Right sided Infective Endocarditis

M. Banumathi

Physician Assistant, Kauvery Hospital, Cantonment, Trichy

Background

Right sided native valve Infective Endocarditis, refers to Infective Endocarditis involving Tricuspid or Pulmonic valves. Isolated right sided infective endocarditis accounts for 10% all infective endocarditis cases. Majority of these are due to IV drug use, implanted cardiac devices/ intra vascular devices or underlying right heart endocardial anomalies.

Here we present a case of right side native valve infective endocarditis not due to any of the causes stated above.

Case Report

  • A 35-Year-old female, Post-Partum, P4 L3, brought with a complaints breathing difficulty for 3 days.
  • H/o cough and cold X 5 days
  • H/o fever X 3 days
  • No H/o chest pain/headache/seizure/vomiting.

Medical and medication history

  • Post-partum status – P4 L3
  • Hypothyroidism – on drug
  • Gestational diabetes mellitus – on Insulin

On examination

  • Patient conscious, oriented, afebrile
  • PR – 106/min, BP – 130/90mmhg, SpO2 – 99% with 4 liters O2
  • CVS – S1S2 (+)
  • RS – Bilateral wheeze (+)
  • P/A – Distended
  • Uterus well contracted
  • L/E – Episiotomy wound minimal gaping noted
  • P/V – Lochia healthy
  • GRBS – 308mg/dl

Course in the Hospital

A 35 years old female, Postpartum status (POD-11), a known case of hypothyroidism, /P4 L3, GDM on insulin, , delivered by normal labor on 16.02.2024. She was received in ER with complaints of fever for 4 days, cough, breathing difficulty and abdominal distension. On arrival, patient was conscious, obeying. L/E; Episiotomy Wound-Minimal gaping noted. .

She had tachypnea and respiratory distress. Her initial assessment of lung by USG had features suggestive of acute lung injury. She was admitted in critical care unit.

Her blood investigations revealed elevated total count and procalcitonin, deranged electrolytes as well as renal parameters.

CT chest showed multifocal peribroncho vascular irregular nodules in both lungs, which was consistent with septic emboli. CT abdomen showed features of paralytic ileus of bowel.

Echo revealed Tricuspid Valve Vegetation with infective Endocarditis

Blood cultures were drawn ad she was started on empirical antibiotics, IV Fluids and NIV support.

Her vaginal swab and blood culture grew Methicillin sensitive staphylococcus aureus. Hence, culture specific antibiotics given.

Gradually patient improved clinically and laboratory tests were improving. She continued to have fever spikes.

Patient had increased abdominal distension due to increasing ascites.

On 07.03.2024 morning patient had tachyarrhythmia followed by cardiac arrest. Airway was secured and patient resuscitated successfully. ROSC obtained; all reversible causes were addressed. Patient connected to mechanical ventilation and ionotropic support was started. She developed severe LV dysfunction-and worsening acidosis.

CT Brain was done in view of encephalopathy, which showed no demonstrable acute lesion. General Condition of the patient worsened; she had refractory metabolic acidosis with renal failure. Her sensorium continued to remain poor. Persistent fever spikes were noted. EEG was abnormal. Patient probably had Hypoxic Ischemic Encephalopathy (HIE). MRI could not be done in view of hemodynamic instability.

She continued to worsen and had a cardiac arrest on 09.03.2024 at 09.25pm. In spite of resusciatative attempts patient succumbed to her illness and was declared dead on 09.03.2024 at 09:40pm.

Investigations

Abdomen Ultrasound Scan

  • Post-partum uterus with no evidence of retained products
  • Hepatosplenomegaly
  • Bilateral minimal pleural effusion

Vaginal swab aerobic culture

  • Escherichia coli
  • MSSA – Staphylococcus aureus.

Urine culture and sensitivity

  • Sterile

Blood culture and sensitivity

  • MSSA – Staphylococcus aureus.

Multislice CT – Abdomen and Pelvis – Report

  • Mild splenomegaly.
  • Post Partum status of uterus.

EEG Record

  • Abnormal record

Echocardiographic findings

  • Normal chambers dimension
  • Global hypokinesia of LV
  • Severe LV dysfunction (EF-30% )
  • Mild MR
  • TV Vegetation (+)
  • Mild TR / PAD (RVSP -36 + RAP)
  • Septate intact
  • No pericardial effusion / No Clot

 

Multislice CT Scan Chest plain study

  • Multifocal peribroncho vascular irregular nodules
  • In both lungs. – Likely infective etiology.-? Septic emboil.

Multislice CT Brain plain study

  • No demonstrable intracranial lesion.

CT – Brain

Conclusion

Tricuspid valve endocarditis is common in Intravenous drug abusers or from another source of infection. In this patient, she had puerperal sepsis where the patient’s high vaginal swab was positive for staphylococcus aureus which seeded into Tricuspid valve causing infective endocarditis. This lead to severe bacteremia and septic shock. Due to the severity and nature of disease, patient succumbed to her illness.

M. Banumathi
Physician Assistant

 

Nightingale Journals

Kauvery Hospital
Find Doctor
Book Appointment