Hemolytic anemia in native valve infective endocarditis: a case report and literature review

Hemolytic anemia is a rare manifestation of infective endocarditis. A 19-year-old man with a small ventricular septal defect developed right-sided infective endocarditis with huge vegetations involving the tricuspid valve, the ventricular septal defect, and the pulmonary valve. Intravascular hemolysis was suggested by the presence of numerous fragmented erythrocytes, giant platelets and polychromasia of the red blood cells. The direct Coombs test was positive, and there were spherocytes and splenomegaly, findings that suggested an immune-mediated mechanism also played a role in the hemolysis. The hematological picture persisted despite antibiotic therapy and recovered only after surgical removal of the vegetations, tricuspid and pulmonary valvectomy, and patch closure of the ventricular septal defect.     

Endocardite infecciosa como primeira manifestação de cardiopatia congénita de apresentação tardia

A diagnosis of congenital heart disease is usually established at an early age, so infective endocarditis is a rare form of presentation.The authors describe the case of a male adolescent with a week-long history of intermittent fever and unquantified weight loss. Physical examination detected pansystolic and diastolic murmurs, and an associated precordial thrill. Laboratory tests showed evidence of an active infection. Etiological investigation revealed a perimembranous ventricular septal defect, aortic regurgitation, and aortic and mitral valve vegetations. A diagnosis of mitral-aortic infective endocarditis was made and he was started on intravenous antibiotics and anticongestive therapy. After initial clinical improvement, he developed symptoms and signs of congestive heart failure. Repeat echocardiography showed an extensive mitral-aortic paravalvular abscess. The antibiotics were changed and anticongestive therapy was intensified, and he subsequently underwent surgery. The outcome has been generally favorable, and at present he is asymptomatic under anticongestive therapy.     

Faux anévrisme de la voie d’éjection du ventricule droit compliquant une endocardite infectieuse après réparation d’une cardiopathie congénitale

A case of an enormous false aneurysm of the right ventricular outflow tract due to infective endocarditis is reported in a 12-year old girl who underwent Rastelli repair of congenital heart disease with reconstruction of the right ventricular outflow tract by bovine jugular vein graft (Contegra). The false aneurysm was associated to desinsertion of the patch of the ventricular septal defect and compresses the right ventricle leading to heart failure and shock. Surgical treatment was performed in emergency but the child died after surgery. Infectious false aneurysm of the right ventricle after surgical reconstruction of the right ventricular outflow tract is very rare. At our knowledge, only three cases have been reported in the literature. We report here another case.     

Streptococcus agalactiae endocarditis

Streptococcus agalactiae endocarditis is a rare clinical entity that is generally characterized by acute onset, the presence of large vegetations, rapid valvular destruction and frequent complications, particularly embolization. Mortality is high with medical therapy alone. The authors present a case report of Streptococcus agalactiae endocarditis in a young patient treated by prompt surgery. The literature is reviewed.     

Successfully treated triple valve infective endocarditis: a case report

A 45-year-old woman presented with triple valve infective endocarditis and ventricular septal defect. There were vegetations on the tricuspid valve, pulmonary valve, and aortic valve. She had multiple complications such as nephrotic syndrome, severe anemia, congestive heart failure, and convulsion. Her general condition was extremely poor. Intensive medical therapy, such as blood transfusion, mechanical ventilation, and continuous venovenous hemofiltration, allowed her to tolerate surgery. Triple valve replacement and ventricular septal defect closure was successfully performed without major complication. She was ambulatory at the time of discharge.     

Echocardiographic demonstration of free wall vegetative endocarditis complicated by a pulmonary embolism in a patient with ventricular septal defect.

A defect in the muscular part of the interventricular septum in a 19 year old man was complicated by infective endocarditis caused by Staphylococcus aureus. The lesion was a large right ventricular free wall vegetation which embolised to the lungs. The vegetation was displayed by cross sectional echocardiography, which also confirmed the clinical diagnosis of ventricular septal defect. This case confirms the concept that the jet stream causes endocarditis at its point of impact. After six weeks' treatment with antibiotics the ventricular septal defect was repaired at operation.     

