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

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.

Inaccuracy of transthoracic echocardiography for the identification of right‐sided vegetation in patients with no history of intravenous drug abuse or cardiac device insertion

Objective:

The use of transthoracic echocardiography (TTE) to identify right-sided infective endocarditis (RSIE) vegetation is controversial. Data are scarce for patients with no history of intravenous drug abuse (IVDA) or cardiac device insertion. This study analysed the consistency of presurgical echocardiographic results with surgical findings for vegetation identification, and the factors that influence accuracy of echocardiography.

Methods:

This retrospective trial divided infective endocarditis (IE) patients into three subgroups according to the results of their presurgical TTE: left-sided native IE (LSNIE), left-sided prosthetic valve IE (LSPIE) and RSIE. The accuracy of TTE was tested by comparing vegetation (number and location), detected presurgery by TTE, with actual findings during surgery.

Results:

In total, 416 patients were analysed, 322 with LSNIE, 31 with LSPIE and 63 with RSIE. Consistency between TTE findings and surgical results was lower in the RSIE group compared with the LSPIE and LSNIE groups. Consistency was lowered by the presence of vegetation in multiple locations and atypical distribution – both of which were increased in the RSIE group. The chance of vegetation in both sides of the heart rose with increased numbers of vegetation locations in RSIE patients. A high proportion of RSIE patients had congenital heart defects, mostly ventricular septal defects.

Conclusions:

TTE may be unsuitable for RSIE patients with no history of IVDA or cardiac device insertion, because multifocal and atypically distributed vegetation may influence detection accuracy.

An Atypical Temporal Sequence for Right Heart Endocarditis: Case Report

In 2010, an 82-year-old patient received a diagnosis of stage IV chronic obstructive pulmonary disease, ischemic dilated cardiomyopathy, severe secondary pulmonary hypertension, atrial fibrillation with slow ventricular response, and severe tricuspid regurgitation. In December 2011, he was hospitalized for exacerbation of chronic obstructive pulmonary disease. The patient received antibiotics via injections (for 2 weeks through a peripheral venous catheter). In February 2012, he returned to the hospital with congestive heart failure and vascular purpura skin lesions. The echocardiography examination revealed a rupture of cordage afferent to the septal tricuspid valve. Because blood cultures were sterile after 10 days and no vegetation was revealed, the Duke criteria were not fulfilled. In March 2012, the patient returned with congestive heart failure, fatigue, and anorexia. Echocardiography evaluation then revealed attached septal tricuspid valve vegetation. The Duke criteria were now satisfied. The patient received antibiotics at doses recommended for infective endocarditis, with a favorable outcome.

Isolated tricuspid valve endocarditis

We present two non-HIV-infected patients with isolated native non-rheumatic tricuspid valve endocarditis who were not intravenous drug abusers. The patients presented with fever and chills. Plain radiography or high-resolution computed tomography of the chest revealed consolidation or infiltrate of the left parenchyma in both patients. Large vegetation located on the tricuspid leaflets was detected by transesophageal echocardiography. Staphylococcus aureus grew in two out of three blood cultures for one patient. Tricuspid valve endocarditis imitates illnesses with fever and pulmonary symptoms or signs of acute or chronic onset, and might be present even without abnormal chest X-rays or intravenous drug addiction.