation on the pulmonic valve with severe insufficiency, leading to a diagnosis of pulmonic valve endocarditis. The patient was treated with antibiotics and underwent a pulmonic valve replacement surgery, which showed a large vegetation on the ventricle portion of the pulmonic valve that was replaced with an interspersed tissue valve. The patient was discharged in stable condition after improvement of symptoms and normalization of liver function enzymes. It is important to note that TTE should be considered initially as a diagnostic tool in such cases. Sometimes, a TEE may not be required if the TTE provides a sufficient assessment.

Possible Isolated Pulmonic Valve Endocarditis in a Patient With Sickle Cell Disease: A Case Report

Pulmonic valve endocarditis is a rare and clinically elusive identity, commonly associated with congenital heart malformations and intravenous (IV) drug abuse. We describe a case of a 40-year-old male who has established sickle cell disease and presented with pain crisis, febrile episodes, and oxygen desaturation on room air. The clinical presentation and echocardiographic findings of a pulmonic mass were consistent with the diagnosis of pulmonic valve endocarditis. Due to the small size of the pulmonic valve vegetation, the patient was treated with antibiotics and discharged home on antibiotics and home oxygen.

Isolated Sub-Pulmonic Valve Endocarditis in a Patient With a History of Konno Procedure and Mechanical Aortic Valve

Pulmonic and sub-pulmonic valve endocarditis are rarely encountered in clinical practice. We present the first case of isolated sub-pulmonic endocarditis. A 30-year-old man with a history of mechanical aortic valve presented to the emergency department with multiple complaints including nausea, vomiting, body aches, and fevers. The patient underwent surgical resection for sub-aortic stenosis followed by a modified Konno procedure later in life. A modified basal short-axis view on the trans-thoracic echocardiogram revealed a sub-pulmonic mobile structure highly suggestive of infective endocarditis. Blood cultures grew methicillin-sensitive Staphylococcus aureus within 24 hours. Higher oxygen demand prompted chest imaging, chest CT showed the development of bilateral airspace consolidation, suggestive of pneumonia. After treatment with extended intravenous antibiotics, follow-up echocardiogram four months later showed no identifiable sub-pulmonic vegetation.

This case describes a situation where clinicians may suspect infective endocarditis in a typical location such as a mechanical aortic valve. However, in patients who develop pneumonia, infective endocarditis of the right heart should be suspected. The pulmonic valve and sub-pulmonic ridge are often difficult to image given their anatomical location, a modified basal short-axis view on trans-thoracic echocardiogram can better image these structures.

Atypical presentation of right-sided native valve infective endocarditis

A previously healthy 55-year-old man presented to hospital with 10 days of progressive dyspnea with fever, night sweats, and a productive cough and no history of recreational drug use or occupational or animal exposures. His wife had developed similar symptoms 2 weeks earlier but had since recovered. Physical exam revealed a new systolic murmur best heard at the left lower sternal border. Transesophageal echocardiogram demonstrated severe tricuspid regurgitation with a small vegetation. Blood cultures were positive for non-typeable Haemophilus influenzae. This case illustrates the necessity of both timely and proficient diagnosis of H. influenzae infection and the unique challenges associated with detecting H. influenzae-related pathology. Clinicians should be aware of the variable presentations of Haemophilus infection, including respiratory infection, neurological infection, and infective endocarditis. Given the fastidious nature of H. influenzae and variability between subtype pathogenicity, microbiology laboratories require tools to culture and differentiate Haemophilus species.

Postpartum-Isolated Native Pulmonic Valve Methicillin-Resistant Staphylococcus aureus Infective Endocarditis Complicated by Pelvic Abscess, Clavicle Osteomyelitis, and Polyarticular Septic Arthritis

Isolated native pulmonic valve infective endocarditis (IE) is a rare occurrence. The most commonly involved valves in injection drug users are the tricuspid valve followed by mitral and then aortic valves. Most reported cases of methicillin-resistant Staphylococcus aureus (MRSA) IE involve multiple valves. Isolated involvement of the pulmonic valve in IE is infrequent, especially in intravenous drug users or patients with indwelling catheters, prosthetic valves, or implantable cardiac devices. Here, we report a young postpartum female patient with isolated native pulmonic valve MRSA IE with MRSA bacteremia and history of active injection drug use. A PubMed literature review revealed a single described prior case report in a postpartum female. The patient's clinical course was complicated by a large native pulmonic valve vegetation, septic pulmonary emboli, pelvic abscess, polyarticular septic arthritis, and clavicular osteomyelitis. The patient underwent bioprosthetic pulmonic valve replacement and finished six weeks of intravenous vancomycin for complete recovery.

Isolated Pulmonary Valve Endocarditis

Infective endocarditis involving the right side of the heart is typically associated with IV drug abuse and chronic indwelling catheters which commonly involve the tricuspid valve. Isolated pulmonary valve endocarditis (PVE) is a rare clinical entity. We report a rare case of a young woman with a history of end-stage renal disease (ESRD) on hemodialysis through tunneled catheter presenting with persistent coagulase-negative staphylococcus (CoNS) epidermidis bacteremia despite being on appropriate treatment with IV vancomycin for two weeks. Because of the persistent bacteremia, a transesophageal echocardiogram was performed and it revealed a thickened pulmonary valve with 1.8 cm vegetation in the left posterior cusp. She was successfully treated with IV daptomycin course for a total of six weeks. The recommended management for PVE is usually medical treatment with IV antibiotics gauged according to sensitivities of the cultures. Our article highlights the fact that the decision to manage it medically versus surgically can propose a challenge as the guidelines are not very robust.