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Unusual case of tricuspid valve endocarditis Rajasekhar et al.

Corresponding Author: Dr D. Rajasekhar, Dean, Professor and Head , Department of Cardiology, Sri VenkateswaraInstitute of Medical Sciences, Tirupati 517507, India. e-mail: sarathpgi@gmail.com

Received: 12 March, 2012.

INTRODUCTIONRight-sided infective endocarditis (IE) is commonwith intravenous drug use (IVDU) and accountsfor 35%-60% of endocarditis cases in thispopulation; tricuspid valve is most often involved.1

Additional risk factors that have been describedfor tricuspid valve endocarditis include abdominalsurgery, incomplete abortion, liver disease andcancer.2 Staphylococcus aureus is the infectingorganism in the majority (80%) of cases withtricuspid valve endocarditis. When S. aureus isinvolved, the course of the disease is commonlyacute and rapidly progressive.3 Prior to theincrease in the prevalence of IVDU observed inthe recent past, right-sided IE was rare andoccurred almost exclusively in patients with cardiacmalformations. According to current estimates only5%-10% of right-sided IE occurs in patientswithout IVDU.

CASE REPORTA nine-year-old male child with a normal birthand developmental history, presented with ahistory of fever 2 month ago that lasted for about15 days and was treated at a local hospital withintravenous injections from which he apparentlyrecovered. No other records were availablepertaining to this episode. Subsequently, he had arecurrence of high grade fever associated withcough, purulent expectoration and breathlessness.

At admission, the child was febrile and toxic. Hewas haemodynamically stable. There were no skinor mucosal stigmata of endocarditis orvenipuncture marks. Respiratory systemexamination was suggestive of right-sided lowerlobe consolidation. On cardiovascular systemexamination, a systolic murmur suggestive oftricuspid regurgitation was present.Laboratory examination showed normocyticanaemia (haemoglobin 10.3 g/dL), leukocytosis(total leukocyte count 10,800/mm3) withneutrophilia (polymorphs 85%) and normal renaland liver function tests. Erythrocyte sedimentationrate (ESR) at the end of the first hour was elevated(90 mm). Serological tests for humanimmunodeficiency virus (HIV) and hepatitis Bsurface antigen (HBsAg) were negative. Chestradiograph (Figure 1) showed bilateral basal

Case Report:An unusual case of native tricuspid valve endocarditis and sepsis in a child

with structurally normal heart mimicking bronchopneumoniaD. Rajasekhar, V. Vanajakshamma, C. Shashanka, M.L. Srinivas Kumar, D. Sarath Babu

Department of Cardiology, Sri Venkateswara Institute of Medical Sciences, Tirupati

ABSTRACTRight sided infectious endocarditis (IE) by involvement of tricuspid valve is mainly associated with cardiac malformationsor intravenous drug use. Occurrence of right-sided IE in children with structurally normal heart is exceptionallyrare. Wereport the case of 9-year-old child presenting with bronchopneumonia and septicaemia who was diagnosed to havenative tricuspid valve staphylococcal endocarditis and was successfully treated.

Key Words: Tricuspid valve endocarditis, Native valve endocarditis, Endocarditis in children

Rajasekhar D, Vanajakshamma V, Shashanka C, Srinivas Kumar ML, Sarath Babu D. An unusual case of nativetricuspid valve endocarditis and sepsis in a child with structurally normal heart mimicking bronchopneumonia. JClin Sci Res 2012;1:97-100.

Figure 1 : Chest radiograph (postero-anterior view)showing bilateral parenchymal lessions suggestiveof bronchopneumonia

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parenchymal lesions, more on the right-sidesuggestive of bronchopneumonia. Ultrasonographyof the abdomen was normal. Staphylococcusaureus was grown in all three blood cultures.Sputum culture and urine culture were negative forany growth. Transthoracic echocardiography wasnormal except for a mobile, 6 x 4 mm, filiformvegetation on the septal leaflet of the tricuspid valve(Figure 2). There were no signs of vegetations inthe mitral, aortic or pulmonary valves, and thesewere all normal. These findings were confirmedon transoesophageal echocardiography.

