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Fever in Postpartum Female Secondary to Tricuspid Valve Endocarditis FREE TO VIEW

Anup Shrestha, MD; Purnima Sharma, MD; Amit Kachalia, MD; Sethu Muralidharan, MD
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ICASM/Queens Hospital Center, Jamaica, NY

Chest. 2014;146(4_MeetingAbstracts):184A. doi:10.1378/chest.1995076
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SESSION TITLE: Infectious Disease Student/Resident Case Report Posters III

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Group B streptococcus (GBS) is an important organism causing fever in postpartum patient. Fever due to Tricuspid Valve endocarditis (TVE) is a rare condition. We present an interesting case of TVE causing postpartum fever.

CASE PRESENTATION: A 37-year-old female with no prior medical condition, had cesarean section 18 days prior to admission, comes in with non-productive cough, fever, shortness of breath of 4 days without orthopnea or paroxysmal nocturnal dyspnea. Physical examination was remarkable for fever, bilateral diffuse crackles, pansystolic murmur in the apex. Labs showed elevated white count 16.4k/mcl, positive D Dimer, ESR of 125. Chest x-ray revealed bilateral fluffy infiltrates. CT Chest showed small bilateral pleural effusion, patchy consolidation and ground glass opacities all over the lungs consistent with multifocal pneumonia with no pulmonary embolism. Echocardiography showed multiple large mobile masses attached to tricuspid valve with largest measuring 2.5 cm in length suggestive of vegetation. Ceftriaxone was started initially for pneumonia, which was switched to high dose penicillin G based on two-blood culture positive for GBS growth. Fever persisted intermittently for a 10 days due to large bacterial burden from septic pulmonary emboli. Follow up echocardiography showed significant reduction in the size of Tricuspid valve mass. Repeat blood cultures were negative for any growth. Her symptoms improved with 6 weeks of intravenous antibiotics.

DISCUSSION: Isolated native valve endocarditis is very rare valvular condition and accounts from 5-10% of infective endocarditis 1. IV drug abuse is the most common cause of TVE2. Staphylococcus aureus is the most common cause. Streptococcus species and gram-negative bacilli are other common causes1. Pulmonary symptoms of pneumonia and dislodged vegetative material are commonly seen than cardiac manifestations in TVE1, 2. Literature review has shown 31 cases of GBS endocarditis associated with pregnancy of which 6 of them colonized tricuspid valve. Fever and chills in postpartum woman should always raise suspicion of endometritis. However same symptoms with signs of multifocal pneumonia should raise suspicion of IE with septic emboli3.

CONCLUSIONS: TVE is a rarely caused by GBS. It manifests mostly as a pulmonary symptoms due to septic emboli.

Reference #1: Chan P, Ogilby J, Segal B. Tricuspid valve endocarditis. Am Heart J 1989;117:1140-6. Shimoni Z, Ben David M, Niven MJ e, Postpartum Group B Streptococcal Tricuspid Valve Endocarditis, The Israel Medical Association Journal 2006 Dec;8(12):883-4.

Reference #2: Sandre RM, Shafran SD. Infective endocarditis: Review of 135 cases over 9 years. Clin Infect Dis 1996;22:276-86.

Reference #3: Shimoni Z, Ben David M, Niven MJ e, Postpartum Group B Streptococcal Tricuspid Valve Endocarditis, The Israel Medical Association Journal 2006 Dec;8(12):883-4.

DISCLOSURE: The following authors have nothing to disclose: Anup Shrestha, Purnima Sharma, Amit Kachalia, Sethu Muralidharan

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