Three‐Dimensional Echocardiographic Delineation of an Acquired Aorto‐Left Atrial Fistula Complicating Native Aortic Valve Endocarditis – “Advantage of Three Dimensions”

Aorto‐atrial fistulas are rare, but important complications resulting from aortic valve infective endocarditis, aortic valve surgery, or aortic dissection. We hereby report a case of a 20‐year male, referred to us with infective endocarditis of the native aortic valve with severe aortic regurgitation and symptoms of heart failure. Detailed evaluation with two‐dimensional and three‐dimensional transthoracic echocardiography revealed aorto‐left atrial fistula secondary to the involvement of the mitral–aortic intervalvular fibrosa (MAIVF) region. The patient underwent successful removal of the vegetations, closure of the defect along with aortic valve replacement, and mitral valve repair.     

Echocardiographic demonstration of free wall vegetative endocarditis complicated by a pulmonary embolism in a patient with ventricular septal defect

A defect in the muscular part of the interventricular septum in a 19 year old man was complicated by infective endocarditis caused by Staphylococcus aureus. The lesion was a large right ventricular free wall vegetation which embolised to the lungs. The vegetation was displayed by cross sectional echocardiography, which also confirmed the clinical diagnosis of ventricular septal defect. This case confirms the concept that the jet stream causes endocarditis at its point of impact. After six weeks' treatment with antibiotics the ventricular septal defect was repaired at operation.     

A case of infective endocarditis due to Streptococcus agalactiae

A 60 year-old woman, who was pointed out as having hyperglycemia, was admitted to our hospital, with a two-week history of fever. Blood sugar on admission was 424 mg/dl and blood cultures yielded Streptococcus agalactiae. Systolic and diastolic heart murmurs were heard. Echocardiography showed aortic regurgitation and vegetation on the aortic valve. Penicillin-G (4 million units every 4 hr) iv and streptomycin (1 g every 12 hr) im were started. Chemotherapy was continued for 48 days. After chemotherapy, aortic valve replacement was done. We reported a very rare infective endocarditis case due to Streptococcus agalactiae.     

Pulmonary homograft endocarditis 19 years after a Ross procedure

We report the case of a patient with acute pulmonary homograft endocarditis secondary to Streptococcus agalactiae from a cat-bite. He had undergone a Ross procedure nineteen years earlier. In view of unremitting infection with large pulmonary trunk and right pulmonary artery vegetations, the patient underwent successful pulmonary vegetectomy and homograft replacement.     

Echocardiographic detection of bacterial vegetations in a child with a ventricular septal defect.

A 13-year-old boy with a small ventricular septal defect was admitted with clinical manifestations of acute endocarditis. Coagulase-positive staphylococci were isolated from the blood. Definitive diagnosis was made by detecting bacterial vegetations in the right ventricle on the echocardiogram. Repeated embolization of these vegetations to the pulmonary circulation led to the death of the patient.     

Recurrent bacterial endocarditis with involvement of the tricuspid valve after surgical correction of congenital heart defect]

A case of recurrent tricuspid valve endocarditis after surgical closure of ventricular septal defect is presented. Intensive medical treatment lasting nearly ten years completely failed. There were still vegetations attached to the septal leaflet of the tricuspid valve with positive cultures (Ps. aeruginosa). Persistent sepsis without signs of heart failure required surgical intervention. Tricuspid valvuloplasty with excision of infected patch was successfully performed. Six months later the patient remained symptomless.     

