Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Abstracts
Cardiovascular, Case Report
Cardiovascular, Commentary
Cardiovascular, Editorial
Cardiovascular, Guest Editorial
Cardiovascular, Images in Cardiology
Cardiovascular, Interventional Round
Cardiovascular, Original Article
Cardiovascular, Perspective Review
Cardiovascular, Preface
Cardiovascular, Review Article
Cardiovascular, Student’s Corner
Case Report
Case Report, Cardiovascular
Case Reports
Case Series, Cardiovascular
Clinical Discussion
Clinical Rounds
CPC
Current Issue
Debate
Dedication
Editorial
Editorial Cardiovascular
Editorial, From the Publisher’s Desk
Expert Comments
Expert's Opinion
Genetic Autopsy
Genetics Autopsy
Guest Editorial, Cardiovascular
Image in Cardiology
Images in Cardiology
Images in Cardiology, Cardiovascular
Interventional Round
Interventional Round, Cardiovascular
Interventional Rounds
Letter to Editor
Letter to the Editor
Media and news
Original Article
Original Article, Cardiovascular
Original Article, Cardiovascular Health
Practice in Medicine
Preface
Review Article
Review Article, Cardiovascular
Scientific Paper
Short Communication
Student's Corner
Supplementary
Supplemetary
WINCARS Activities
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Abstracts
Cardiovascular, Case Report
Cardiovascular, Commentary
Cardiovascular, Editorial
Cardiovascular, Guest Editorial
Cardiovascular, Images in Cardiology
Cardiovascular, Interventional Round
Cardiovascular, Original Article
Cardiovascular, Perspective Review
Cardiovascular, Preface
Cardiovascular, Review Article
Cardiovascular, Student’s Corner
Case Report
Case Report, Cardiovascular
Case Reports
Case Series, Cardiovascular
Clinical Discussion
Clinical Rounds
CPC
Current Issue
Debate
Dedication
Editorial
Editorial Cardiovascular
Editorial, From the Publisher’s Desk
Expert Comments
Expert's Opinion
Genetic Autopsy
Genetics Autopsy
Guest Editorial, Cardiovascular
Image in Cardiology
Images in Cardiology
Images in Cardiology, Cardiovascular
Interventional Round
Interventional Round, Cardiovascular
Interventional Rounds
Letter to Editor
Letter to the Editor
Media and news
Original Article
Original Article, Cardiovascular
Original Article, Cardiovascular Health
Practice in Medicine
Preface
Review Article
Review Article, Cardiovascular
Scientific Paper
Short Communication
Student's Corner
Supplementary
Supplemetary
WINCARS Activities
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Abstracts
Cardiovascular, Case Report
Cardiovascular, Commentary
Cardiovascular, Editorial
Cardiovascular, Guest Editorial
Cardiovascular, Images in Cardiology
Cardiovascular, Interventional Round
Cardiovascular, Original Article
Cardiovascular, Perspective Review
Cardiovascular, Preface
Cardiovascular, Review Article
Cardiovascular, Student’s Corner
Case Report
Case Report, Cardiovascular
Case Reports
Case Series, Cardiovascular
Clinical Discussion
Clinical Rounds
CPC
Current Issue
Debate
Dedication
Editorial
Editorial Cardiovascular
Editorial, From the Publisher’s Desk
Expert Comments
Expert's Opinion
Genetic Autopsy
Genetics Autopsy
Guest Editorial, Cardiovascular
Image in Cardiology
Images in Cardiology
Images in Cardiology, Cardiovascular
Interventional Round
Interventional Round, Cardiovascular
Interventional Rounds
Letter to Editor
Letter to the Editor
Media and news
Original Article
Original Article, Cardiovascular
Original Article, Cardiovascular Health
Practice in Medicine
Preface
Review Article
Review Article, Cardiovascular
Scientific Paper
Short Communication
Student's Corner
Supplementary
Supplemetary
WINCARS Activities
View/Download PDF

Translate this page into:

