Infective Endocarditis Post-surgical Termination of Pregnancy: From Misdiagnosis to Life-Saving Clarity – A Catastrophe Averted

INTRODUCTION

There exists a significant dearth of published literature regarding right-sided infective endocarditis (IE) owing to its lower incidence and a more varied clinical presentation. Right- sided IE, although rare, accounts for approximately 5–10% of all IE cases and predominantly affects the tricuspid valve (TV). In comparison with left-sided IE, it has a greater likelihood of forming septic emboli and is more often associated with intravenous drug use, intracardiac devices, and central venous catheters.^[1] IE post-surgical termination of pregnancy (STOP) is a rare but serious complication that clinicians can easily overlook.^[2] The diagnosis of IE is based on clinical, imaging, and laboratory criteria. Diagnosis hinges on clinical, laboratory, and imaging findings, with the modified Duke criteria being central to establishing the diagnosis.^[3] Here, we present a case of a 30-year-old woman whose diagnosis of IE was not immediately recognized and was only established later as the symptoms persisted and worsened, highlighting the need for enhanced awareness among clinicians when managing patients with a history of STOP.

CASE REPORT

A 30-year-old multiparous woman with a known history of pulmonary tuberculosis (TB) presented to the emergency department with complaints of persistent fever for 15 days associated with chills along with productive cough, burning micturition with reduced urine output, and sudden onset of breathlessness for 2 days [Figure 1]. Approximately 1.5 months ago, she underwent a medical termination of pregnancy (MTP). During a follow-up ultrasound, retained products of conception (RPOC) were identified, necessitating a dilatation and curettage procedure. One week later, the patient had complaints of fever and consulted at a hospital, where the work-up showed a total leukocyte count (TLC) of 22,000, chest X-ray had fibro-infiltrative disease in the right upper-mid zone and Widal test was positive for titers of both Salmonella Typhi “O” and “H” at 1:320. Hence, the patient was treated according to the typhoid treatment guidelines. Unfortunately, the patient’s condition deteriorated after which she presented to our center with the above-mentioned complaints. On examination, the patient was tachycardic with a pulse rate of 140 beats/min, oxygen saturation of 80% on room air, abdominal distension, and basal crepitations bilaterally on auscultation. Comprehensive blood investigations, including blood and urine cultures, were performed. A provisional diagnosis of urinary tract infection with urosepsis was made, and the patient started on intravenous antibiotics. A repeat ultrasound of the abdomen and pelvis revealed no RPOC but identified a heterogenic hypoechoic lesion in the left adnexa (possibly old tubercular), mild ascites, and splenomegaly. The widal test was negative, and TB workup yielded no positive findings. Laboratory results showed hemoglobin of 7.4 g%, a TLC of 25,400/µL, blood urea of 104 mg/dL, serum creatinine of 5.75 mg/dL, and a positive serum procalcitonin. The patient underwent one cycle of hemodialysis on the 4^th day of admission, after which kidney function tests improved; however, her clinical condition remained critical. The following day, the patient was planned for contrast-enhanced computed tomography (CECT) chest and abdomen and CT pulmonary angiography which was indicative of multiple peripheral focal areas of consolidation with air bronchograms and areas of cavitary breakdown seen diffusely scattered in bilateral lung fields, with prominent feeding vessels and surrounding ground glass opacities suggestive of infective etiology, likely secondary to septic embolization to lung, bilateral pleural effusions, mediastinal lymphadenopathy, and hepatosplenomegaly. CECT was also suggestive of bilateral renal cortical necrosis and pulmonary arterial hypertension with dilated right atrium, right ventricle, and right and left branches of main pulmonary artery. Echocardiographic correlation was advised which showed a vegetation of 1.1X1.3 cm with severe tricuspid regurgitation (TR), moderate mitral regurgitation, global left ventricular hypokinesia with an ejection fraction of 20–25%, and mild pericardial effusion. Following this, cardiac surgery was planned. Meanwhile, the patient’s condition worsened and she had to be intubated and put on mechanical ventilation due to respiratory distress on the 10^th admission day. At this point, the patient was on injection gentamycin, meropenem, and vancomycin. The following day, liposomal amphotericin B 150 mg was added as an antifungal cover. The patient’s repeat blood culture came back positive for Klebsiella sensitive to colistin and tigecycline on the 21^st admission day. After stepping up antibiotics, multiple cycles of hemodialysis, and blood transfusion, the patient was weaned off and extubated after 1 week of ventilatory support. After extubation, the patient’s condition deteriorated, and non-invasive ventilation was initiated. Surgery was then performed under general anesthesia 23 days after admission. Transesophageal echocardiography revealed a 2 × 1 cm vegetation on the posterior leaflet of the TV along with severe TR [Videos 1 and 2] [Figures 2-4]. Vegetectomy and postero-septal commissuroplasty were performed with the patient on cardiopulmonary bypass and Del Nido cold blood cardioplegia was administered through the aortic root [Figure 2]. The patient’s intraoperative course was uneventful and following the procedure, the patient was shifted to the intensive care unit for close observation on mechanical ventilation and intravenous dobutamine infusion. She was extubated the following day and intravenous antibiotics were continued for 2 weeks postoperatively. The patient was subsequently discharged in stable condition after 37 days of hospitalization.

