Systemic septic emboli in tricuspid endocarditis due to an atrial communication with a right-to-left shunt

Abstract

We present the case of a patient admitted to hospital in septic shock. He had a history of tricuspid valve infective endocarditis (IE) 6 months prior and regularly injected intravenous drugs. A bedside echo on arrival confirmed vegetations on his tricuspid valve, torrential tricuspid regurgitation and signs of significantly raised right-sided pressures. The admission chest radiograph showed consolidative changes in the lungs, suggestive of septic pulmonary emboli. He was commenced on antibiotics and treated in the high-dependency unit. He subsequently developed an acutely ischaemic right foot and nasal tip. Suspicions were raised of a paradoxical septic embolus through a right-to-left shunt, subsequently confirmed on bubble echo which showed passage of agitated saline between the atria. This was not apparent clinically or on echocardiogram during his previous episode of tricuspid valve IE, raising the possibility of the development of an acquired inter-atrial communication since his previous episode.

Surgery for Tricuspid Valve Endocarditis in the Current Era

“…Large vegetations can lead to valvular obstruction or recurrent septic pulmonary embolization (Figure 1(A)) and hemoptysis or pulmonary abscesses (Figure 1(B)). This repeat pulmonary embolization can result in elevation of the right-sided pressures, which in the presence of atrial level shunting, can lead to systemic embolization as well [21]. In severe cases, abscess formation is not uncommon [22], so as varying degrees of atrioventricular block.…”

Hampton’s Hump: A Notable Radiographic Finding in a Patient with Infectious Endocarditis

“…Recognized risk factors include intravenous drug use (IVDU), chronic intravenous access, predisposing valvular pathology (e.g., prosthetic valve, mitral valve regurgitation, or aortic valve regurgitation), and invasive procedures within the previous 2 months [ 2 ]. IE rarely presents with the classic symptoms described in textbooks [ 2 ] and may instead present with a wide variety of nonspecific symptoms from dyspnea to altered mentation [ 3 ] or systemic paradoxical emboli with small foci of necrotic tissue [ 4 ]. As a result, physicians must maintain a high clinical suspicion to avoid missing the diagnosis.…”