septic thrombophlebitis causing pulmonary valve ......11.park h e, cho g, kim h, kim y, sohn d....
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Septic Thrombophlebitis Causing Pulmonary Valve Endocarditis and
Septic Pulmonary Emboli: A Rare and Troublesome Trifecta
Journal of Cardiology & Clinical Research
Cite this article: Lakkakula VM, Perke DA, Crook II JJ, Overly TL (2016) Septic Thrombophlebitis Causing Pulmonary Valve Endocarditis and Septic Pulmo- nary Emboli: A Rare and Troublesome Trifecta. J Cardiol Clin Res 4(6): 1076.
*Corresponding author
Perkel, David A, Department of Cardiology, University of Tennessee Medical Center, Knoxville, Tennessee. USA, Tel: 865-544-2800; Email:
Submitted: 10 August 2016
Accepted: 07 September 2016
Published: 09 September 2016
OPEN ACCESS
Case Report
Septic Thrombophlebitis Causing Pulmonary Valve Endocarditis and Septic Pulmonary Emboli: A Rare and Troublesome Trifecta Vamsee M. Lakkakula, David A. Perkel*, Jerry J Crook II, and Tjuan L. Overly Departments of Biology and Otolaryngology, University of Washington, USA
Abstract
Pulmonic valve endocarditis is a rare entity with a prevalence of 1.5-2.0% in all cases of endocarditis. As few as 45 cases were reported in patients with structurally normal hearts between 1960 and 2005. Several cases have been reported with unique etiologies and have been seen in patients with PDA, sickle cell, Valsalva sinus aneurysm, skin infection of the hallux, VSD, and following a pulmonary artery catheterization. We present a case of septic thrombophlebitis inducing pulmonary endocarditis and septic pulmonary emboli.
CASE DESCRIPTION Pulmonic valve endocarditis is a rare entity with a prevalence
of 1.5-2.0% in all cases of endocarditis. As few as 45 cases were reported in patients with structurally normal hearts between 1960 and 2005 [1-4]. Several cases have been reported with unique etiologies and have been seen in patients with PDA, sickle cell, Valsalva sinus aneurysm, skin infection of the hallux, VSD, and following a pulmonary artery catheterization [7-12]. We present a case of septic thrombophlebitis inducing pulmonary endocarditis and septic pulmonary emboli.
A 25-year-old female with history of IV drug abuse with a recent IV use to the left lower extremity was admitted with septic shock endorsing a 1-week history of fatigue, fevers, chills and left lower leg pain. Physical exam revealed a febrile, ill appearing female with a split S2 and lower extremity swelling with multiple ecchymoses. Broad spectrum antibiotic therapy was initiated along with intravenous vasopressors. Five temporally separated blood cultures were obtained and all were negative. Initial imaging showed diffuse left lower extremity deep vein thrombosis. CT angiogram on hospital day 2 revealed multiple septic emboli in the lungs. A three-dimensional transesophageal echocardiogram on hospital day 3 showed moderate pulmonic valve regurgitation. Mobile densities measuring approximately 2 cm were seen on the pulmonic valve visualized in multiple views. The vegetations were evident in the high esophageal and
transgastric views. Three dimensional images were obtained in the high esophageal view showing vegetations involving the right and non-coronary cusps. The echocardiographic findings with a predisposition (IVDA), fevers and vascular phenomena met the Duke criteria for a diagnosis of infective endocarditis. The patient clinically improved with intravenous antibiotic therapy, completing a 28 day course. Surgery was deferred given clinical response and likelihood of continuing intravenous drug abuse. A transthoracic echocardiogram was performed at one month follow up which did not show evidence of pulmonic valve vegetations. In addition, the pulmonic regurgitation improved from moderate to trace (Video 1). Systolic function and size of both ventricles remained normal.
