Profile of right-sided endocarditis: an Indian experience

Unusual Case of Right-Side Infective Endocarditis in a 40-Year-Old Woman with Postpartum Endometritis: A Case Report

Rarely observed during pregnancy and the postpartum period, right side infective endocarditis (IE) is particularly uncommon among non-drug-addicted individuals. Nonetheless, if it does occur, it poses significant health risks for both the mother and the fetus, even in the absence of pre-existing heart diseases. This case report describes a rare presentation of right-sided IE (IE) in a 40-year-old woman from rural Ethiopia with postpartum endometritis. The patient presented with atypical symptoms, making it challenging to identify the underlying cause. Through careful diagnostic evaluation and a multidisciplinary approach, the team successfully diagnosed and treated the patient, highlighting the importance of swift and accurate diagnosis for managing uncommon right-sided IE cases.

Clinical characteristics and outcome of infective endocarditis among intravenous drug abusers in India

INTRODUCTION

Infective endocarditis (IE) is the most dreaded complication of intravenous drug abuse (IVDA). IVDA is present in significant proportions in India. Since there is scarcity of Indian data on IVDA associated IE, we report a study comparing IVDA to non IVDA associated IE. We compare differences in clinical profile, microbiology, echocardiography and clinical outcome from a tertiary care hospital.

METHODS

A total of 133 patients admitted from 1st January 2017 to 31st December 2019 who met the Modified Duke ''definitive'' criteria for IE were included. Detailed Information was collected regarding demography, clinical data and laboratory investigations. All patients underwent transthoracic echocardiography and trans-esophageal echocardiogram wherever necessary.

RESULTS

Among a total of 133 patients, 54 patients (40.6%) were iv drug abusers. Patients in IVDA-group were younger, mostly males, more likely to have concomitant HCV and HIV infections compared to non IVDA-group. Chronic comorbidities such as DM and CKD were more common in non IVDA-group. Rate of positive blood culture was higher in IVDA-group compared to non IVDA-group (74.1%v/s 32.9%,p < 0.001) with different microbiological profile. Percentage of Methicillin resistant staphylococcus aureus (42.6%v/s17.7%,p = 0.003) and pseudomonas related IE (18.5%v/s2.5%,p = 0.003) was significantly higher among IVDA-group. IVDA-group most commonly had tricuspid valve involvement Whereas mitral and aortic valve were most commonly involved valve in non IVDA-group. Mortality was slightly higher among IVDA-group compared to non IVDA-group, though statistically non-significant. Left sided valve involvement and Congestive heart failure were independent predictors of mortality.

CONCLUSION

IVDA-IE is a significant problem in India. Demographic, microbiological and echocardiographic profile is quite different in IVDA and non IVDA-group. There is urgent need to conduct larger studies.

Tricuspid valve endocarditis in non-drug abusers: A case series from India

Objective

The etiology of tricuspid valve endocarditis (TVE) seems to be different in our country as intravenous (IV) drug abuse is not known to be a major health hazard. The objective of this communication is to study the risk factors, clinical profile, follow-up data of TVE patients and focus on the difficulties in diagnosis and variations encountered.

Methods

A retrospective analysis of data of 10 patients of TVE managed in a tertiary care center during January 1992 to June 2015 was done.

Results

TVE was encountered in a diverse subset of patients with cardiac implantable electronic device (CIED) (group I; 3 patients), immunocompromised state with indwelling central venous catheter (CVC) (group II; 2 patients), congenital heart disease (CHD) (group III; 3 patients) and in apparently healthy individuals (group IV; 2 patients). Blood cultures were negative in half the patients. In group I early surgical extraction of leads, device and vegetation provided excellent results. Prognosis was poor with 100% mortality in immunocompromised patients. Patients in group III did well on medical management. The overall mortality was high (30% in hospital and additional 20% within one year).

Conclusions

TVE is rare and can occur in different clinical scenarios. Indiscriminate use of antibiotics modifies the clinical picture causing delay in diagnosis and referral to speciality care. Echocardiography remains the main modality and should be used serially to facilitate early diagnosis. The prognosis is guarded. Early surgery is recommended in pacemaker lead, fungal endocarditis, persistent sepsis or hemodynamic instability for favorable prognosis.