A diagnosis of native tricuspid valve,staphylococcal endocarditis with septic pulmonaryembolism was made and the patient was startedon intravenous ceftriaxone therapy as per cultureand sensitivity, for 28 days. The patient becameafebrile, his general condition improved andsubsequent chest radiographs showed completeclearance of parenchymal opacities (Figure 3).Repeat blood cultures were negative. Follow-upechocardiography showed a reduction in the sizeof the vegetation and increase in echogenicityindicating healing (Figure 4).

DISCUSSIONIsolated occurrence of native tricuspid valveendocarditis in subjects without underlying valvularheart diseases, central venous lines or IVDU non-addicted patients is an elusive disease which mimicsseveral other illnesses. In children with normalhearts tricuspid valve endocarditis is an extremelyuncommon disease. There are only five suchreported cases in published literature in the

paediatric age group.4 Intracardiac and intravenouscatheters, abdominal surgery andhyperalimentation are predisposing factors forhospital-acquired right-sided endocarditis,whereas dental and cutaneous infections,alcoholism, liver disease, colon cancer and colonicprocedures were identifiable risk factors incommunity-acquired cases with right-sidedendocarditis.

Often, pulmonary rather than cardiacmanifestations are usually the predominant clinicalfeatures of tricuspid valve endocarditis. Symptomsarising from pneumonia or septic pulmonaryemboli from dislodged vegetations are common.The clinical presentation usually consists ofpersistent fever associated with pulmonarymanifestations, anaemia and microscopic

Figure 2 : Echocardogram (4-chamber view) showingmobile vegetation on the septal leaflet of tricuspidvalve

Figure 4 : Echocardogram (4-chamber view) at thetime of discharge showing significant decrease in thesize, mobility and increase in the intensity ofvegetation suggestive of healing endocarditis

Figure 3 : Chest radiograph (postero-antenor view)obtained at the time of discharge showing completeresolution of bronchopneumonia

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hematuria, signs that constitute the "tricuspidsyndrome".2 The absence of peripheral stigmataof endocarditis or relevant murmurs in the majorityof cases is noteworthy. Right-sided endocarditisinvolving the tricuspid valve should be included inthe differential diagnosis of patients withstaphylococcal or streptococcal bacteraemiaaccompanied by clinical and or radiological signsof pulmonary involvement. Even in the absence ofclassic predisposing risk factors for right-sidedendocarditis, a diagnosis of right-sided endocarditisshould be considered and echocardiographyshould be promptly carried out to document thepresence of vegetation .4

The microbial etiology of endocarditis depends onthe anatomic location of the lesion and thepredisposing factors. Staphylococcus aureus is themost common microorganism causing tricuspidvalve endocarditis; accounting for 50%-80% ofall cases.5 Other pathogens implicated asaetiological agents include Streptococcus spp.,Gram-negative bacilli (especially Pseudomonasaeruginosa) and Candida species.6 AlthoughStreptococcus species may result in right-sidedendocarditis in combination with a left-sidedendocarditis, in patients with a history of IVDU orcardiac abnormalities, only a few cases of isolatedtricuspid valve endocarditis are described inpatients without cardiac abnormalities or IVDU.Similar to the situation in adults, aetiologicorganisms are also likely to shift towards thosewith a predilection for prosthetic material(Staphylococcus epidermidis) and repeatedinterventions (Staphylococcus aureus).

In a recently published series,6 20% of IE occurredin children with no known predisposing factors; infive of the six children, the organism wasStaphylococcus aureus. This emphasiz es thepotential threat of this organism even in patientswith structurally normal hearts. In persons withoutIVDU, endocarditis arising from Staphylococcusaureus primarily involves the left-side of the heartand is associated with mortality rates ranging from25% to 40%. Staphylococcus aureus endocarditisin IVDU often involves the tricuspid valve. Curerates for right-sided Staphylococcus aureusendocarditis in IVDUs are high (>85%) and may

be achieved with relatively short courses oftreatment (< 4 weeks). Weight of evidencesuggests that parenteral β-lactam short-coursetherapy, with or without aminoglycoside, isadequate for the treatment of uncomplicatedoxacillin-sensitive or community acquiredStaphylococcus aureus right-sided IE.7

Interestingly, our patient presented with pleuro-pulmonary symptoms after a period ofhospitalisation for fever. Our patient did not haveany other classic risk factors for tricuspid valveendocarditis. The portal of entry of Staphylococcusaureus is not clear, though cutaneous route due tointravenous cannulation can be speculated.Superficial skin sepsis due to the multipleintravenous injections the patient had receivedmight have also been the possible source.

