A 27 years old man with fever, rigors, night sweating, severe weight loss (about 15 Kg) from 4 months ago was admitted to our hospital. On admission, he was ill, febrile and suffered from pleuretic chest pain. He was in good health until 4 months ago. The patient didn't have history of IV drug abuse.
He had an episode of sub massive hemoptesia a week before admission. On physical examination, he appeared febrile, anemic, and toxic. Blood pressure was 110/70 mmHg, heart rate was 105 bpm and regular. Jugular veins were distended. On auscultation, there was 4/6 grade to-and-fro murmur at pulmonary area without radiation and another 5/6 grade holosystolic murmur in left sternal border. Multiple sub conjunctive petechia, osler nodes on pulm of the left upper limb and clubbing was also seen. Electrocardiography showed sinus tachycardia with right axis deviation. Chest x-ray showed cardiomegaly with multiple patchy infiltrations in both lung parenchyma. Transthoracic echocardiography showed large highly mobile bulky vegetation on pulmonic valve with valve destruction and severe free pulmonic insufficiency (, ).
Parasternal short axis view revealed two vegetations on pulmonic valve and PA free wall
Parasternal short axis color Doppler imaging revealed severe free pulmonic insufficiency
Another mobile vegetation was also seen on pulmonary artery free wall with significant thickening and inflammation of endothelium (). There was also small sub aortic ventral septal defect (VSD) (defect = 5 mm) and secondary aortic valve prolapse and mild aortic insufficiency. No vegetation on other valves was seen.
Laboratory data indicated anemia (Hg = 7.5 gr/dl, PMN = 85%), ESR was 113, and CRP was positive.
Axial thorax CT scan showed multiple diffused nodules especially in basal portion.
Respect to Duke Criteria, infective endocarditis was confirmed and full dose antibiotic therapy was started. Due to recurrent pulmonic septic emboli, the patient referred to surgical department for surgery, pulmonic valve replacement with bioprosthesis, removal of pulmonary artery vegetation and VSD closure was performed () and patient was discharged 2 weeks after surgery without any complication.
Macroscopic surgical view revealed vegetation on pulmonic valve