Triology of fallot presenting with isolated
pulmonary valve infective endocarditis - A rare
case report
SHASHIKANTHA [1], PHANI KONIDE [2], RAVI.B.N [3], SHENOY RAMANATH
MS [5] , PHANEESH BHARADWAJ [6], YAMINI ADDEPALLI [7].
[4]
, HARISH
1. Professor, Department of Medicine Adichunchanagiri Institute of Medical Sciences
Balagangadharanatha Nagara, Nagamangala, mandya-571448, Karnataka, India.
2. 3rd year Resident, Department of Medicine, Adichunchanagiri Institute of Medical
Sciences Balagangadharanatha Nagara, Nagamangala, mandya-571448, Karnataka,
India.
3. Associate Professor, Department of Medicine, Adichunchanagiri Institute of Medical
Sciences Balagangadharanatha Nagara, Nagamangala, mandya-571448, Karnataka,
India.
4. Assistant Professor, Department of Medicine, Adichunchanagiri Institute of Medical
Sciences Balagangadharanatha Nagara, Nagamangala, mandya-571448, Karnataka,
India.
5. 3rd year Resident, Department of Medicine, Adichunchanagiri Institute of Medical
Sciences Balagangadharanatha Nagara, Nagamangala, mandya-571448, Karnataka,
India.
6. 2nd year Resident, Department of Medicine, Adichunchanagiri Institute of Medical
Sciences Balagangadharanatha Nagara, Nagamangala, mandya-571448, Karnataka,
India.
7. 2nd year Resident, Department of Medicine, Adichunchanagiri Institute of Medical
Sciences Balagangadharanatha Nagara, Nagamangala, mandya-571448, Karnataka,
India.
Abstract
Isolated pulmonary valve endocarditis is an uncommon clinical entity
and is usually associated with intravenous drug abuse. The majority of cases
involve the tricuspid valve. Isolated pulmonary valve bacterial endocarditis
complicating Triology of Fallot ( which constitutes pulmonary valve
stenosis, right ventricular hypertrophy and atrial septal defect) is very
rare. A rare complication of a rare case is reported here.
Key words
Isolated pulmonary valve, Infective endocarditis, Triology of Fallot.
Introduction
Isolated pulmonary valve endocarditis is rare, affecting less than 1.5–2% of
patients suffering from infective endocarditis.[1] Review of previously
published data showed fewer than 90 cases of isolated pulmonary
valve endocarditis.[2] Risk factors include intravenous drug abuse, sepsis,
central venous catheter and congenital heart diseases. A case of triology
of fallot with isolated pulmonary valve endocarditis is presented here.
Case report
A 63 year old non diabetic and non hypertensive male patient presented with
the history of high grade fever from one day associated with chills and rigors
.On examination patient was conscious oriented had blood pressure of 90/60
mm Hg, with pulse 76 bpm and regular, on examination there was raised jvp
,bilateral pedal edema and grade 3 systolic murmur best heard in pulmonary
area .
Investigations revealed ECG suggestive of right ventricular hypertrophy,
chest x ray was showing Cardiomegaly with right ventricular hypertrophy
and pulmonary artery hypertension (figure 1). Echocardiography
showed ostium secundum ASD and L->R shunt ,severe pulmonary
valvular stenosis with vegetations attached to pulmonary valve ,right
ventricular hypertrophy ,reduced RV function and normal LV function
(figure2,3and 4) .Blood investigations showed neutrophilic leukocytosis and
no growth after blood culture. patient improved symptomatically with
antibiotic therapy within two weeks of admission
Figure 1
Figure 3
Figure 2
Figure 4
Discussion
The incidence of right-sided infective endocarditis ranges from 5 to
10% in different series [3,4]. The majority of cases involve the tricuspid valve.
Isolated pulmonary valve endocarditis is rare. It is assumed that its rarity is
due to the low pressure gradients within the right heart, the low prevalence
of congenital malformations, the lower oxygen content of venous blood, and
the differences in the covering and vascularization of the right heart
endothelium[5]. Most cases of pulmonary valve endocarditis in children are
secondary to the presence of a congenitally abnormal pulmonary valve and
in adults secondary to intravenous drug abuse. Isolated pulmonary valve
endocarditis has also been identified in patients undergoing chronic
hemodialysis and orthotopic liver transplantation [6,7]. A significant number
of patients present with primarily pulmonary symptoms such as pleuritic
chest pain, cough, and dyspnea. When peripheral embolic or neurologic
features occur, either left sided endocarditis or paradoxical embolism should
be considered.
A conservative approach is recommended for the majority of patients
with infective endocarditis affecting the tricuspid or pulmonary valve [8]. In
our case, the patient responded to antibiotics and became asymptomatic
within two weeks of initial admission. A review of the published data
indicated that the role of surgery in isolated pulmonic valve endocarditis is
unclear. Recurrent pulmonary emboli are not an indication for surgery,
which is only needed if fever persists despite 3 weeks of appropriate
antibiotic treatment in the absence of a pulmonary abscess [9]. Surgical
options include debridement of the infected area, vegetation excision with
either valve preservation or valve repair or valve replacement. Preservation
of the native pulmonary valve is recommended whenever possible, and use
of a homograft or xenograft is preferred if replacement is unavoidable.
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