Pulmonary valve endocarditis with septic pulmonary thromboembolism in a patient with ventricular septal defect

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.

Injection drug induced septic embolism—A growing concern

Septic pulmonary embolism is an obstruction of the pulmonary vasculature due to embolization of an infected thrombus. In many instances, the etiology is cardiac in origin, given the increased prevalence of intravenous drug users in the United States. This condition usually presents with fever, chest pain, dyspnea, and cough. In order to make the diagnosis, it is helpful to utilize tools like the modified Duke criteria when evaluating for infective endocarditis in the context of pulmonary emboli and septic shock. The gold standard method for establishing the diagnosis of this condition involves imaging modalities, including echocardiogram and computed tomography findings. This case report details a 36-year-old male with a history of drug abuse and hepatitis C, who was found to have an isolated vegetation on the pulmonic valve and septic pulmonary embolism. The patient experienced a rapidly deteriorating clinical course, however improved over the course of 2 weeks with supportive measures and appropriate antibiotic treatment. The purpose of this case report is to highlight the uncommon nature of pulmonary valve involvement in patients with infective endocarditis. Moreover, the goal of this report is to recognize the paralleled increase in septic pulmonary emboli with the rising incidence of patients using injectable opioids in the United States.

Septic pulmonary emboli in pulmonary valve endocarditis with concurrent ventricular septal defect and coronary artery disease: a case report

Background

Infective endocarditis (IE) is one of the common causes of life-threatening infections. Compared to left-sided endocarditis, right-sided infective endocarditis is rarer, with pulmonary valve endocarditis much rarer than the tricuspid valve. Its diagnosis poses a challenge, owing to its rarity, low index of clinical suspicion, and lack of availability of appropriate diagnostic measures. Risk factors include indwelling central venous catheter, sepsis, intravenous drug use, pacemaker with lead infection, or ventricular septal defect (VSD).

Case summary

We describe a case of pulmonary valve endocarditis that led to septic pulmonary emboli in a patient scheduled for elective bypass surgery for triple vessel disease. There was an incidental finding of VSD on echocardiography, which is also a risk factor for pulmonary valve endocarditis owing to the jet of VSD to the pulmonary valve. The patient was given 4 weeks of antibiotics and subsequently underwent coronary artery bypass graft, pulmonary valve replacement, and VSD closure.

Discussion

Our case demonstrated the importance of high clinical suspicion and vigilance of diagnosing pulmonary valve endocarditis when dealing with pyrexia of unknown origin in a patient with a congenital VSD as VSD-associated pulmonary valve endocarditis remained a rare disease. Besides, an active search for clinical and radiological signs of pulmonary embolization is necessary in patients with right-sided endocarditis especially those with large and mobile vegetation. A conservative approach or valve repair is recommended for most patients with right sided IE affecting the tricuspid or pulmonary valve.

A rare case of pulmonary valve infective endocarditis in a patient with ventricular septal defect

Right-sided infective endocarditis (IE) is rare and often affects the tricuspid valve. We report a unique case of pulmonary valve IE in a patient with a predisposing congenital heart defect – a ventricular septal defect (VSD). A 23-year old man with a VSD was admitted following 3 months’ history of fever and malaise. An initial transthoracic echocardiogram (TTE) failed to reveal any visible vegetations or mass. However, blood cultures revealed persistent methicillin-sensitive S taphylococcus aureus (MSSA). A transoesophageal echocardiogram (TOE) showed multiple hyperechoic structures in the entirety of the anterior cusp of the pulmonary valve, suggestive of vegetations. In view of his young age and subacute presentation, a trial of prolonged antibiotics was opted for. The patient was commenced on intravenous cloxacillin for 6 weeks, which was successful. Common risk factors for right-sided IE include intravenous drug abuse, central venous catheterization and alcoholism. Less common risk factors include left-to-right shunts, including VSD. Proposed mechanisms include turbulent jet flow causing damage to the valve and vegetation formation. Although response to antibiotics and prognosis in right-sided IE tend to be better than in left-sided IE, surgical intervention may still be indicated, and unfortunately, evidence remains scarce on the appropriate patient selection for surgical intervention. Isolated pulmonary valve IE due to predisposing VSD remains a rare entity. It is important to consider this diagnosis in prolonged pyrexia of unknown origin in individuals with known congenital heart defects.