As in any case with IE, the clinical picture, positivefindings on blood culture and echocardiographyare the main diagnostic tools in native tricuspidvalve IE. The diagnosis of tricuspid valveendocarditis is often delayed because the cardiacmanifestations are subtle and the murmur oftricuspid regurgitation is inconspicuous. It has beensuggested that in every child with acutestaphylococcal sepsis and no obvious primaryfocus, early 2D echocardiography should becarried out particularly if the fever does not abatedespite antibiotic therapy.7-9

Early surgical management was not considered inour patient because of the good response toantibiotic therapy. In patients with tricuspid valveendocarditis surgical excision of the vegetationswith or without prosthetic valve replacement isindicated in the presence of vegetations larger than1 cm, congestive heart failure or coexistent left-sided endocarditis and is probably needed in 25%of adult patients. Only one of the reported fivepaediatric patients with tricuspid valve endocarditiswas successfully managed by medical treatmentalone whereas the remaining four had alsoundergone surgery (subtotal excision in 2 cases,valve replacement in 2 cases) with three of themsurviving.4 If appropriate culture and sensitivity dataare available, conservative therapy preserving the

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native valve should translate into improved latesurvival, freedom from re-operation and functionaloutcomes.10

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Maheshwari P, Freels S. Clinical features, site ofinvolvement, bacteriologic findings, and outcome ofinfective endocarditis in intravenous drug users. ArchInt Med 1995; 155:1641-8.

2. Nandakumar R, Raju G. Isolated tricuspidal valveendocarditis in nonaddicted patients: a diagnosticchallenge. Am J Med Sci 1997;314: 207-12 .

3. Shimoni Z, Pitlik S, Kravitz MS, Sagie A, Bishara J.Tricuspid valve endocarditis in adult patients withoutknown predisposing factors. Eur J Clin MicrobiolInfect Dis 2001;20:49-51.

4. Karthikeyan G, Nalini P, Sethuraman KR. Tricuspidvalve endocarditis in a child with structurally normalheart. Indian Pediatrics.1998;33: 692-4.

5. Shimoni Z, Pitlik S, Szyper-Kravitz M, Sagie A, BisharaJ. Tricuspid valve endocarditis in adult patientswithout known predisposing factors. Eur J ClinMicrobiol Infect Dis 2001;20:49-51.

6. Spoladore R, Agricola E, D'Amato R, Durante A,Fragasso G, Margonato A. Isolated native tricuspid

valve endocarditis due to group A beta #hemolyticStreptococcus without drug addiction. J CardiovascMed (Hagerstown) 2010 Jul 27, (Epub ahead of print).

7. Baddour LM, Wilson WR, Bayer AS, Fowler VG Jr,Bolger AF, Levison ME, et al. Diagnosis, antimicrobialtherapy, and management of complications: astatement for healthcare professionals from theCommittee on Rheumatic Fever, Endocarditis, andKawasaki Disease, Council on CardiovascularDisease in the Young, and the Councils on ClinicalCardiology, Stroke, and Cardiovascular Surgery andAnesthesia, American Heart Association; InfectiousDiseases Society of America. Circulation2005;111:e394-434.

8. Musewe NN, Hecht BM, Hesslein PS, Rose V,Williams WG. Tricuspid valve endocarditis in twochildren with normal hearts: diagnosis and therapyof an unusual entity. J Pediatr 1987;110:735-8.

9. Tornos MP, Castro A, Toran N, Girona J. Tricuspidvalve endocarditis in children with normal hearts. AmHeart J 1989;118:624-5.

10. Hickey E J, Jung G, Manlhiot C, Sakopoulos AG,Caldarone CA, Coles JG, et al. Infective endocarditisin children: native valve preservation is frequentlypossible despite advanced clinical disease. Eur JCardiothoracic Surg 2009;35:130-5.

Unusual case of tricuspid valve endocarditis Rajasekhar et al.