A RARE CASE OF RIGHT-SIDED TRICUSPID VALVE ENDOCARDITIS

Abstract

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Right-sided endocarditis is a well-known condition that occurs predominantly in intravenous drug users (IVDA) and patients with cardiovascular implantable electronic devices, central venous lines, and congenital heart disease. The objective of this report is to describe a rare case of right-sided endocarditis that leads to cardiogenic shock and death. CASE PRESENTATION: A 29-year-old caucasian male with a history of polysubstance abuse, acromioclavicular joint septic arthritis, status epilepticus secondary to cerebral septic emboli, presented to the emergency department with complaints of shortness of breath, generalized weakness, and malaise. He was noted to have significant respiratory distress requiring initially noninvasive mechanical ventilation, he was intubated due to worsening respiratory failure. Cardiovascular examination revealed a pansystolic murmur heard over the left parasternal border. Transthoracic echocardiogram showed severe tricuspid valve regurgitation and moderately dilated right ventricle with an ejection fraction of 63%. A transesophageal echocardiogram revealed severe 3+ to 4+ tricuspid valve regurgitation along with large vegetation on the anterior leaflet of the tricuspid valve measuring 2.2 cm x 0.8 cm. There is the involvement of the subvalvular apparatus with another large vegetation measuring 1.1 cm x 0.8 cm on the chordal apparatus (FIGURE 1). The patient was found to be in cardiogenic versus septic shock related to tricuspid valve recurrent infective endocarditis. Despite the patient being placed on intravenous antibiotics and two pressors he still continued to deteriorate. Discussion with the family decided to make the patient comfort-care. The patient ultimately expired. DISCUSSION: Right-sided infective endocarditis (RSIE) patients represent 5-10% of all infective endocarditis cases, making it a rare clinical entity. It is most commonly seen in patients with a history of IVDA; however, it is also seen in patients on dialysis, congenital heart disease, immunocompromised states patients, and patients who have an intracardiac device. The diagnosis of RSIE is often delayed due to its signs and symptoms relatively different than left-sided infective endocarditis which is the specific target of the modified duke's criteria. Common symptoms include cough, hemoptysis, dyspnea, chest pain, and persistent fever. The primary diagnostic modalities are echocardiography and positive blood cultures. The mainstay of medical treatment is antibiotics; however if refractory then surgery is indicated in cases of right-sided heart failure due to severe tricuspid regurgitation, persistent bacteremia, refractory to culture-directed antibiotics, and tricuspid valve vegetations greater than 20 mm in length. CONCLUSIONS: Clinicians should be aware of the variety of presentations a patient with suspected endocarditis could have as disease prognosis relies on a prompt diagnosis. REFERENCE #1: Narvaez Muñoz Adrian Fernando, Ibarra Vargas Daniela Albina. Right-Sided Infective Endocarditis, Infective Endocarditis, Peter Magnusson and Robin Razmi. IntechOpen. March 24th 2019 REFERENCE #2: Varona J., Guerra J. Tricuspid Valve Endocarditis in a Nonaddicted Patient Without Predisposing Myocardiopathy. Revista Española De Cardiología (English Edition) 2004;57(10):993–996. REFERENCE #3: Ye R., Zhao L., Wang C., Wu X., Yan H. Clinical characteristics of septic pulmonary embolism in adults: A systematic review. Respiratory Medicine. 2014;108(1):1–8. DISCLOSURES: No relevant relationships by Adeeb Alquthami, source=Web Response No relevant relationships by Nishad Barve, source=Web Response No relevant relationships by HANAD BASHIR, source=Web Response No relevant relationships by NICOLE LAO, source=Web Response No relevant relationships by Gauranga Mahalwar, source=Web Response