DISCUSSION Pulmonic valve endocarditis may go undiagnosed for some
time due to its often indolent course. Because of non-specificity of symptoms and the lack of typical peripheral findings that as- sociated with left-sided endocarditis, the diagnosis of pulmonic valve endocarditis may be delayed for up to 6 months, with a mean of delay noted in one study of 65 days. [7]. Pulmonic valve endocarditis is rare compared with the other cardiac valves, and usually only seen in the setting of tricuspid endocarditis [7]. Causative organisms are similar to other valves with staphylococcus aureus being the most com mon microorganism detected in blood culture. Approximately 10% of reported cases
Central Bringing Excellence in Open Access
2/2J Cardiol Clin Res 4(6): 1076 (2016)
are culture negative [13,14]. The development of pulmonary valve endocarditis sparing the tricuspid valve complicated by septic pulmonary emboli following septic thrombophlebitis represents an unusual and interesting case. In culture negative endocarditis, parenteral antibiotic therapy is gener ally recommended for 4 to 6 weeks, while indications for surgery remain the same as for endocarditis of the tricuspid valve, i.e. locally invasive infections, including abscess formation, progressive valve obstruction, incompetence, and relapsing infection despite full-dose an tibiotic therapy. Studies have suggested that vegetation less than 1-2 cm long usually responds well to medical therapy, which occurred in this case [5,6]. Of importance, there is a surgical indication in patients with severe valve regurgitation and mobile vegetations greater than 10 mm to prevent emboli, although it is generally not advisable in the IV drug abuse population [15]. In our case, as the patient already demonstrated septic emboli, the decision was made to undergo a prolonged course of antibiotics in a controlled hospital setting. As three-dimensional echocardiographic technology continues to improve, there will likely be greater elucidation of the clinical picture of pulmonic valve endocarditis.
REFERENCES 1. Ramadan FB, Beanlands DS, Burwash IG. Isolated pulmonic valve
endocarditis in healthy hearts: a case report and review of the literature. Can J Cardiol. 2000; 16: 1282-1288.
2. Cassling RS, Rogler WC, McManus BM. Isolated pulmonic valve infective endocarditis: a diagnostically elusive entity. Am Heart J. 1985; 109: 558-67.
3. Nishida K, Fukuyama O, Nakamura DS. Pulmonary valve endocarditis caused by right ventricular outflow obstruction in association with sinus of valsalva aneurysm: a case report. J Cardiothorac Surg., 2008; 3: 46.
4. Schroeder RA. Pulmonic valve endocarditis in a normal heart. Journal of the American Society of Echocardiography. 2005; 18: 197-198.
5. Robbins MJ, Frater RW, Soeiro R, Frishman WH, Strom JA. Strom. Influence of vegetation size on clinical outcome of right-sided infective endocarditis. Am J Med. 1986; 80: 165-171.
6. Hecht SR, Berger M. Right-sided endocarditis in intravenous drug users: prognostic features in 102 episodes. Ann Intern Med. 1992; 117:560-566.
7. Tekin R, Acet H. An Unusual Case of Endocarditis: Isolated Pulmonary Valve Endocarditis in Patient With Patent Ductus Arteriosus. J Med Cases Journal of Medical Cases. 2012; 3: 340-343.
8. Glew T, Feliciano M, Finkielstein D, Hecht S, Hoffman D. Pulmonic Valve Repair in a Patient with Isolated Pulmonic Valve Endocarditis and Sickle Cell Disease. Case Rep Cardiol. 2015; 732073.
9. Nishida K, Fukuyama O, Nakamura DS. Pulmonary valve endocarditis caused by right ventricular outflow obstruction in association with sinus of valsalva aneurysm: A case report. Journal of Cardiothoracic Surgery. 2008; 3: 2008.
10. Moreira D, Correia E, Rodrigues B, Santos L, Capelo J, Abreu L, et al. Isolated pulmonary valve endocarditis in a normal heart. Revista Portuguesa De Cardiologia. 2012; 31: 615-617.
11. Park H E, Cho G, Kim H, Kim Y, Sohn D. Pulmonary Valve Endocarditis with Septic Pulmonary Thromboembolism in a Patient with Ventricular Septal Defect. J Cardiovasc Ultrasound. 2009; 17: 138-140.
12. Soding PF, Klinck JP, Kong A, Farrington M. Infective endocarditis of the pulmonary valve following pulmonary artery catheterisation. Intensive Care Medicine. 1994; 20: 222-224.
13. Cassling RS, Rogler WC, McManus BM. Isolated pulmonic valve infective endocarditis: a diagnostically elusive entity. Am Heart J. 1985; 109: 558-567.
14. Tariq M, Smego RA Jr, Soofi A, Islam N. Pulmonic valve endocarditis. South Med J. 2003; 96: 621-623.
15. Nishimura R A, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guytonet RA. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 129. 2014; 23: 2440-2492.
Lakkakula VM, Perke DA, Crook II JJ, Overly TL (2016) Septic Thrombophlebitis Causing Pulmonary Valve Endocarditis and Septic Pulmonary Emboli: A Rare and Troublesome Trifecta. J Cardiol Clin Res 4(6): 1076.