Case Report
Cardiovascular
8 (
4
); 268-270
doi:
10.25259/IJCDW_41_2023

A Rare Case of Postpartum Native Tricuspid Valve Infective Endocarditis with Septic Pulmonary Embolization

Department of Cardiology, Guntur Medical College, Guntur, Andhra Pradesh, India
Corresponding author: Boochibabu Mannuva, Department of Cardiology, Guntur Medical College, Guntur, Andhra Pradesh, India. e.mbb99@gmail.com
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Bose Yannam JC, Mannuva B, Konda S. A rare case of postpartum native tricuspid valve infective endocarditis with septic pulmonary embolization. Indian J Cardiovasc Dis Women. 2023;8:268-70.

Abstract

Infective endocarditis (IE) is a rare life-threatening infection in pregnancy and postpartum period. In 90% of cases, right-sided IE involves the tricuspid valve. This case report illustrates acute IE with native tricuspid valve vegetation with septic pulmonary embolization in immediate postpartum period.

Keywords

Tricuspid valve infective endocarditis
Infective endocarditis
Septic embolization
Pulmonary embolism
Postpartum

INTRODUCTION

Acute infective endocarditis (IE) is a rare but life-threatening infection during pregnancy and in the postpartum period that requires a high index of suspicion for the early diagnosis and management. In the current era, risk factors are changing, with a marked decrease in prevalence of rheumatic heart disease with a concomitant increase in congenital heart disease and intravenous drug use. IE has been difficult to study in randomized controlled trials due to its low incidence and the absence of uniformity in presentation, risk factors, and microbial organisms involved. Our understanding of IE in pregnancy and postpartum period is further limited by extremely low incidence. Postpartum IE is uncommon but holds a high mortality rate 11.1%.[1] Here, we report a rare case of postpartum IE of tricuspid valve in a previously apparently healthy woman.

CASE REPORT

A 24-year-old female presented after 5 days of normal vaginal delivery with fever with chills and rigors, dyspnea, and cough with mild expectoration. There is no history of foul smelling vaginal discharge, burning micturition, and lower abdominal pain. There is no history of pain and swelling in the limbs. She has no significant medical illness in past. She has normal antenatal checkups and labor was uneventful. She has no history of IV drug abuse. She was admitted in gynecology department and empirically started her on intravenous ceftriaxone 1 g and levofloxacin 500 mg orally. In view of worsening her symptoms, cardiology consultation was taken.

On examination, she was febrile (temperature 102°F), tachypneic and few petechiae were noted over the right ankle. There was no clubbing, pedal edema, or lymphadenopathy. Systemic examinations showed crepitations in the bilateral upper and lower interscapular area. Heart sounds were normal and grade 3/6 pansystolic murmur in the left lower sternal border increasing with inspiration was heard. There was no hepatosplenomegaly and other system examination was normal. Complete blood counts showed hemoglobin – 9.0 g/dL and total leukocyte count 24,600 and predominantly neutrophilic and platelets 196,000. Serological tests for human immunodeficiency virus, hepatitis B, and hepatitis C were negative. Her electrocardiogram showed sinus tachycardia. Her transthoracic echocardiography [Figure 1] (TTE) showed vegetation (1.4 × 1.05 cm) over the anterior leaflet of tricuspid valve on the right atrial side with severe low-pressure tricuspid regurgitation (TR), trans-esophageal echocardiography (TEE) [Figure 2] confirmed TTE findings. Chest radiograph [Figure 3] showed bilateral parenchymal infiltrates. High-resolution computed tomography (HRCT) [Figure 4] chest showed that multiple peripheral ill-defined nodular opacities of varying sizes with few of them cavitatory in the bilateral lung fields were suggestive of septic pulmonary emboli.

