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Pulmonic valve endocarditis in a normal heart
Pulmonic Valve Endocarditis in a Normal Heart Rebecca A. Schroeder, MD, Durham, North Carolina
The patient was a 55-year-old man admitted for
acute parotitis approximately 1 month after dental extraction of decayed teeth for which he had received prophylactic antibiotics. On admission to an outside hospital, he had fever, trismus, an elevated white blood cell count, and blood cultures positive for Streptococcus viridans. A transthoracic echocardiogram (TTE) revealed normal findings. He was transferred to our institution where he underwent operative drainage of a masseter muscle abscess and broad-spectrum antibiotics were administered. A repeated TTE produced negative results. The patient improved clinically after surgical drainage but because of the risk of bacterial endocarditis, a transesophageal echocardiogram (TEE) was performed 5 days after the second TTE. It revealed a 1.- ⫻ 1-cm mass attached to the arterial surface of the pulmonic valve (PV) (Figures 1 and 2). The rest of the examination revealed normal findings. He was treated with 4 weeks of intravenous antibiotics with resolution of his PV mass and a complete return to his former state of good health. The first PV vegetation was reported in 1977 in a patient with a history of intravenous drug use.1 Since that time, echocardiography has dramatically improved the physician’s ability to diagnose PV endocarditis before autopsy. The PV is rarely involved in subacute bacterial endocarditis, being present in less than 2% of autopsies performed for suggested endocarditis.2 Significant risk factors include intravenous drug use and congenital heart disease, but also alcoholism, sepsis, and central line infection. Clinical presentation is often subtle but may include pleural effusion, pneumonia, or pulmonary infarction from vegetation emboli. Although a murmur of pulmonic regurgitation is often present, it develops late in the disease. Staphylococcus aureus is the most common organism isolated, although a variety of culprits have been identified.
From the Durham Veterans Medical Center, Duke University School of Medicine. Reprint requests: Rebecca A. Schroeder, MD, Durham Veterans Medical Center, Duke University School of Medicine, VAMC (112C), 508 Fulton St, Durham, NC 27705 (E-mail: [email protected]). J Am Soc Echocardiogr 2005;18:197– 8. 0894-7317/$30.00 Copyright 2005 by the American Society of Echocardiography. doi:10.1016/j.echo.2004.08.006
Figure 1 Upper esophageal view of main pulmonary artery, bifurcation, and proximal right and left pulmonary arteries all in long axis, and aorta in short axis. Vegetation is visible as area of brightness at origin of main pulmonary artery.
Figure 2 Midesophageal view of aortic valve, proximal ascending aorta, and right ventricular outflow tract (RVOT) below, in long axis. Area of echogenic brightness is mass attached to pulmonic valve.
Pulmonic endocarditis in a normal heart, however, is even more uncommon with total of 45 cases reported. Again, risk factors include intravenous drug use although 28% have no predisposing factor. In cases of right-sided endocarditis in nondrug users, 55% to 65% are caused by S viridans whereas S aureus predominates in drug users.3 Other organisms include Neisseria, Pseudomonas, Enterococ-
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cus, and Haemophilus species. Diagnosis has been primarily with echocardiography.2,4,5 The sensitivity of TTE is 30% to 63%, with a specificity of 91% to 100% for diagnosis of PV endocarditis. In contrast, the sensitivity of TEE ranges from 87% to 100% with a specificity of 91% to 100%. Of the 45 reported cases, 76% were diagnosed by TTE. Only 13% had a negative TTE finding and several were diagnosed at autopsy.2,4,5 In addition, 64% were treated medically with 28% mortality. Importantly, in the 34% treated surgically, there were no deaths. Our patient had one predisposing factor, a recent dental procedure with a resultant abscess requiring surgical drainage. However, he had two negative TTE results within days of a positive TEE finding. Given the low risk of TEE and the high mortality in those patients with PV endocarditis who are treated medically or who experience a delay in diagnosis, a
Journal of the American Society of Echocardiography February 2005
TEE should be performed even in patients with normal hearts who present with a significant risk factor and positive blood cultures. REFERENCES 1. Kramer NE, Gill SS, Patel R, Towne WD. Pulmonary valve vegetations detected with echocardiography. Am J Cardiol 1977;39: 1064-7. 2. Ramadan FB, Beanlands DS, Burwash IG. Isolated pulmonic valve endocarditis in healthy hearts: a case report and review of the literature. Can J Cardiol 2000;10:1282-8. 3. Panidis IP, Kotler MN, Mintz GS, Segal BL, Ross JJ. Rightheart endocarditis: clinical and echocardiographic features. Am Heart J 1984;107:759-64. 4. Tariq M, Smego RA, Soofi A, Islam N. Pulmonic valve endocarditis. South Med J 2003;96:621-3. 5. Hussain KM, Kabins S, Lieb D, Chandna H, Denes P. Coagulase-negative Staphylococcus endocarditis restricted to the normal pulmonic valve in a patient with end-stage renal disease. Case report and review. 1998;27:1550-1.