Cite this article
Video 1 3-dimensional transesophageal echo with an en-face view of the pulmonic valve from the pulmonary artery side showing vegetations on 2 leaflets of the pulmonic valve.
Abstract
Journal of Cardiology & Clinical Research
Cite this article: Lakkakula VM, Perke DA, Crook II JJ, Overly TL (2016) Septic Thrombophlebitis Causing Pulmonary Valve Endocarditis and Septic Pulmo- nary Emboli: A Rare and Troublesome Trifecta. J Cardiol Clin Res 4(6): 1076.
*Corresponding author
Perkel, David A, Department of Cardiology, University of Tennessee Medical Center, Knoxville, Tennessee. USA, Tel: 865-544-2800; Email:
Submitted: 10 August 2016
Accepted: 07 September 2016
Published: 09 September 2016
OPEN ACCESS
Case Report
Septic Thrombophlebitis Causing Pulmonary Valve Endocarditis and Septic Pulmonary Emboli: A Rare and Troublesome Trifecta Vamsee M. Lakkakula, David A. Perkel*, Jerry J Crook II, and Tjuan L. Overly Departments of Biology and Otolaryngology, University of Washington, USA
Abstract
Pulmonic valve endocarditis is a rare entity with a prevalence of 1.5-2.0% in all cases of endocarditis. As few as 45 cases were reported in patients with structurally normal hearts between 1960 and 2005. Several cases have been reported with unique etiologies and have been seen in patients with PDA, sickle cell, Valsalva sinus aneurysm, skin infection of the hallux, VSD, and following a pulmonary artery catheterization. We present a case of septic thrombophlebitis inducing pulmonary endocarditis and septic pulmonary emboli.
CASE DESCRIPTION Pulmonic valve endocarditis is a rare entity with a prevalence
of 1.5-2.0% in all cases of endocarditis. As few as 45 cases were reported in patients with structurally normal hearts between 1960 and 2005 [1-4]. Several cases have been reported with unique etiologies and have been seen in patients with PDA, sickle cell, Valsalva sinus aneurysm, skin infection of the hallux, VSD, and following a pulmonary artery catheterization [7-12]. We present a case of septic thrombophlebitis inducing pulmonary endocarditis and septic pulmonary emboli.
A 25-year-old female with history of IV drug abuse with a recent IV use to the left lower extremity was admitted with septic shock endorsing a 1-week history of fatigue, fevers, chills and left lower leg pain. Physical exam revealed a febrile, ill appearing female with a split S2 and lower extremity swelling with multiple ecchymoses. Broad spectrum antibiotic therapy was initiated along with intravenous vasopressors. Five temporally separated blood cultures were obtained and all were negative. Initial imaging showed diffuse left lower extremity deep vein thrombosis. CT angiogram on hospital day 2 revealed multiple septic emboli in the lungs. A three-dimensional transesophageal echocardiogram on hospital day 3 showed moderate pulmonic valve regurgitation. Mobile densities measuring approximately 2 cm were seen on the pulmonic valve visualized in multiple views. The vegetations were evident in the high esophageal and
transgastric views. Three dimensional images were obtained in the high esophageal view showing vegetations involving the right and non-coronary cusps. The echocardiographic findings with a predisposition (IVDA), fevers and vascular phenomena met the Duke criteria for a diagnosis of infective endocarditis. The patient clinically improved with intravenous antibiotic therapy, completing a 28 day course. Surgery was deferred given clinical response and likelihood of continuing intravenous drug abuse. A transthoracic echocardiogram was performed at one month follow up which did not show evidence of pulmonic valve vegetations. In addition, the pulmonic regurgitation improved from moderate to trace (Video 1). Systolic function and size of both ventricles remained normal.
