Tricuspid valve endocarditis in the drug addict: a reconstructive approach ("vegetectomy")

This report describes the case of a 24-year-old female heroin addict with large tricuspid valve vegetation, recurrent septic pulmonary emboli, and renal failure, due to immune-complex nephritis. The clinical course was initially complicated by acute hepatitis A. Because of recurrent emboli and persistent fever despite adequate antibiotic therapy she underwent excision of the vegetation ("vegetectomy") and tricuspid valvuloplasty. She was well at follow-up 12 months later with trivial tricuspid regurgitation shown by doppler-echocardiography. Kidney and liver function were normal. Right-heart endocarditis in drug addiction and therapeutic approaches are discussed. In selected cases "vegetectomy" and valvuloplasty offer a promising therapeutic alternative.     

Coagulase-negative staphylococcal endocarditis. Occurrence in patients with mitral valve prolapse

Although coagulase-negative staphylococci (CoNS) are frequent etiologic agents in prosthetic valve endocarditis, they rarely infect native heart valves. We report three cases of CoNS endocarditis in patients with mitral valve prolapse (MVP). Review of other reports of MVP-associated endocarditis and of the limited experience with CoNS infection of native heart valves suggests that our experience is not unique. Coagulase-negative staphylococcal endocarditis superimposed on MVP may be difficult to recognize and to treat. The cardiac dysfunction can be quite subtle, the clinical course indolent, the blood culture results difficult to interpret, and the response to antimicrobial agents suboptimal.     

Prosthetic valve endocarditis due to small-colony staphylococcal variants

Although Staphylococcus epidermidis is a major cause of prosthetic valve endocarditis, little is known about the pathogenesis of this disease. In one case described herein, small-colony variant forms of S. epidermidis were isolated from clinical specimens obtained from a patient with prosthetic valve endocarditis. Data from the rat model of experimental endocarditis provide further evidence that small-colony variants may be operative in the production of prosthetic valve infection. Moreover, a review of the literature indicates that small-colony variants could account for the subtle clinical course after prolonged dormant infection that characterizes S. epidermidis prosthetic valve endocarditis. It is therefore hypothesized that small-colony variants of S. epidermidis may play a role in the pathogenesis of prosthetic valve endocarditis.     

Candida albicans tricuspid valve endocarditis in an intravenous drug addict: successful treatment with fluconazole

An addicted, intravenous drug user was treated for Candida albicans tricuspid valve endocarditis with high dose fluconazole for 8 months, without relapse after 30 months.     

Association of bacterial endocarditis and alcoholic cirrhosis in 9 patients

Ten cases of bacterial endocarditis were observed in cirrhotic patients. In 7 cases, endocarditis was due to group D Streptococcus, 5 of which were Streptococcus D. bovis. Special features were the involvement of tricuspid valve and the involvement of two or more valves in 4 cases. Surgery was necessary in the acute phase in 5 patients: cure was definitely obtained in 8 cases after a particularly long interval. A colonic lesion could have been the portal of entry in some cases. Liver cirrhosis was considered as a predisposing factor for bacterial endocarditis, especially due to group D Streptococcus or to other bacteria of intestinal origin. This is probably related to the frequency of the colonic origin of group D Streptococcus endocarditis. Loss of filter function of the liver may partly explain the features of these forms of endocarditis.     

Pulmonary valve endocarditis caused by Streptococcus D bovis in a patient with a colorectal adenocarcinoma

A case of pulmonary endocarditis caused by Streptococcus D bovis in a female patient with colorectal adenocarcinoma is reported. The M-mode and two-dimensional echocardiographic and pulsed doppler ultrasound findings are described. A review of the literature shows that Streptococcus D bovis pulmonary endocarditis is rare. Any septicaemia or endocarditis caused by this organism calls for invasive exploration of the digestive tract, and especially the colon.     

Bacterial remnants in an aortic valve after treatment for staphylococcal endocarditis

A patient with staphylococcal endocarditis was treated for 6 weeks with high doses of nafcillin. Despite a prompt clinical response and bacteriologic cure, residual damage to the aortic valve led to severe congestive heart failure necessitating surgery. Valve tissue obtained at surgery was sterile, but organisms consistent with staphylococci were observed in the inflammatory infiltrate by light and electron microscopy.     

Mitral homograft in the tricuspid position, aortic homograft and mitral plasty in a drug addict with multiple valve endocarditis

The case is reported of multiple valve surgery using as little prosthetic material as possible in a drug addict with recurrent right and left bacterial endocarditis. The patient underwent aortic valve replacement with a cryopreserved aortic homograft, mitral repair and tricuspid valve replacement with a mitral homograft, using a modified technique. The indications and surgical options for tricuspid valve endocarditis in this patient group are discussed, with particular focus on technical aspects of using mitral homografts in the tricuspid position.     

Infective endocarditis in the narcotic addict

As long as the illicit use of heroin and other drugs continues in our society, infective endocarditis will remain a significant medical problem in the drug-using population. The majority of infections are produced by S. aureus, and the tricuspid valve is most commonly involved. Addicts, unlike the general population, may also develop endocarditis with a variety of gram-negative bacilli and have a higher incidence of fungal infection. The outcome of each individual infection is dependent on the prompt recognition of the underlying valvular infection and the institution of antimicrobial therapy. Infection of the tricuspid valve has a much more favorable prognosis than does infection of the aortic or mitral valves. Fungal endocarditis, and frequently gram-negative bacillary endocarditis, require valvular surgery to effect a cure.     

Pulmonary valve gonococcal endocarditis. A forgotten disease

Although gonococcal infections of the pulmonary valve were common before the introduction of antibiotics, such infections have rarely been reported since penicillin became available. In an elderly man with gonococcal endocarditis of the pulmonary valve the non-specific signs and symptoms, the late appearance of a pulmonary murmur, and the sterility of early blood cultures made the diagnosis unclear until three weeks after admission. Endocarditis was localised to the pulmonary valve by M-mode and cross-sectional echocardiography. Echocardiography may be useful for diagnosing endocarditis in patients with fever of unknown origin. Gonococcal infection should be suspected in patients with pulmonary vegetations and sterile blood cultures.