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Clinical Infection & Immunity

Case Report

Volume 2, Number 1, March 2017, pages 10-12

Multivalvular Endocarditis With Eustachian Valve Endocarditis in a Child With Perimembranous Ventricular Septal Defect

Infective endocarditis denotes infection of the endocardial surface of the heart involving predominantly the heart valves. Less commonly other cardiac structures like mural endocardium, ventricular septal defects (VSDs), etc. may be involved. Eustachian valve endocarditis is a rare cause of right-sided endocarditis with few cases reported in literature. We here report a case of multivalvular endocarditis involving tricuspid valve and mitral valve along with Eustachian valve involvement in a child with peri-membranous VSD.

Our patient was a 6-year-old boy who presented to us with complaints of chest pain, breathlessness and cough for last 2 weeks. Patient was a diagnosed case of peri-membranous VSD which was detected at the age of 1 year. On presentation, patient was febrile having a temperature of 102.4 °F. His pulse rate was 107/min, BP was 96/60 mm Hg and respiratory rate was 26 beats/min. On cardiovascular examination, a pansystolic murmur of grade 3/6 was heard at the apex which was radiating to axilla and another pansystolic murmur grade 4/6 was present at the lower left sternal border.

Hematological investigation showed an elevated white blood cell count (24,100 cells/μL) with left shift and hemoglobin level of 10.6 gm%. Erythrocyte sedimentation rate was 90 mm at the end of 1 h and C-reactive protein level was 7 mg/100 mL. Chest radiography revealed cephalization of pulmonary veins and electrocardiogram was non-contributory. Transthoracic echocardiography was performed which revealed vegetations on tricuspid valve, mitral valve and Eustachian valve (Fig. 1). Peri-membranous ventral septal defect was also visualized (Fig. 2). Moderate to severe mitral regurgitation and tricuspid regurgitation was present. Biventricular function was detected to be normal.

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Figure 1. (a) Apical four chambered view showing vegetations on mitral, tricuspid and Eustachian valve. (b) Resultant mitral and tricuspid regurgitation are seen.

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Figure 2. Peri-membranous ventricular septal defect visualized in para-sternal long axis view (a), with a maximum gradient of 120.7 mm Hg (b). 3D transthoracic echocardiographic view of the peri-membranous ventricular septal defect (c). Flow through the defect is visualized (d).

A set of three peripheral blood cultures from different sites was sent. Patient was started on empirical antibiotic regimen with vancomycin and gentamycin. Blood culture results revealed vancomycin sensitive Staphylococcus aureus and the patient was continued on weight-based vancomycin.

Patient gradually improved over 1 week and was afebrile at the end of 1 week. He was finally discharged at the end of 4 weeks of antibiotic regimen.

Multivalvular endocarditis is an uncommon presentation of endocarditis distinctly less common than single valve endocarditis. Kim et al reported the incidence of multivalvular endocarditis to be 18% in a series of 77 patients [1]. The most common etiologic micro-organism isolated in cases of multivalvular endocarditis is Staphylococcus aureus [1]. Most cases of multivalvular endocarditis are associated with structural heart disease or intravenous drug abuse or transcatheter intracardiac device implantation. Mortality rate is more likely to be higher in patients with multivalvular endocarditis and these patients might require early surgical intervention for management of complications [2].

Right-sided endocarditis is reported to be responsible for 5-10% of total burden of infective endocarditis. It is mainly associated with predisposing factors such as central venous line, permanent wires or intravenous drug abuse. Eustachian valve endocarditis is reported to cause 3.3% among all cases [3]. Eustachian valve endocarditis is a very rare form of endocarditis reported first by Edwards et al [4]. Eustachian valve is benign rudimentary structure in adults which is the embryological remnant of sinus venosus which redirects oxygenated fetal blood from the inferior vena cava across foramen ovale and into left atrium in fetal life. Endocarditis of Eustachian valve is rare and found predominantly in patients with history of intravenous drug use [5]. Staphylococcus aureus is the most common cause of Eustachian valve endocarditis reported in literature [6]. Eustachian valve involvement in these patients could be due to direct damage caused to the valve by particulate matter during intravenous drug abuse or to secondary spread from the tricuspid insufficiency jet [5].

Our patient was a young 6-year-old boy with peri-membranous VSD who presented with multivalvular endocarditis along with Eustachian valve endocarditis. Patient improved within 1 week of starting antibiotic regimen and was discharged at the end of 4 weeks of antibiotic therapy. This case emphasizes on the importance of carefully scrutinizing all the cardiac valves in a patient with infective endocarditis of a cardiac valve.

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