Isolated pulmonic valve endocarditis caused by group B streprococcus (Streptococcus agalactiae)--a case report and literature review

The pulmonic valve is the least commonly involved valve in infective endocarditis. Pulmonic valve endocarditis is usually associated with tricuspid valve endocarditis, and isolated pulmonic valve endocarditis is exceedingly rare. The predisposing factors for developing pulmonic valve endocarditis include a congenitally anomalous pulmonic valve, intravenous drug abuse, and the presence of indwelling intravenous or flow-directed pulmonary artery catheters. More cases of group B streptococcus endocarditis are being reported. The risk factors for group B streptococcus endocarditis include diabetes mellitus, cancer, alcoholism, malnutrition, immunocompromised status, intravenous drug abuse, postpartum and postabortion states, and underlying valvular disease. The vegetations of this type of endocarditis are usually large and have a higher tendency to result in embolism. The presentation of group B streptococcus endocarditis is usually acute and may result in rapid valve destruction if not treated promptly. A case of isolated pulmonic valve endocarditis caused by group B streptococcus, Streptococcus agalactiae, is presented that was diagnosed with multiplane transesophageal echocardiography in a 40-year old, alcoholic, malnourished man, who was successfully treated with intravenous penicillin G. The literature on the isolated pulmonic valve endocarditis caused by group B streptococcus is reviewed.     

Profile of right-sided endocarditis: an Indian experience

The clinical profile of right-sided infective endocarditis in India was studied from a review of records of patients with infective endocarditis admitted to this hospital. From November 1982 to November 1989, 109 patients with infective endocarditis showed vegetations on cross-sectional echocardiography confirming the diagnosis of infective endocarditis. In 19 (17.4%) patients, only the right side of the heart was involved: specifically the tricuspid valve alone in 10; tricuspid and pulmonary valves in 4; tricuspid valve and right ventricular outflow tract in 1; tricuspid valve and right ventricular free wall in 1; pulmonary valve alone in 2; and bifurcation of pulmonary trunk in 1. Eleven patients (57.9%) had underlying congenital heart disease whereas the remaining 8 patients (42.1%) did not have any underlying heart disease. The latter group, therefore, had isolated right-sided infective endocarditis. Previous illnesses leading to isolated right-sided infective endocarditis were: puerperal sepsis in 4; septic abortion in 1; staphylococcal pneumonia in 2; and epididymoorchitis in one. Eight out of 11 patients with congenital heart disease did not report any previous illness. In the remaining 3, right-sided endocarditis followed cardiac surgery in one; dental extraction without prophylaxis in one; and pulmonary balloon valvoplasty in one. All patients with isolated right-sided infective endocarditis had features of septicaemia, but a murmur of tricuspid regurgitation was audible in only 4 (50%) of them. We conclude that, unlike western reports, the pattern of right-sided infective endocarditis in India is different. No drug addict with right-sided infective endocarditis was seen; puerperal sepsis and septic abortion were the commonest causes of isolated right-sided infective endocarditis.(ABSTRACT TRUNCATED AT 250 WORDS)     

Right atrial vegetation in left ventricular-right atrial communication

We report a case of right-sided endocarditis with left ventricular-right atrial communication in which right atrial vegetation was demonstrated by two-dimensional echocardiography. The present case demonstrates that the right atrial vegetation in ventricular septal defect is suggestive of left ventricular-right atrial communication.     

ILL型右室双出口(附一例报告)

<正> 全内脏转位合并镜面右位心是心脏原发位置异常,多无其他心脏畸形,但在先天性心脏畸形中有全内脏转位的发生率可达0.8%。最常见的合并畸形是纠正型大动脉转位。右室双出口是大动脉转位的一种,即主动脉及肺动脉均发自右心室,较为少见。全内脏转位、镜面右位心合并右心室双出口更为少见,本院曾收治一例,介绍如下: 临床资料王×(住院号21821)女、13岁,自幼发现心脏杂音,经检查为室间隔缺损、肺动脉高压,合并内脏转位、右位心,转来本院。患儿生后易患感冒、肺炎。近两年来有劳累后心     

Echodetection of disseminated endocardial vegetations in a patient with active IV drug abuse

Infective endocarditis is a known complication of intravenous (IV) drug abuse and typically involves cardiac valves, sparing the myocardial endocardium. We present the case of a young IV drug using patient who developed sepsis. Although cardiac symptoms and signs were minimal, an echocardiogram was done as patient had a history of IV drug abuse and was in sepsis. Echocardiogram demonstrated disseminated vegetations involving the left ventricular and right ventricular endocardium while sparing the valves. Although diagnosis of infective endocarditis was made on two-dimensional transthoracic echocardiogram, two-dimensional and three-dimensional transesophageal echocardiograms demonstrated the pattern of endocarditis with clarity. This patient had severe sepsis and bacteremia with Methicillin sensitive Staphylococcus aureus.     