Rare case report of infective endocarditis due to Kocuria kristinae in a patient with ventricular septal defect

Background

Infective endocarditis (IE) is an uncommon but life-threatening infection. It is commonly associated with diseased or damaged valves. Patients with congenital heart disease are more prone to getting IE than the general population. The typical organisms that cause IE include Staphylococcus, Coagulase-negative Staphylococcus, Streptococcus viridians and Enterococci. However, the importance of rare micro-organisms like Kocuria kristinae should not be underestimated especially when isolated from multiple blood cultures in patients suspected of IE.

Case presentation

We report a rare case of right-sided infective endocarditis due to K. kristinae in a young non-diabetic, non-addict female of low socioeconomic class who presented with undiagnosed fever for 1 year. She was investigated and treated for fever by several general practitioners without relief. Later on, she was diagnosed by a local cardiologist to have perimembranous ventricular septal defect with a small pulmonary valve vegetation. She was referred to a tertiary care cardiac hospital in Rawalpindi, Pakistan for further management. Transthoracic and transesophageal echocardiography confirmed IE secondary to preexisting congenital heart disease complicated with a small pulmonary vegetation. Her blood cultures yielded growth of K. kristanae, a rare micro-organism to cause IE. The patient responded to the antibiotic therapy.

Conclusion

Clinicians should have a high index of suspicion for K. kristanae IE as a possible cause of a prolonged fever especially in the presence of congenital heart disease. Antibiotic susceptibility is required for adequate therapy.

Surgical Treatment of Infective Endocarditis in Pulmonary Position-15 Years Single Centre Experience

Background and Objectives: Infective endocarditis in the pulmonary position is a rare disease. Isolated pulmonary valve endocarditis is extremely rare. The aim of our study was to assess patients who were treated surgically for pulmonary endocarditis at our institution from January 2003 to December 2017. Materials and Methods: We analyze eight cases of infectious endocarditis in pulmonary position out of 293 patients who were operated for infective endocarditis (2.7%, 8/293). Only two of these eight patients were not related to congenital heart malformation. They were followed for early and late mortality, long-term survival, postoperative morbidity and reoperations. Results: Among six patients suffering from congenital heart disease, four patients underwent corrections of pulmonary valve malformation previously, and their infected grafts were replaced by two allografts and two xenografts. The two other patients had replaced their infected pulmonary valves with allografts. Two non-congenital patients with pulmonary valve endocarditis underwent valve replacement with biological prosthesis. All patients survived the early postoperative course. The mean follow-up time was 9.1 (interquartile range (IQR), 5.3-12.6) years. The long-term follow-up included seven patients. One patient (12.5%, 1/8) died more than 4 years after the surgery due to sepsis. Pulmonary endocarditis was the rarest endocarditis treated surgically (p < 0.001). Conclusion: Surgery for infective endocarditis in the pulmonary position (IEPP) is an effective method of treatment with excellent early outcome and good late results despite a very uncommon pathology and few operations being performed. Surgery performed earlier may make the procedure less radical.

Large septic pulmonary embolus complicating streptococcus mutans pulmonary valve endocarditis

Large septic pulmonary embolus is a rare finding in right-sided endocarditis. The entity represents a challenging diagnosis due to its variable and nonspecific clinical and radiological presentation and similarities with other conditions. We present a case of a 41 year-old woman who developed a large main pulmonary artery embolus and bilateral cavitary lung nodules in the setting of severe sepsis. Pulmonary artery exploration and clot retrieval ultimately revealed a large septic embolus from Streptococcus mutans native pulmonary valve endocarditis. The diagnosis of septic pulmonary emboli from right-sided endocarditis should be considered in patients with ancillary findings of septic embolic phenomenon, particularly the presence of multifocal cavitary nodules and in the setting of appropriate predisposing factors.

