Tricuspid valve endocarditis with septic pulmonary embolism following induced abortion in an immunocompetent patient: A case report

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 2020 Dec 5];9:70-2. Available from: https://www.atmph.org/text.asp?2016/9/1/70/168708
Introduction

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

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

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Figure 2: Two-dimensional echocardiography showing tricuspid leaflet vegetations

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Figure 3: Two dimensional echocardiography showing tricuspid regurgitation

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

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Figure 5: Cavitating lesions in the left upper lobe of the lung field posteriorly

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Figure 6: Cavitating lesions in the apical region of the left lower lobe of the lung

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Figure 7: Showing small mycotic aneurysm involving second order bronchi of RS

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Figure 8: Showing mycotic aneurysm involving lower branch of pulmonary artery

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Discussion

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 aureusStreptococcus 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
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.
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.
3.
Ferri FF. Practical Guide to the Care of the Medical Patient. 6 th ed. St. Louis: Mosby; 2004.
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.
5.
Ward H. Hickman RC. Bacterial endocarditis in pregnancy. Aust N Z J Obstet Gynaecol 1971;11:189-91.
6.
Henshaw S, Forrest JD, Sullivan E, Tietze C. Abortion in United States, 1978-1979. Fam Plann Perspect 1981;13:6-7, 10-8.

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/1755-6783.168708

Figures

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

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