22 year-old female patient was referred to our center with diagnosis of infective endocarditis(IE). On medical anamnesis of patient; she defined recurrent abortus attacks and she had been diagnosed as native tricuspid valve (TV) endocarditis after abortus seven months ago. She had been treated with antibiotics for a month and because of uncontrolled infection, she had undergone TV replacement with bioprosthetic valve. Then she had been asymptomatic for sixh months.
Before presentation, she was admitted to public hospital with complaints of fever, malaise and fatigue. Her complaints had also begun after termination of pregnancy with abortion. Transthoracic echocardiography (TTE) had revealed large vegetation on bioprosthetic TV and patient had been hospitalized. Vancomycine 2 g/day, gantamycine 180 mg/day, cefoperazone 4 g/day and rifampicin 600 mg/day had begun as antibiotic treatment.
After two weeks of therapy patient referred to our center for surgical treatment. After initial evaluation, medical treatment was tried once more. TTE was showed 1.8*1.7 cm sized mobile vegetation attached to bioprosthetic TV (Figure 1).
Click on figure to enlarge
Blood culture was showed the proliferation of enterococcus and pseudomonas species. Antibiotic therapy was continued as vancomycine 2 g/day, metronidazole 2 g/day, rifampicin 600 mg/day and meropenem 6 g/day. However; patient general status was deteriorited progressively.
After ten days of medication; septic shock and disseminated intravascular coagulation (DIC) was developped with a concominant retroperitoneal hemorrage, gastrointestinal hemorrage and signs of liver, kidney and heart failure. And then, patient was intubated and supportive medical care was given including large units of transfusion.
After that, emergent surgical management was done as resection of infected tricuspid valve without replacement. Right after the operation, patient began to ameliorate dramatically and DIC clinic disappeared within first postoperative day. In the postoperative period, antibiotic treatment consist of vancomycine 2 g/day and metronidazole 2 g/day was continued for two weeks more. In third postoperative day, sedimantation was decreased to 55 mm/h that had been 105 mm/h initially. After surgery, patient was showed fast convalescence period surprisingly and signs of kidney, liver and heart failure was disappeared progressively.
Patient was discharged from hospital at the end of second week. Culture taken from surgical specimen was found as clear. Elective TV replacement will be scheduled within next three months.
Although incidence of IE associated with abortus or curettage had been reported as one per million, there was an increase in the such cases that reported in recent medical literature. Among reported cases, group B streptococcal endocarditis was the most frequent clinical event. Involvement of tricuspid valve was extremely rare in patients without pre-existing cardiac disease or other comorbities. Mortality rate was reported near to 15% and surgical treatment could be chosen when antibiotics fail to control disease. However, there was no clear data or case reports that define the coarse of bioprosthetic TV endocarditis treated with antibiotics.
Urgent surgical therapy is also clinical challenge and its effectiveness is restricted to selected cases. Surgical resection of infected valve without replacament could be alternative way to limit the dissemination of uncontrolled endocarditis cases.
Notes to editor
submited by Ahmet Karabulut (Istanbul, Turkey), Özgür Sürgit (Istanbul, Turkey) and Aydın Yıldırım (Istanbul, Turkey)