The patient was a 55-year-old man admitted for
acute parotitis approximately 1 month after dental extraction of decayed teeth for which he had received prophylactic antibiotics. On admission to an outside hospital, he had fever, trismus, an elevated white blood cell count, and blood cultures positive for Streptococcus viridans. A transthoracic echocardiogram (TTE) revealed normal findings. He was transferred to our institution where he underwent operative drainage of a masseter muscle abscess and broad-spectrum antibiotics were administered. A repeated TTE produced negative results. The patient improved clinically after surgical drainage but because of the risk of bacterial endocarditis, a transesophageal echocardiogram (TEE) was performed 5 days after the second TTE. It revealed a 1.- ⫻ 1-cm mass attached to the arterial surface of the pulmonic valve (PV) (Figures 1 and 2). The rest of the examination revealed normal findings. He was treated with 4 weeks of intravenous antibiotics with resolution of his PV mass and a complete return to his former state of good health. The first PV vegetation was reported in 1977 in a patient with a history of intravenous drug use.1 Since that time, echocardiography has dramatically improved the physician’s ability to diagnose PV endocarditis before autopsy. The PV is rarely involved in subacute bacterial endocarditis, being present in less than 2% of autopsies performed for suggested endocarditis.2 Significant risk factors include intravenous drug use and congenital heart disease, but also alcoholism, sepsis, and central line infection. Clinical presentation is often subtle but may include pleural effusion, pneumonia, or pulmonary infarction from vegetation emboli. Although a murmur of pulmonic regurgitation is often present, it develops late in the disease. Staphylococcus aureus is the most common organism isolated, although a variety of culprits have been identified.
From the Durham Veterans Medical Center, Duke University School of Medicine. Reprint requests: Rebecca A. Schroeder, MD, Durham Veterans Medical Center, Duke University School of Medicine, VAMC (112C), 508 Fulton St, Durham, NC 27705 (E-mail: [email protected]). J Am Soc Echocardiogr 2005;18:197– 8. 0894-7317/$30.00 Copyright 2005 by the American Society of Echocardiography. doi:10.1016/j.echo.2004.08.006
Figure 1 Upper esophageal view of main pulmonary artery, bifurcation, and proximal right and left pulmonary arteries all in long axis, and aorta in short axis. Vegetation is visible as area of brightness at origin of main pulmonary artery.
Figure 2 Midesophageal view of aortic valve, proximal ascending aorta, and right ventricular outflow tract (RVOT) below, in long axis. Area of echogenic brightness is mass attached to pulmonic valve.
Pulmonic endocarditis in a normal heart, however, is even more uncommon with total of 45 cases reported. Again, risk factors include intravenous drug use although 28% have no predisposing factor. In cases of right-sided endocarditis in nondrug users, 55% to 65% are caused by S viridans whereas S aureus predominates in drug users.3 Other organisms include Neisseria, Pseudomonas, Enterococ-
197
198 Schroeder
cus, and Haemophilus species. Diagnosis has been primarily with echocardiography.2,4,5 The sensitivity of TTE is 30% to 63%, with a specificity of 91% to 100% for diagnosis of PV endocarditis. In contrast, the sensitivity of TEE ranges from 87% to 100% with a specificity of 91% to 100%. Of the 45 reported cases, 76% were diagnosed by TTE. Only 13% had a negative TTE finding and several were diagnosed at autopsy.2,4,5 In addition, 64% were treated medically with 28% mortality. Importantly, in the 34% treated surgically, there were no deaths. Our patient had one predisposing factor, a recent dental procedure with a resultant abscess requiring surgical drainage. However, he had two negative TTE results within days of a positive TEE finding. Given the low risk of TEE and the high mortality in those patients with PV endocarditis who are treated medically or who experience a delay in diagnosis, a
Journal of the American Society of Echocardiography February 2005
TEE should be performed even in patients with normal hearts who present with a significant risk factor and positive blood cultures. REFERENCES 1. Kramer NE, Gill SS, Patel R, Towne WD. Pulmonary valve vegetations detected with echocardiography. Am J Cardiol 1977;39: 1064-7. 2. Ramadan FB, Beanlands DS, Burwash IG. Isolated pulmonic valve endocarditis in healthy hearts: a case report and review of the literature. Can J Cardiol 2000;10:1282-8. 3. Panidis IP, Kotler MN, Mintz GS, Segal BL, Ross JJ. Rightheart endocarditis: clinical and echocardiographic features. Am Heart J 1984;107:759-64. 4. Tariq M, Smego RA, Soofi A, Islam N. Pulmonic valve endocarditis. South Med J 2003;96:621-3. 5. Hussain KM, Kabins S, Lieb D, Chandna H, Denes P. Coagulase-negative Staphylococcus endocarditis restricted to the normal pulmonic valve in a patient with end-stage renal disease. Case report and review. 1998;27:1550-1.