Annals of Tropical Medicine and Public Health
Home About us Ahead Of Print Instructions Submission Subscribe Advertise Contact e-Alerts Editorial Board Login 
Users Online:4099
  Print this page  Email this page Small font sizeDefault font sizeIncrease font size
 


 
Table of Contents   
CASE REPORT  
Year : 2016  |  Volume : 9  |  Issue : 1  |  Page : 70-72
Tricuspid valve endocarditis with septic pulmonary embolism following induced abortion in an immunocompetent patient: A case report


Department of Medicine, Calcutta National Medical College, 24, Gorachand Road, Kolkata, West Bengal, India

Click here for correspondence address and email

Date of Web Publication22-Jan-2016
 

   Abstract 

Infective endocarditis (IE) is a life-threatening disease where infections most commonly involve heart valves but may occur at the site of a septal defect or chordate tendinea or on the mural endocardium. Infection of arteriovenous shunts, arterioarterial shunts (patent ductus arteriosus), or coarctation of the infective aorta are clinically and pathologically similar to IE. Conditions predisposing to native valve endocarditis are rheumatic heart disease (where the mitral valve is frequently involved followed by the aortic valve), congenital heart disease (commonly patent ductus arteriosus, ventricular septal defect, and bicuspid aortic valve), and intravenous (IV) drug abusers [tricuspid valve (TV) commonly involved followed by the mitral valve and the aortic valve]. We report a case of TV endocarditis in a 25-year-old female patient after induced abortion at 16 weeks of pregnancy presented with pyrexia of unknown origin (PUO) and septic pulmonary embolism. The patient presented with fever with chills and rigors 2 weeks after the induced abortion. She remained febrile for 1.5 months and did not respond to therapy. After subsequent investigations, she was found to have TV endocarditis. She was not an IV drug abuser and did not have any underlying cardiac anomaly or any cardiac prosthesis implantation, which are common causes of right-sided endocarditis. This patient had responded to injection ceftriaxone 1 g IV/twice a day (bd), injection vancomycin 500 mg IV/bd, and injection gentamycin 80 mg IV/bd for total 28 days and was discharged to follow-up.

Keywords: Abortion, infective endocarditis (IE), pulmonary embolism, tricuspid valve (TV)

How to cite this article:
Das BK, Chaudhuri I, Gajbhiye S. Tricuspid valve endocarditis with septic pulmonary embolism following induced abortion in an immunocompetent patient: A case report. Ann Trop Med Public Health 2016;9:70-2

How to cite this URL:
Das BK, Chaudhuri I, Gajbhiye S. Tricuspid valve endocarditis with septic pulmonary embolism following induced abortion in an immunocompetent patient: A case report. Ann Trop Med Public Health [serial online] 2016 [cited 2019 Nov 20];9:70-2. Available from: http://www.atmph.org/text.asp?2016/9/1/70/168708

   Introduction Top


Infective endocarditis (IE) is defined as an infection of the endocardial surface of the heart, which may include one or more heart valves, the mural endocardium, or a septal defect. [1] The prototype lesion of IE, the vegetation is a mass of platelets, fibrin microcolonies of microorganisms, and scant inflammatory cells. [2] Isolated tricuspid valve (TV) endocarditis accounts for 5-10% of cases of IE. [3] TV endocarditis is a frequent complication of intravenous drug use (IVDU) or any abnormality of the TV, mainly by Staphylococcus aureus. [1] We report the case of a previously healthy young woman, who was neither an intravenous (IV) drug user nor had any congenital heart disease, developed TV endocarditis after an induced abortion. This case exemplifies the need for strong suspicion for right-sided IE in patients presenting with pyrexia of unknown origin (PUO) or cardiorespiratory symptoms after gynecological interventions.


   Case Report Top


A 25-year-old female presented with fever for 1.5 months, pain in the abdomen for 1.5 months, right-sided chest pain, breathlessness, and cough with scanty expectoration for 2 weeks. Her fever started 2 weeks after an induced abortion, which was done at 16 weeks of gestation. The fever was low grade, intermittent in type for the initial 1 month, associated with anorexia, malaise, and weakness. Subsequently, the intensity of fever increased with a high rise of temperature. Then, she developed right-sided chest discomfort, cough with scanty mucus expectoration, and shortness of breath. She got admitted in a local hospital and was treated for 2 weeks but the symptoms did not subside and she was referred to our hospital. She did not give any history of purulent expectoration, yellowish discoloration of eyes and urine, arthritis, photosensitivity, oral ulcer, sore throat, and burning micturation.

