Septic Thrombophlebitis Causing Pulmonary Valve ......11.Park H E, Cho G, Kim H, Kim Y, Sohn D. Pulmonary Valve Endocarditis with Septic Pulmonary Thromboembolism in a Patient with
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.
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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