ALL OVER THE PLACE: A CASE OF MULTIVALVULAR INFECTIVE ENDOCARDITIS

Abstract

SESSION TITLE: The Cardiac Intensivist 2SESSION TYPE: Rapid Fire Case ReportsPRESENTED ON: 10/18/2022 12:25 pm - 01:25 pmINTRODUCTION: Infective endocarditis (IE) is a feared outcome of intravenous drug use (IVDU) that carries significant mortality up to 30% within one year of diagnosis, directly correlating with the number of valves affected. Having four-valve IE is extremely rare, with only thirteen documented cases.CASE PRESENTATION: A 32-year-old female with a history of IVDU was admitted to our institution for a 5-day history of new-onset dyspnea, chest pain, and fevers. On admission, bedside echocardiography demonstrated a >1 cm mitral valve vegetation with valvular regurgitation. A computerized tomography (CT) of the chest and abdomen showed scattered pulmonary, hepatic, and renal septic emboli. Two sets of blood cultures were positive for Staphylococcus Aureus, and using Duke’s modified criteria, a diagnosis of IE was made. She was admitted to the Intensive Care Unit for acute hypoxic respiratory failure, acute metabolic encephalopathy, acute kidney injury, and severe sepsis. She was treated with intravenous fluids and empiric antibiotics with vancomycin and cefepime. A transthoracic echocardiogram (TTE) showed two vegetations localized in the mitral (1.9 cm x 1.9 cm) and aortic valves. A follow-up transesophageal echocardiogram (TEE) demonstrated additional vegetations in the tricuspid and pulmonic valves. A multidisciplinary approach was used, and a non-surgical path of management was implemented. Sensitivities showed that Staphylococcus aureus was resistant to vancomycin, and the patient was switched to daptomycin and ceftaroline. Her hospital course was complicated by rupture of the pulmonary septic emboli causing bilateral pneumothoraxes and pneumomediastinum. The patient ultimately recovered after completing antibiotic therapy, and a TEE showed resolution of all but the pulmonic valve vegetation.DISCUSSION: Methicillin-resistant Staphylococcus Aureus (MRSA) is the leading pathogen in the subpopulation of IE caused by IVDU, with one study showing MRSA as the culprit in up to 67% of those infected. Most cases of multivalvular IE found in the literature involve two valves whereas our case was a unique presentation with vegetations found on four valves. A review of the literature found that only 19% of IE cases are multivalvular and that this is associated with increased mortality with a survival rate of 83% at one year and 64.98% at 15 years. The study also showed that as the number of valves increases so does the risk of mortality. Consensus management of multivalvular IE is surgical intervention, however our case supports literature which states that a non-surgical approach may be non-inferior to the later. This non-surgical approach has been supported within the literature.CONCLUSIONS: In essence, this patient presentation shows the ability to treat multivalvular IE with a non-surgical approach appropriately with a positive outcome.Reference #1: Chambers HF, Korzeniowski OM, Sande MA. Staphylococcus aureus endocarditis: clinical manifestations in addicts and nonaddicts. Medicine . 1983;62(3):170-177.Reference #2: Khan I, Brookes E, Yaftian N, Wilson A, Darby J, Newcomb A. Multivalve Infective Endocarditis In Intravenous Drug Using Patients: An Epidemiological Study. QJM. Published online September 6, 2021. doi:10.1093/qjmed/hcab225Reference #3: Cahill TJ, Baddour LM, Habib G, et al. Challenges in Infective Endocarditis. J Am Coll Cardiol. 2017;69(3):325-344.DISCLOSURES: No relevant relationships by Benjamin CarmelNo relevant relationships by Davide FoxNo relevant relationships by Siddarth KathuriaNo relevant relationships by Nader LamaaNo relevant relationships by Jose LopezNo relevant relationships by Ana Martinez Nunez SESSION TITLE: The Cardiac Intensivist 2 SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: Infective endocarditis (IE) is a feared outcome of intravenous drug use (IVDU) that carries significant mortality up to 30% within one year of diagnosis, directly correlating with the number of valves affected. Having four-valve IE is extremely rare, with only thirteen documented cases. CASE PRESENTATION: A 32-year-old female with a history of IVDU was admitted to our institution for a 5-day history of new-onset dyspnea, chest pain, and fevers. On admission, bedside echocardiography demonstrated a >1 cm mitral valve vegetation with valvular regurgitation. A computerized tomography (CT) of the chest and abdomen showed scattered pulmonary, hepatic, and renal septic emboli. Two sets of blood cultures were positive for Staphylococcus Aureus, and using Duke’s modified criteria, a diagnosis of IE was made. She was admitted to the Intensive Care Unit for acute hypoxic respiratory failure, acute metabolic encephalopathy, acute kidney injury, and severe sepsis. She was treated with intravenous fluids and empiric antibiotics with vancomycin and cefepime. A transthoracic echocardiogram (TTE) showed two vegetations localized in the mitral (1.9 cm x 1.9 cm) and aortic valves. A follow-up transesophageal echocardiogram (TEE) demonstrated additional vegetations in the tricuspid and pulmonic valves. A multidisciplinary approach was used, and a non-surgical path of management was implemented. Sensitivities showed that Staphylococcus aureus was resistant to vancomycin, and the patient was switched to daptomycin and ceftaroline. Her hospital course was complicated by rupture of the pulmonary septic emboli causing bilateral pneumothoraxes and pneumomediastinum. The patient ultimately recovered after completing antibiotic therapy, and a TEE showed resolution of all but the pulmonic valve vegetation. DISCUSSION: Methicillin-resistant Staphylococcus Aureus (MRSA) is the leading pathogen in the subpopulation of IE caused by IVDU, with one study showing MRSA as the culprit in up to 67% of those infected. Most cases of multivalvular IE found in the literature involve two valves whereas our case was a unique presentation with vegetations found on four valves. A review of the literature found that only 19% of IE cases are multivalvular and that this is associated with increased mortality with a survival rate of 83% at one year and 64.98% at 15 years. The study also showed that as the number of valves increases so does the risk of mortality. Consensus management of multivalvular IE is surgical intervention, however our case supports literature which states that a non-surgical approach may be non-inferior to the later. This non-surgical approach has been supported within the literature. CONCLUSIONS: In essence, this patient presentation shows the ability to treat multivalvular IE with a non-surgical approach appropriately with a positive outcome. Reference #1: Chambers HF, Korzeniowski OM, Sande MA. Staphylococcus aureus endocarditis: clinical manifestations in addicts and nonaddicts. Medicine . 1983;62(3):170-177. Reference #2: Khan I, Brookes E, Yaftian N, Wilson A, Darby J, Newcomb A. Multivalve Infective Endocarditis In Intravenous Drug Using Patients: An Epidemiological Study. QJM. Published online September 6, 2021. doi:10.1093/qjmed/hcab225 Reference #3: Cahill TJ, Baddour LM, Habib G, et al. Challenges in Infective Endocarditis. J Am Coll Cardiol. 2017;69(3):325-344. DISCLOSURES: No relevant relationships by Benjamin Carmel No relevant relationships by Davide Fox No relevant relationships by Siddarth Kathuria No relevant relationships by Nader Lamaa No relevant relationships by Jose Lopez No relevant relationships by Ana Martinez Nunez