On examination, she was anxious and ill. She had mild-to-moderate pallor and the jugular venous pressure was raised by 5 cm above the clavicle with prominent c-v waves. Her pulse rate was 100 bpm, regular, blood pressure was 100/70 mmHg, and respiratory rate was 24 breaths/min. There was no clubbing or icterus. Cardiovascular examination revealed ejection systolic murmur in the tricuspid area. Her respiratory system showed impaired percussion note and coarse crepitations in the right lower chest in midaxillary and subscapular lines. Abdominal examination revealed tender soft hepatomegaly 2 cm below the right costal margin, and there was no splenomegaly or lymphadenopathy. Gynecological examination revealed no obvious abnormality. Investigations showed hemoglobin of 8.5 g%, total leukocyte count of 12,900/cmm, platelets of 1 lac/cmm, and erythrocyte sedimentation rate of 65 mm in 1 h. Blood urea was 21 mg% and creatinine 1.8 mg/dL. Sodium level was 131 mEq/L and potasium level was 3.8 mEq/L. Arterial blood gas showed continuous hypoxemia for consecutive 3 days after admission. Liver function test was within the normal limit. X-ray of her chest [Figure 1] showed wedge-shaped opacity abating the right diaphragm with crowding of the right-sided ribs, suggesting Hampton Hump. Electrocardiogram showed sinus tachycardia. Three consecutive blood (aerobic and anerobic) cultures showed no growth. Echocardiogram [Figure 2] and [Figure 3] showed grade II tricuspid regurgitation and tricuspid leaflet vegetations, raised right ventricular systolic pressure (RVSP) was 40 mmHg. Computed tomography (CT) scan of the thorax [Figure 4], [Figure 5] and [Figure 6] showed ill-defined resolving inflammatory consolidation in the right lower lobe of the lung and cavitating lesions in the left upper lobe of the lung field posteriorly and apical region of the left lower lobe of the lung. Multidetector CT (MDCT) pulmonary angiogram [Figure 7] and [Figure 8] showed small mycotic aneurysm involving second order bronchi of the respiratory tract (RT) and lower branch of the pulmonary artery.
Figure 1: Chest x-ray posterioranterior (PA) view showing wedge-shaped opacity abating the right diaphragm with crowding of the right-sided ribs suggesting Hampton's sign

Click here to view
Figure 2: Two-dimensional echocardiography showing tricuspid leaflet vegetations

Click here to view
Figure 3: Two dimensional echocardiography showing tricuspid regurgitation

Click here to view
Figure 4: Showing ill-defined resolving inflammatory consolidation in the right lower lobe of the lung

Click here to view
Figure 5: Cavitating lesions in the left upper lobe of the lung field posteriorly

Click here to view
Figure 6: Cavitating lesions in the apical region of the left lower lobe of the lung

Click here to view
Figure 7: Showing small mycotic aneurysm involving second order bronchi of RS

Click here to view
Figure 8: Showing mycotic aneurysm involving lower branch of pulmonary artery

Click here to view



   Discussion Top


Right-sided endocarditis mainly affects IV drug users, although it can also be associated with the use of pacemakers or central venous catheters and cutaneous or gynecological infections or bacteremia in patients with congenital heart disease with left-to-right shunt. Septic pulmonary embolism is a common form of presentation. [3] TV involvement in our patient was due to the transmission of infection into the venous system through pelvic veins from a septic uterus. In such cases, right-sided valves being on the venous side of the heart are more prone to be seeded with microorganisms and develop endocarditis. The reported culprit organisms causing endocarditis associated with abortion and gynecologic interventions include Staphylococcus aureus, Streptococcus viridans, and Clostridium perfringens. [4] The incidence of IE after obstetrics and gynecological procedures is low, ranging 0.03-0.14 out of 1,000 deliveries. [5] The incidence is lower after abortions; it is estimated to be approximately one per one million abortions. [6] We conclude that the suspicion of IE should be kept in mind whenever a patient presents with diverse and confusing clinical features with a history of septic abortion or any gynecological intervention.

 
   References Top

1.
Brusch JL. Infective endocarditis and its mimics in the critical care unit. In: Cunha BA, editor. Infectious Diseases in Critical Care. 2 nd ed. New York, NY: Informa Healthcare; 2007. p. 261-2.  Back to cited text no. 1
    
2.
Keystone JS, Kozarsky PE. Health recommendations for international travel. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, editors. Harrison's Principles of Internal Medicine 18 th ed. New York: McGraw-Hill; 2012. p. 1042-51.  Back to cited text no. 2
    
3.
Ferri FF. Practical Guide to the Care of the Medical Patient. 6 th ed. St. Louis: Mosby; 2004.  Back to cited text no. 3
    
4.
Akram M, Khan IA. Isolated pulmonic valve endocarditis caused by group B streprococcus (Streptococcus agalactiae) - A case report and literature review. Angiology 2001;52:211-5.  Back to cited text no. 4
    
5.
Ward H. Hickman RC. Bacterial endocarditis in pregnancy. Aust N Z J Obstet Gynaecol 1971;11:189-91.  Back to cited text no. 5
    
6.
Henshaw S, Forrest JD, Sullivan E, Tietze C. Abortion in United States, 1978-1979. Fam Plann Perspect 1981;13:6-7, 10-8.  Back to cited text no. 6
[PUBMED]    

Top
Correspondence Address:
Indranil Chaudhuri
2/23, Oiabibitala 1st Bye Lane, Howrah - 711 104, West Bengal
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1755-6783.168708

Rights and Permissions


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *


    Abstract
   Introduction
   Case Report
   Discussion
    References
    Article Figures

 Article Access Statistics
    Viewed1545    
    Printed57    
    Emailed0    
    PDF Downloaded23    
    Comments [Add]    

Recommend this journal