Pulmonary Valve Endocarditis with Septic Pulmonary Thromboembolism in a Patient with Ventricular Septal Defect

Abstract

We describe a 42-year-old man who presented as life-threatening sepsis and septic shock with multiple septic pulmonary embolism and septic pneumonia due to pulmonary valve endocarditis. The patient had history of untreated ventricular septal defect (VSD) and complained of severe dyspnea and orthopnea. Transthoracic and transesophageal echocardiograms revealed severe pulmonary regurgitation with large, hypermobile vegetation on pulmonary valve and right ventricular outflow tract (RVOT), and a small subarterial type VSD. Emergency operation was done due to rapid deterioration of the patient, and after 6 weeks of antibiotics coverage, he was discharged. online © ML Comm L/min, at which oxygen saturation (SaO2) was 91%. The initial chest X-ray showed multifocal consolidation and grassground opacity (GGO) at both lung fields. Transthroacic echocardiogram revealed dilated right ventricle (RV) with hypertrophy and severe pulmonary regurgitation with large, hypermobile vegetation on pulmonary valve and right ventricular outflow tract (RVOT). The pulmonary valve was severely destructed, with almost invisible remnant functioning leaflet tissue, which accounted for the torrential pulmonary regurgitation (Fig. 1A). Other cardiac valves were clear, with normal morphology and function. Chest CT showed diffuse irregular thickening of pulmonary valve, multifocal pulmonary embolism and diffuse GGO with multifocal patchy and nodular consolidations at both lungs (Fig. 2). The clinical course of the patient progressed rapidly, with development of hypotension and rapid progression of hypoxia despite full oxygen and inotropics supplement. The patient monitor revealed SaO2 of 50% even at full oxygen support via facial mask and systolic blood pressure of 77 mmHg, and he was admitted to intensive care unit (ICU) after intubation. A portable transesophageal echocardiogram revealed a small ventricular septal defect with left to right shunt and multiple huge mobile echogenic mass at right ventricle side of VSD and RVOT (Fig. 1B). The patient was sent for emergency operation. A 0.8 cm-sized subarterial type VSD was repaired. Massive amount of vegetation and thrombus was found in RV and RVOT which extended to pulmonary valve and caused extensive valve destruction. The pulmonary valve was replaced with a mechanical valve. No bacteria was grown from the blood culture, but pathologic specimen of the tissue showed fibrinous exudates with colonies of numerous cocci and chronic active inflammation. A combination of ampicillin, nafcillin and gentamicin was continued, and at post-op day 5, the patient was transferred to sub-ICU. After 6 weeks of combination antibiotics therapy, the patient was discharged. A B D Di is sc cu us ss si io on nRight-sided endocarditis is relatively rare and mainly affects the tricuspid valve. Pulmonary valve endocarditis is even rarer than tricuspid valve endocarditis, and comprises less than 2% of hospital admissions for endocarditis. Different hemodynamic pressure gradients across the valves, different frequencies of ...

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Infective Endocarditis Complicated by Septic Pulmonary Emboli in a Case of a Ventricular Septal Defect

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