Transcatheter closure of ruptured sinus of valsalva aneurysm

Percutaneous transcatheter closure of ruptured sinus of valsalva aneurysm was attempted in eight patients between January 1995 and March 2003 as an alternative strategy to surgery as this technique at present is an accepted therapeutic modality for various intracardiac defects. The age range was 14-35 years, all were male, seven in symptomatic class III and one in class IV on medical treatment. Two-dimensional and color Doppler echocardiography revealed rupture of an aneurysm of right coronary sinus into right ventricle in five and noncoronary sinus into right atrium in three and none had associated ventricular septal defect. The echo estimated size of the defect was 7-12 mm. On cardiac catheterization left ventricular end-diastolic pressure ranged from 20 to 40 mmHg and the calculated Qp/Qs ratio was 2-3.5. In all patients the defect was crossed retrogradely from the aortic side and over an arterio-venous wire loop after balloon sizing, devices were successfully deployed by antegrade venous approach (Rashkind umbrella device in two and Amplatzer occluders in six, which included Amplatzer duct occluder in five and Amplatzer septal occluder in one). One patient who had residual shunt developed hemolysis on the next day and was taken up for reintervention. That patient continued to have intermittent hemolysis and was sent for surgical repair. On follow-up (2-96 months), there was no device embolization, infective endocarditis, and aortic regurgitation. One patient died of progressive congestive heart failure while other six are asymptomatic. These data highlight that transcatheter closure is feasible and effective, especially safe with the available Amplatzer devices. Definitely, it has the advantage of obviating open heart surgery but complete occlusion is mandatory to prevent hemolysis and infective endocarditis.     

Right ventricular and septal anomalies complicated by subacute bacterial endocarditis

We report the case of a 31-year-old woman with no history of heart disease. She came to the hospital with fever, dyspnea, palpitation, and edema of the lower extremities. She was found to have aortic, mitral, and pulmonary valve insufficiency, and the initial diagnosis was subacute bacterial endocarditis. At surgery, we replaced the aortic and mitral valves with mechanical prostheses and the pulmonary valve with a bioprosthesis. The prostheses were soaked intraoperatively with fluconazole and the heart chambers were irrigated with povidone-iodine to prevent infection by bacteria and fungi. We also found 2 previously unsuspected anomalies: 1 was a muscular bundle that divided the right ventricle into 2 chambers, and the other was a ventricular septal defect, 1.0 cm in diameter. We resected the muscular bundle and patched the septal defect. The patient had an uneventful postoperative course and was in New York Heart Association functional class I at the 15-month follow-up visit. We speculate that this patient's congenital anomalies made the heart more susceptible to damage from the endocarditis. Therefore, any patient who has infective endocarditis should also be examined closely for congenital defects.     

Echocardographic findings in discrete subaortic stenosis associated with infective endocarditis of the aortic valve

The echocardiographic findings of three patients with discretesubaortic stenosis associated with infective endocarditis arereported. This disorder was suspected because of early systolicaortic valve partial closure followed by a fine fluttering throughoutsystole in each case. Narrowing of the left ventricular outflowtract as judged by the left ventricular outflow tract/aorticroot ratio was of limited diagnostic value because the presenceof echoes of aortic vegetations at this level in two cases preventedaccurate measurement of the outflow tract. This study suggeststhat a careful echocardiographic study may detect discrete subaorticstenosis in the presence of aortic valve endocarditis. Thus,whenever left ventricular outflow obstruction is associatedwith infective endocarditis, early systolic aortic valve partialclosure followed by a fine fluttering throughout systole shouldbe carefully sought