Transthoracic echocardiography images showing apical 4 chamber view showing vegetation on anterior leaflet of tricuspid valve and severe low-pressure tricuspid regurgitation.
Figure 1:
Transthoracic echocardiography images showing apical 4 chamber view showing vegetation on anterior leaflet of tricuspid valve and severe low-pressure tricuspid regurgitation.
Transesophageal echocardiography images showing vegetation on anterior leaflet of tricuspid valve and severe tricuspid regurgitation.
Figure 2:
Transesophageal echocardiography images showing vegetation on anterior leaflet of tricuspid valve and severe tricuspid regurgitation.
Chest radiograph showing bilateral parenchymal infiltrates.
Figure 3:
Chest radiograph showing bilateral parenchymal infiltrates.
Computed tomography chest showing cavitating septic pulmonary emboli.
Figure 4:
Computed tomography chest showing cavitating septic pulmonary emboli.

She was provisionally diagnosed as acute IE of tricuspid valve with severe TR with septic pulmonary embolization and after sending three initial sets of blood cultures; she was started on empirical antibiotics in Inj. Amikacin 500 mg once daily and Inj. Vancomycin 500 mg twice daily. Her vitals and renal function tests were monitored regularly. Blood cultures were sterile at 48 h and 7 days. Gradually, her symptoms improved and she became afebrile by 10th day. Amikacin was continued for 2 weeks and vancomycin for 4 weeks. After completion of antibiotic treatment for 4 weeks, repeat TEE was done and found that vegetation was decreased in size to 12 × 7 mm and TR is moderate to severe. As the patient is asymptomatic and hemodynamically stable, she was discharged and kept on close follow-up with future plan of tricuspid valve repair.

DISCUSSION

Right-sided IE is very rare (10%) predominantly seen in IV drug abuse.[2] Transient bacteremia, a condition required for the development of bacterial endocarditis, may arise after infected delivery conditions. Group B streptococci can be isolated from genital or lower gastrointestinal tract cultures of pregnant and non-pregnant women ranging from 5% to 40%.[3] This colonization in pregnant women serves as the origin of puerperal and neonatal sepsis, maternal endometritis, chorioamnionitis, and bacteremia.

In a retrospective study of 82 women with IE developed after childbirth and abortion, 71% occur in the postpartum period and 29% in the post-abortion period.[3] The most common form of IE in that study was primary IE – 88% and only 12% – secondary IE. Among the causative agents of IE, staphylococcus was the leading in women after childbirth and abortion - 63%.[4]

Pulmonary rather than cardiac manifestations are usually the predominant clinical features of tricuspid valve endocarditis (TVE).[5] Symptoms arising from pneumonia or septic pulmonary emboli from dislodged vegetative material are common findings in TVE as seen in our case. Cardiac manifestations are less prominent than in the left-sided endocarditis.

CONCLUSION

We report a case of culture negative native tricuspid valve endocarditis occurring after a normal vaginal delivery. Despite the fact that this is a rare condition, it emphasizes the importance of blood cultures and echocardiography in postpartum patients with persistent fever.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Conflicts of interest

There are no conflicts of interest.

Financial support and sponsorship

Nil.

References

  1. , , , . Post Partum Infective Endocarditis Caused by E. faecium without Predisposing Disease. Available from: from: https://shmabstracts.org/abstract/post-partum-infective-endocarditis-caused-by-e-faecium-without-predisposing-disease [Last accessed on 2021 Nov 17]
    [Google Scholar]
  2. , , , , , , et al. Pregnancy and postpartum infective endocarditis: Systematic review. Mayo Clin Proc. 2014;89:1143-52.
    [CrossRef] [PubMed] [Google Scholar]
  3. , , . Infective endocarditis as a result of obstetric and gynecological sepsis. J Obstetr Womens Dis. 2005;54:118-21.
    [CrossRef] [Google Scholar]
  4. , , . Postpartum Group B streptococcal tricuspid valve endocarditis. Isr Med Assoc J. 2007;8:883-4.
    [Google Scholar]
  5. , , . Isolated native tricuspid valve endocarditis caused by viridans Streptococcus. Can J Infect Dis. 2001;12:305-7.
    [CrossRef] [PubMed] [Google Scholar]
Show Sections