An unusual case of infective endocarditis: Extension of a tricuspid valve vegetation into the left atrium through a patent foramen ovale

Abstract

T ricuspid valve endocarditis is a frequent complication of intravenous drug use (IVDU). An unusual case of tricuspid valve endocarditis with extension of a complicated mass into the left atrium through a patent foramen ovale (PFO) is reported. This complication was detected by transthoracic echocardiography and resolved within days of antibiotic treatment, leaving two residual tricuspid valve vegetations. CASE prESEntAtionA 37-year-old woman with a history of IVDU presented to the hospital with fever, hematuria and general malaise. She had been feeling unwell for one month before presentation and was experiencing persistent shortness of breath. The patient also described progressively increasing abdominal and neck pain. She had associated nausea, vomiting, fatigue and polyarthralgia, and had no known history of valve abnormality.On examination, the patient was febrile and was found to have a supine blood pressure of 111/67 mmHg with a sitting blood pressure of 90/57 mmHg. She had a heart rate of 130 beats/min and a respiratory rate of 22 breaths/min. She was hypoxic, and had diffuse abdominal, flank and costophrenic tenderness. Her jugular venous pulsation was elevated and she was found to have a grade 2/6 systolic murmur, loudest at the right upper sternal border, which had not been previously documented. No other stigmata of infective endocarditis were elicited on physical examination.Laboratory investigations revealed a white blood cell count of 16.5×10 9 /L (normal range 4.0×10 9 /L to 10.5×10 9 /L) and a hemoglobin level of 75 g/L (normal range 120 g/L to 160 g/L). Her creatinine was elevated at 353 µmol/L (normal is 80 µmol/L or lower). Her erythrocyte sedimentation rate was 140 mm/h (normal range 0 mm/h to 27 mm/h). A qualitative urine drug screen was positive for opiates, cocaine metabolites, cannabinoids and benzodiazepines.A transthoracic echocardiogram confirmed the suspicion of endocarditis (Figures 1 and 2). The patient had a large right atrial mass (40 mm in length) extending from the tricuspid valve to the atrial septum and then into the left atrium. The left atrial component of the mass was bulkier than the right atrial component and measured 20 mm × 6 mm. The mass appeared to cross the septum through a PFO. The mass was associated with severe tricuspid regurgitation, and there was moderate pulmonary hypertension with a pulmonary artery systolic pressure measured at 48 mmHg. Left and right ventricular size and systolic function were normal.Concurrently, the patient's blood cultures were positive for methicillin-sensitive Staphylococcus aureus. Computed tomography (CT) of the chest revealed the presence of bilateral pleural effusions and multiple areas of airspace disease suggestive of septic emboli.She was treated with fluid hydration, acetylsalicylic acid and intravenous cloxacillin 2 g every 4 h for eight weeks. Echocardiography conducted after seven days of treatment revealed significant improvement in the appearance of the tricuspid valve vegetation (Figure 3). The mass in the left atrium wa...

Vegetation Attached to the Left Interatrial Septal Surface at the Congenital Location of the Foramen Ovale: A Rare Occurrence

“…This vegetation or thrombus could have lodged into the foramen ovale and increased in size due to superimposed infection, thereby causing a temporary closure of the PFO. A similar phenomenon was discussed by Johri et al in their case report [7]. …”

Right and Left Sided Endocarditis with Systemic Embolization and Leptomeningeal Disease in a Young Intravenous Drug User

“…The outcomes and benefits of early surgical intervention versus late surgical intervention in patients with right and left sided valve involvement are yet to be reported, and this offers itself as a topic for future studies. The conundrum of antibiotic therapy (medical treatment) versus early surgical therapy in infective endocarditis remains enigmatic and thus requires careful clinical surveillance and close adherence to American College of Cardiology Guidelines for timing of surgery in native valve endocarditis [6].…”

Septic pulmonary and systemic embolism in tricuspid endocarditis

“…Similarly to the reported cases, transoesophageal colour Doppler echocardiography was helpful to detect the PFO, and successful treatment was achieved through PFO closure in our patient. In these patients, tricuspid regurgitation or pulmonary hypertension secondary to pulmonary embolism may have increased right atrial pressure, which promoted right-to-left shunting through the PFO 5 10 11. It remains uncertain if patients with tricuspid valve endocarditis and PFOs would benefit from defect closure, although it would prevent further embolic events and seeding.…”