Cardiac septic pulmonary embolism: A retrospective analysis of 20 cases in a Chinese population

Based on the source of the embolus, septic pulmonary embolism (SPE) can be classified as cardiac, peripheral endogenous, or exogenous. Cardiac SPEs are the most common.We conducted a retrospective analysis of 20 patients with cardiac SPE hospitalized between 1991 and 2013 at a Chinese tertiary referral hospital.The study included 14 males and 6 females with a median age of 38.1 years. Fever (100%), cough (95%), hemoptysis (80%), pleuritic chest pain (80%), heart murmur (80%), and moist rales (75%) were common clinical manifestations. Most patients had a predisposing condition: congenital heart disease (8 patients) and an immunocompromised state (5 patients) were the most common. Staphylococcal (8 patients) and Streptococcal species (4 patients) were the most common causative pathogens. Parenchymal opacities, nodules, cavitations, and pleural effusions were the most common manifestations observed via computed tomography (CT). All patients exhibited significant abnormalities by echocardiography, including 15 patients with right-sided vegetations and 4 with double-sided vegetations. All patients received parenteral antimicrobial therapy as an initial treatment. Fourteen patients received cardiac surgery, and all survived.Among the 6 patients who did not undergo surgery, only 1 survived. Most patients in our cardiac SPE cohort had predisposing conditions. Although most exhibited typical clinical manifestations and radiography, they were nonspecific. For suspected cases of SPE, blood culture, echocardiography, and CT pulmonary angiography (CTPA) are important measures to confirm an early diagnosis. Vigorous early therapy, including appropriate antibiotic treatment and timely cardiac surgery to eradicate the infective source, is critical.

Healthcare-associated infective endocarditis of the pulmonary valve

We report a case of a 66-year-old man with known ischaemic heart disease, diabetes mellitus and stage 4 kidney disease who was admitted to our tertiary centre with shortness of breath and atrial flutter. Transoesophageal echocardiography (TOE) was without suspicion of endocarditis. During hospitalisation, the patient suffered a nosocomial infection in a peripheral vascular catheter caused by Staphylococcus aureus. TOE after positive blood cultures revealed a new vegetation on the pulmonary valve that resolved after antibiotic treatment.

Right-sided infective endocarditis: recent epidemiologic changes

BACKGROUND

Infective endocarditis (IE) has been increasingly reported, however, little is available regarding recent development of right-sided IE.

METHODS

Right-sided IE was comprehensively analyzed based on recent 5⅓-year literature.

RESULTS

Portal of entry, implanted foreign material, and repaired congenital heart defects were the main predisposing risk factors. Vegetation size on the right-sided valves was much smaller than those beyond the valves. Multiple logistic regression analysis revealed that predisposing risk factors, and vegetation size and locations were independent predictive risks of patients' survival.

CONCLUSIONS

Changes of right-sided IE in the past 5⅓ years included younger patient age, and increased vegetation size, but still prominent Staphylococcus aureus infections. Complication spectrum has changed into more valve insufficiency, more embolic events, reduced abscess formation, and considerably decreased valve perforations. With effective antibiotic regimens, prognoses of the patients seemed to be better than before.

Isolated pulmonary infective endocarditis with septic pulmonary embolism complicating a right ventricular outflow tract obstruction: scarce and devious presentation

We present a case of a fifty-three-year-old male who presented with severe sepsis. He had been treated as a pneumonia patient for five months before the admission. Investigations revealed isolated pulmonary valve endocarditis and septic pulmonary embolism in addition to undiagnosed right ventricular outflow tract (RVOT) obstruction. The patient underwent surgery for the relief of RVOT obstruction by substantial muscle resection of the RVOT, pulmonary artery embolectomy, pulmonary valve replacement, and reconstruction of RVOT and main pulmonary artery with two separate bovine pericardial patches. He was discharged from our hospital after 6 weeks of intravenous antibiotics. He recovered well on follow-up 16 weeks after discharge. A high-suspicion index is needed to diagnose right-side heart endocarditis. Blood cultures and transesophageal echocardiogram are the key diagnostic tools.