DISCUSSION Pulmonic valve endocarditis may go undiagnosed for some
time due to its often indolent course. Because of non-specificity of symptoms and the lack of typical peripheral findings that as- sociated with left-sided endocarditis, the diagnosis of pulmonic valve endocarditis may be delayed for up to 6 months, with a mean of delay noted in one study of 65 days. [7]. Pulmonic valve endocarditis is rare compared with the other cardiac valves, and usually only seen in the setting of tricuspid endocarditis [7]. Causative organisms are similar to other valves with staphylococcus aureus being the most com mon microorganism detected in blood culture. Approximately 10% of reported cases
Central Bringing Excellence in Open Access
2/2J Cardiol Clin Res 4(6): 1076 (2016)
are culture negative [13,14]. The development of pulmonary valve endocarditis sparing the tricuspid valve complicated by septic pulmonary emboli following septic thrombophlebitis represents an unusual and interesting case. In culture negative endocarditis, parenteral antibiotic therapy is gener ally recommended for 4 to 6 weeks, while indications for surgery remain the same as for endocarditis of the tricuspid valve, i.e. locally invasive infections, including abscess formation, progressive valve obstruction, incompetence, and relapsing infection despite full-dose an tibiotic therapy. Studies have suggested that vegetation less than 1-2 cm long usually responds well to medical therapy, which occurred in this case [5,6]. Of importance, there is a surgical indication in patients with severe valve regurgitation and mobile vegetations greater than 10 mm to prevent emboli, although it is generally not advisable in the IV drug abuse population [15]. In our case, as the patient already demonstrated septic emboli, the decision was made to undergo a prolonged course of antibiotics in a controlled hospital setting. As three-dimensional echocardiographic technology continues to improve, there will likely be greater elucidation of the clinical picture of pulmonic valve endocarditis.
REFERENCES 1. Ramadan FB, Beanlands DS, Burwash IG. Isolated pulmonic valve
endocarditis in healthy hearts: a case report and review of the literature. Can J Cardiol. 2000; 16: 1282-1288.
2. Cassling RS, Rogler WC, McManus BM. Isolated pulmonic valve infective endocarditis: a diagnostically elusive entity. Am Heart J. 1985; 109: 558-67.
3. Nishida K, Fukuyama O, Nakamura DS. Pulmonary valve endocarditis caused by right ventricular outflow obstruction in association with sinus of valsalva aneurysm: a case report. J Cardiothorac Surg., 2008; 3: 46.
4. Schroeder RA. Pulmonic valve endocarditis in a normal heart. Journal of the American Society of Echocardiography. 2005; 18: 197-198.
5. Robbins MJ, Frater RW, Soeiro R, Frishman WH, Strom JA. Strom. Influence of vegetation size on clinical outcome of right-sided infective endocarditis. Am J Med. 1986; 80: 165-171.
6. Hecht SR, Berger M. Right-sided endocarditis in intravenous drug users: prognostic features in 102 episodes. Ann Intern Med. 1992; 117:560-566.
7. Tekin R, Acet H. An Unusual Case of Endocarditis: Isolated Pulmonary Valve Endocarditis in Patient With Patent Ductus Arteriosus. J Med Cases Journal of Medical Cases. 2012; 3: 340-343.
8. Glew T, Feliciano M, Finkielstein D, Hecht S, Hoffman D. Pulmonic Valve Repair in a Patient with Isolated Pulmonic Valve Endocarditis and Sickle Cell Disease. Case Rep Cardiol. 2015; 732073.
9. Nishida K, Fukuyama O, Nakamura DS. Pulmonary valve endocarditis caused by right ventricular outflow obstruction in association with sinus of valsalva aneurysm: A case report. Journal of Cardiothoracic Surgery. 2008; 3: 2008.
10. Moreira D, Correia E, Rodrigues B, Santos L, Capelo J, Abreu L, et al. Isolated pulmonary valve endocarditis in a normal heart. Revista Portuguesa De Cardiologia. 2012; 31: 615-617.
11. Park H E, Cho G, Kim H, Kim Y, Sohn D. Pulmonary Valve Endocarditis with Septic Pulmonary Thromboembolism in a Patient with Ventricular Septal Defect. J Cardiovasc Ultrasound. 2009; 17: 138-140.
12. Soding PF, Klinck JP, Kong A, Farrington M. Infective endocarditis of the pulmonary valve following pulmonary artery catheterisation. Intensive Care Medicine. 1994; 20: 222-224.
13. Cassling RS, Rogler WC, McManus BM. Isolated pulmonic valve infective endocarditis: a diagnostically elusive entity. Am Heart J. 1985; 109: 558-567.
14. Tariq M, Smego RA Jr, Soofi A, Islam N. Pulmonic valve endocarditis. South Med J. 2003; 96: 621-623.
15. Nishimura R A, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guytonet RA. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 129. 2014; 23: 2440-2492.
Lakkakula VM, Perke DA, Crook II JJ, Overly TL (2016) Septic Thrombophlebitis Causing Pulmonary Valve Endocarditis and Septic Pulmonary Emboli: A Rare and Troublesome Trifecta. J Cardiol Clin Res 4(6): 1076.
Cite this article
Video 1 3-dimensional transesophageal echo with an en-face view of the pulmonic valve from the pulmonary artery side showing vegetations on 2 leaflets of the pulmonic valve.
Abstract