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Year : 2022  |  Volume : 6  |  Issue : 2  |  Page : 162-163

Small Ventricular Septal Defect Presenting in an Adult as Quadruple Valve Infective Endocarditis


Department of Cardiology, Holy Family Hospital, New Delhi, India

Date of Submission31-Aug-2021
Date of Acceptance02-Oct-2021
Date of Web Publication16-Dec-2021

Correspondence Address:
Dr. Mohan Nair
Department of Cardiology, Holy Family Hospital, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiae.jiae_54_21

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How to cite this article:
Kataria V, Kitey P, Gupta A, Malpani V, Nair M. Small Ventricular Septal Defect Presenting in an Adult as Quadruple Valve Infective Endocarditis. J Indian Acad Echocardiogr Cardiovasc Imaging 2022;6:162-3

How to cite this URL:
Kataria V, Kitey P, Gupta A, Malpani V, Nair M. Small Ventricular Septal Defect Presenting in an Adult as Quadruple Valve Infective Endocarditis. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2022 [cited 2022 Oct 3];6:162-3. Available from: https://jiaecho.org/text.asp?2022/6/2/162/332709



A 36-year-old male presented with fever for the past 1 month and shortness of breath associated with bilateral pedal edema and decreased urine output for 10 days. The patient had a previous diagnosis of small ventricular septal defect (VSD) [Yellow arrows, [Figure 1]a at birth, which was treated conservatively. The patient had been perfectly healthy until this episode of pyrexia. There was no history of intravenous drug abuse or any other addiction. Serology for human immunodeficiency virus infection was nonreactive.
Figure 1: (a) Atrioventricular septal defect with left-to-right shunt is seen in this image. (b) Transthoracic echocardiogram image in parasternal long-axis view: vegetations are seen on mitral (white arrow) and aortic valves (blue arrow). Moderate pericardial effusion is also seen in this image. (c) Transthoracic echocardiogram image in parasternal short-axis view showing vegetation over pulmonary valve (red arrow). (d) Apical four-chamber view: vegetations are seen on mitral (yellow arrow) and tricuspid valves (white arrow). (e) Severe mitral, tricuspid regurgitation and mild aortic regurgitation (yellow arrowhead) are seen in this apical four-chamber view with color Doppler

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Clinical examination demonstrated pyrexia (39.4°C), sinus tachycardia (120 beats/min), and hypotension. Auscultation disclosed pansystolic as well as early diastolic murmurs at the apex and left sternal border. The patient had clubbing in all fingers of the upper limb. There were no other peripheral stigmata of endocarditis. Initial blood tests showed a hemoglobin of 10.3 g/dL; white cells 15.3 × 109/L; neutrophils 12.5 × 109/L; erythrocyte sedimentation rate (ESR) 78 mm/h, C-reactive protein 2.50 mg/dL; urea 46 mg/dL, and creatinine 1.2 mg/dL. Transthoracic and transesophageal echocardiograms showed vegetations on mitral, tricuspid, aortic, and pulmonary valves [Figure 1]b, [Figure 1]c, [Figure 1]d, [Video 1]. Mitral, aortic, and tricuspid valves had severe regurgitation [Figure 1]e. Left ventricle was nondilated hyperdynamic with small VSD (Gerbode defect) with left ventricular to right atrial shunt [Figure 1]a.

[Additional file 1]

Video 1: Transesophageal echocardiography image showing vegetations on all four valves and small ventricular septal defect.

A diagnosis of quadruple valve infective endocarditis was made. Blood cultures grew group alpha-hemolytic Streptococci. The patient was given intravenous benzylpenicillin and gentamicin, in addition to other supportive therapy.

The patient improved with this therapy and became afebrile in 15 days. Inflammatory markers such as ESR were also normalized. He is now planned for mitral and aortic valve replacement with the reconstruction of the tricuspid valve and VSD repair.

It is extremely rare to have infective endocarditis involving all four cardiac valves, particularly in the absence of intravenous drug abuse.[1] In our patient, we feel that the presence of a VSD facilitated left-to-right spread of endocarditis. Such a combination has been described only once previously in a patient with perimembranous VSD.[2]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

We would like to thank Dr. Bheemraj Gupta. He is the treating consultant nephrologist who first suspected infective endocarditis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Piran S, Rampersad P, Kagal D, Errett L, Leong-Poi H. Extensive fulminant multivalvular infective endocarditis. JACC Cardiovasc Imaging 2009;2:787-9.  Back to cited text no. 1
    
2.
Tavakkoli Hosseini M, Quarto C, Bahrami T. Quadruple-valve infective endocarditis and ventricular septal defect. Tex Heart Inst J 2013;40:209-10.  Back to cited text no. 2
    


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