Actinomycotic Endocarditis of the Eustachian Valve: A Rare Case and a Review of the Literature

Abstract

Eustachian valve endocarditis caused byA ctinomyces species are anaerobic-to-microaerophilic bacteria that survive as normal flora within the mouth, bronchi, gastrointestinal tract, and female genital tract. These organisms are rarely associated with chronic pyogenic or granulomatous infections in the general population.1 Actinomycotic infections are generally limited to the cervicofacial (50%), pulmonary (15%), and intra-abdominal (20%) areas. Cardiac involvement is relatively rare; most infections occur by contiguous metastasis to the pericardium and very rarely by hematogenous metastasis to the cardiac valves.2 Infection of the eustachian valve (EV) by Actinomyces species is extremely rare, having (to our knowledge) been reported only once before. 3 We report a case of EV endocarditis caused by Actinomyces turicensis in an apparently healthy young woman, possibly transmitted by an intrauterine contraceptive device (IUD). In our accompanying review of the relevant literature, we discuss the predisposing factors, the clinical course, and the treatment of various actinomycotic and EV endocarditis. Case ReportIn September 2011, a 30-year-old woman was admitted with right upper quadrant pain and swelling of one week's duration. Her medical history included no recent dental work, no human immunodeficiency viral infection, and no history of intravenous drug use. She had undergone a cesarean section 2 years before presentation, after which an IUD had been placed. Physical examination at admission revealed a firm mass, slightly painful to the touch, in the right upper quadrant. Laboratory results showed marked leukocytosis. A transvaginal ultrasonogram and a computed tomogram revealed multiple large masses in the ovaries, pelvis, and liver that were suspect for extensive metastatic disease, presumably ovarian in origin. Histopathologic studies of tubo-ovarian (Fig. 1A) and liver (Fig. 1B) biopsy samples failed to reveal any malignant cells. Instead, they showed microabscesses with branching filamentous microorganisms consistent with Actinomyces species. The patient subsequently underwent an exploratory laparotomy, which revealed multiple pockets of pus with extensive inflammatory changes and fibrinous adhesions. Evacuation of pus was performed, along with total abdominal hysterectomy, right salpingo-oophorectomy, appendectomy, and lysis of adhesions. Cultures of fluid from both the abdominal cavity and the IUD grew A. turicensis. Multiple sets of blood cultures performed on the day of Case Reports

Intrauterine device infection causing concomitant streptococcal toxic shock syndrome and pelvic abscess withActinomyces odontolyticusbacteraemia

“…In the literature, there have been case reports of Actinomyces spp causing infectious endocarditis (IE), including A. israelii 40 41 and A. neuii 42. However, IE caused by A. odontolyticus has not been reported previously.…”

Actinomyces naeslundii: An Uncommon Cause of Endocarditis

“…Almost half of these patients were noted to have predisposing cardiac pathology. One recent report described a case of eustachian valve endocarditis caused by Actinomyces turicensis [28]. Four of the 20 patients who received therapy died from pulmonary edema and acute respiratory failure.…”

Right-Sided Infective Endocarditis

“…Reports of eustachian valve infective endocarditis (EVIE) are approximately 29 cases [43]. An incidence of 3.3% in patients with right-sided endocarditis has been reported [44].…”

“…Eustachian valve is a rudimentary structure in adults and, during fetal life, directs oxygenated blood from the inferior vena cava through the foramen ovale and into the left atrium [43,45].…”

“…IVDA is the main high-risk population to develop an EVIE (over 50% of cases). Staphylococcus aureus is the most common bacteria implicated in this process [43]. TOE is necessary to identify the vegetation at eustachian valve because this structure is not accessible with TTE [45].…”