Pulmonic valve endocarditis in a normal heart

Abstract

The patient was a 55-year-old man admitted for acute parotitis approximately 1 month after dental extraction of decayed teeth for which he had received prophylactic antibiotics. On admission to an outside hospital, he had fever, trismus, an elevated white blood cell count, and blood cultures positive for Streptococcus viridans. A transthoracic echocardiogram (TTE) revealed normal findings. He was transferred to our institution where he underwent operative drainage of a masseter muscle abscess and broad-spectrum antibiotics were administered. A repeated TTE produced negative results. The patient improved clinically after surgical drainage but because of the risk of bacterial endocarditis, a transesophageal echocardiogram (TEE) was performed 5 days after the second TTE. It revealed a 1.- 1-cm mass attached to the arterial surface of the pulmonic valve (PV) (Figures 1 and 2). The rest of the examination revealed normal findings. He was treated with 4 weeks of intravenous antibiotics with resolution of his PV mass and a complete return to his former state of good health. The first PV vegetation was reported in 1977 in a patient with a history of intravenous drug use. 1 Since that time, echocardiography has dramatically improved the physician’s ability to diagnose PV endocarditis before autopsy. The PV is rarely involved in subacute bacterial endocarditis, being present in less than 2% of autopsies performed for suggested endocarditis. 2 Significant risk factors include intravenous drug use and congenital heart disease, but also alcoholism, sepsis, and central line infection. Clinical presentation is often subtle but may include pleural effusion, pneumonia, or pulmonary infarction from vegetation emboli. Although a murmur of pulmonic regurgitation is often present, it develops late in the disease. Staphylococcus aureus is the most common organism isolated, although a variety of culprits have been identified.