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Figure 1:

Timeline of patient with relevant data of episodes and interventions. Admission to our hospital is taken as Day 0. (USG A+P: Ultrasound abdomen pelvis, TLC: Total leukocyte count, BUN: Blood urea nitrogen, HD: Hemodialysis, IE: Infective endocarditis, CECT: Contrast-enhanced computed tomography, CTPA: Computed tomography pulmonary angiography, TEE: Transesophageal echocardiography, TV: Tricuspid valve, ECHO :Echocardiography, MTP: Medical termination of pregnancy, BT: Blood transfusion, NIV: Non-invasive ventilation, ICU: Intensive care unit).

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Figure 2:

(a) ME RV inflow outflow view with color Doppler showing TR jet (Red arrow) and a vegetation involving the posterior leaflet of TV (red circle); (b) Black arrow pointing at the vegetation visualized intraoperatively. (ME: Midesophageal, RV: Right ventricle, TR: Tricuspid regurgitation, TV: Tricuspid valve, LA: Left atrium, RA: Right atrium, AV: Aortic valve.)

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Figure 3:

Midesophageal right ventricle inflow outflow view depicting a large vegetation in the right atrium (red arrow).

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Figure 4:

Midesophageal modified bicaval view depicting a large vegetation in the right atrium (red arrow).

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DISCUSSION

The primary differential diagnosis in this case was septic abortion due to RPOC, for which a check scan was performed and returned negative. Despite this, the patient was managed for urosepsis based on clinical suspicion. Although blood and urine cultures were appropriately sent at admission, echocardiography which could have provided a definitive diagnosis was regrettably not performed. A sterile blood culture till post 3 weeks of admission also masked the diagnosis of IE. This highlights how initial biases can delay appropriate diagnosis in complex clinical scenarios.

Most of the available research on IE following STOP is limited to case reports, highlighting the rarity of the condition and the need for further comprehensive studies to better understand its incidence, risk factors, and management. Singh et al. published a review on the cardiovascular complications following MTP. They reported the most common cardiovascular complication to be IE involving TV and takotsubo cardiomyopathy with mortality only reported after IE.^[4] Baniya et al. reported a similar case report of a woman developing IE of the TV following septic abortion.^[5] Her blood culture was positive for Staphylococcus aureus and echocardiography showed 2 mobile vegetations on the TV causing severe TR. The patient was managed medically and showed clinical improvement over the days. In our case, despite being on I.V antibiotics, the patient’s clinical condition deteriorated, and hence, the patient was managed surgically. Persistent vegetations and significant TR causing right heart failure justify operative management in such cases.^[1]

Prophylactic antibiotics and strict asepsis during surgical abortion remain essential, as highlighted in the National Institute for Health and Care Excellence abortion care guidance (NG140) and Cochrane reviews.^[6,7]

CONCLUSION

Right-sided IE, although rare, can be a life-threatening complication. Early diagnosis and timely intervention are quintessential. Such cases highlight the importance of adequate antibiotic prophylaxis and adherence to aseptic techniques while performing surgical procedures to combat morbidity and mortality.