Echocardiographic demonstration of free wall vegetative endocarditis complicated by a pulmonary embolism in a patient with ventricular septal defect

Sub-pulmonic stenosis caused by a right ventricular outflow tract vegetation in a children with restricted ventricular septal defect

Infective endocarditis involving the right heart is rarely observed in the pediatric population. Echocardiography plays an important role in its diagnosis, and surgery is indicated in patients with heart failure and persistent sepsis not responding to medical treatment. Here, we report a rare case of restricted ventricular septal defect complicated by a vegetation developed in the right ventricular outflow tract and causing sub-pulmonic stenosis in a 3-year-old male child.

Right-Sided Infective Endocarditis and Pulmonary Infiltrates: An Update

Sixty years after its initial description, right-sided infective endocarditis (RSIE) still poses a challenge to all medical practitioners. Epidemiological data reveal a rising incidence attributable to the global surge in the number of intravenous drug users and the increased use of central vascular catheters and implantable cardiac devices. RSIE differs from left-sided infective endocarditis in more than just the location of the involved cardiac valve. They have different clinical presentations, diagnostic findings, and prognoses; hence, they require different management strategies. Cardiac murmurs and systemic emboli are usually absent in RSIE, whereas pulmonary embolism and its related complications dominate the clinical picture. Diagnostic delay of RSIE is secondary to the similarity in its initial presentation to other entities. Complications may ensue as a result of this delay. Diagnosis can be initially confirmed by using transthoracic echocardiography, except in patients with implanted cardioverter defibrillator, where a transesophageal echocardiogram is necessary. Various factors may increase mortality and morbidity in RSIE such as tricuspid valve vegetation size, fungal etiology, and low CD4 cell count in HIV patients. Oxacillin and vancomycin had been the traditionally used agents for the treatment of methicillin-susceptible and methicillin-resistant Staphylococcus aureus, respectively. More recently, daptomycin has shown promising results, which has led to its Food and Drug Administration (FDA) approval for the treatment of S. aureus bacteremia and associated RSIE. The aim of this article is to provide a comprehensive update on RSIE including epidemiology, pathogenesis, microbiology, diagnosis, management, and prognosis.

Native valve right sided infective endocarditis

Right-sided infective endocarditis (RSIE) accounts for 5-10% of all cases of infective endocarditis (IE), and is predominantly encountered in the injecting drug user (IDU) population, where HIV and HCV coinfections often coexist. Staphylococcus aureus is the most common pathogen. The pathogenesis of RSIE is still not well understood. RSIE usually presents as a persistent fever with respiratory symptoms whilst signs of systemic embolisation as seen in left-sided IE are notably absent. The prompt diagnosis of RSIE thus requires a high index of suspicion. Transthoracic echocardiography (TTE) can detect the majority of RSIE, whilst transoesophageal echocardiography (TOE) can increase sensitivity. Virulence of the causative organism and vegetation size are the major determinants of prognosis. Most cases of RSIE resolve with appropriate antibiotic administration.

A case of intra-cardiac right-sided mural infective endocarditis associated with ventricular septal defect despite prophylactic antibiotics: a case report

Bacterial endocarditis secondary to jet lesions from congenital heart disease is not uncommon, and has been reported on numerous occasions in the literature. These cases usually involve one or more cardiac valves. Our case is that of isolated intracardiac right-sided mural infective endocarditis associated with ventricular septal defect. Importantly, this patient had preceding dental work treated with antibiotic prophylaxis. This case highlights bacteraemia secondary to dental instrumentation versus routine oral hygiene. His presentation was predominantly that of respiratory symptoms and sepsis, and he was culture negative throughout his admission. The lesion was detailed on echocardiography and transoesophageal echocardiography, and treated conservatively. He has subsequently been referred for VSD closure.

Atrial endocarditis--the importance of the regurgitant jet lesion

The jet lesions of valvular regurgitation or intracardiac shunts have been hypothesized to play an important role in the pathogenesis of endocarditis for many years. We describe a case of mitral valve endocarditis that involved the left atrium along the path of a jet lesion. This resulted in atrial endocarditis and pericarditis, both of which complicated her presentation and hospital course. Using transesophageal echocardiography, we were able to directly visualize the path and full extent of infection prior to surgery. Special attention should be focused upon the path of eccentric jets in order to fully define the extent of endocarditis.

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.

Unusual cases of infective endocarditis

We report 2 patients with unusual cases of infective endocarditis. The first patient had a large, mural vegetation on left ventricle that was diagnosed with transthoracic echocardiography; and the second patient had a large, mobile vegetation in the descending prosthetic aorta with an abscess cavity around the vessel, diagnosed by transesophageal echocardiography. This report confirms the usefulness of transthoracic and transesophageal echocardiography in the diagnosis and management of uncommon cases of endocarditis.

Criteria for the diagnosis of endocarditis and the role of echocardiography

When infective endocarditis is a diagnostic possibility, echocardiography permits noninvasive imaging of cardiac structures. As involvement of the endocardium is a sine qua non of endocarditis, echocardiography may assist in its diagnosis by demonstrating such involvement. The ability of echocardiography to detect the intracardiac manifestations of infective endocarditis has continued to improve, especially with the introduction of transesophageal imaging. This article will discuss some of the echocardiographic findings in endocarditis and elucidate the incorporation of these findings in the new Duke criteria for the diagnosis of endocarditis.