Pregnancy and postpartum infective endocarditis: a systematic review

The objective of this review was to describe the clinical characteristics, risk factors, and outcomes of infective endocarditis (IE) in pregnancy and the postpartum period. We conducted a systematic review of Ovid MEDLINE, Ovid Embase, Web of Science, and Scopus from January 1, 1988, through October 31, 2012. Included studies reported on women who met the modified Duke criteria for the diagnosis of IE and were pregnant or postpartum. We included 72 studies that described 90 cases of peripartum IE, mostly affecting native valves (92%). Risk factors associated with IE included intravenous drug use (14%), congenital heart disease (12%), and rheumatic heart disease (12%). The most common pathogens were streptococcal (43%) and staphylococcal (26%) species. Septic pulmonary, central, and other systemic emboli were common complications. Of the 51 pregnancies, there were 41 (80%) deliveries with survival to discharge, 7 (14%) fetal deaths, 1 (2%) medical termination of pregnancy, and 2 (4%) with unknown status. Maternal mortality was 11%. Infective endocarditis is a rare, life-threatening infection in pregnancy. Risk factors are changing with a marked decrease in rheumatic heart disease and an increase in intravenous drug use. The cases reported in the literature were commonly due to streptococcal organisms, involved the right-sided valves, and were associated with intravenous drug use.

Native valve right sided infective endocarditis

Right-sided infective endocarditis (RSIE) accounts for 5-10% of all cases of infective endocarditis (IE), and is predominantly encountered in the injecting drug user (IDU) population, where HIV and HCV coinfections often coexist. Staphylococcus aureus is the most common pathogen. The pathogenesis of RSIE is still not well understood. RSIE usually presents as a persistent fever with respiratory symptoms whilst signs of systemic embolisation as seen in left-sided IE are notably absent. The prompt diagnosis of RSIE thus requires a high index of suspicion. Transthoracic echocardiography (TTE) can detect the majority of RSIE, whilst transoesophageal echocardiography (TOE) can increase sensitivity. Virulence of the causative organism and vegetation size are the major determinants of prognosis. Most cases of RSIE resolve with appropriate antibiotic administration.

Right-sided infective endocarditis: surgical management

Right-sided infective endocarditis (RSIE) accounts for 5-10% of all cases of infective endocarditis and is predominantly encountered among injecting drug users (IDUs). RSIE diagnosis requires a high index of suspicion as respiratory symptoms predominate. Prognosis of isolated RSIE is favourable, and most cases (70-80%) resolve following antibiotic administration. Surgical intervention is indicated in patients with persistent infection that does not respond to antibiotic therapy, recurrent pulmonary emboli, intractable heart failure and if the size of a vegetation increases or persists at >1 cm. Techniques can be divided into 'prosthetic' (valve replacement or prosthetic annular implantation) or 'non-prosthetic' ones (Kay's or De Vega's annuloplasty, bicuspidalization or valvectomy). In IDUs who run a high risk of complications, vegetectomy and valve repair, avoiding artificial material should be considered as the first line of surgical management as is associated with better late survival.

Right-side endocarditis in injection drug users: review of proposed mechanisms of pathogenesis

Infective endocarditis of the right-side heart valves occurs commonly in injection drug users. Although a variety of hypotheses have been put forward to explain this clinical observation, no single hypothesis is adequate. In this article, basic scientific, clinical, and microbiological data on this topic are presented. It is apparent that no clear unifying mechanism emerges to explain the well-documented clinical predilection for the infection of the right-side heart valves in this population. Further investigation of this topic utilizing large international clinical registries may help to clarify matters further.

Hemolytic anemia in native valve infective endocarditis: a case report and literature review

Hemolytic anemia is a rare manifestation of infective endocarditis. A 19-year-old man with a small ventricular septal defect developed right-sided infective endocarditis with huge vegetations involving the tricuspid valve, the ventricular septal defect, and the pulmonary valve. Intravascular hemolysis was suggested by the presence of numerous fragmented erythrocytes, giant platelets and polychromasia of the red blood cells. The direct Coombs test was positive, and there were spherocytes and splenomegaly, findings that suggested an immune-mediated mechanism also played a role in the hemolysis. The hematological picture persisted despite antibiotic therapy and recovered only after surgical removal of the vegetations, tricuspid and pulmonary valvectomy, and patch closure of the ventricular septal defect.

Infective endocarditis in congenital heart disease

The average life expectancy of patients with congenital heart disease has dramatically improved over the past four decades because of advances in medical and surgical therapy, with patients with complex lesions surviving to adolescence and adulthood. Tetralogy of Fallot, transposition of the great arteries, ventricular septal defects, patent ductus, and bicuspid aortic valves in particular are susceptible to infective endocarditis. Most operated patients are left with some form of residua or sequelae, many of which predispose to infective endocarditis. Surgical palliation, such as systemic-to-pulmonary shunts, and reparative surgery, often requiring prosthetic valve or conduit replacement, are major predisposing conditions. Accordingly, recognition, prevention, and treatment strategies for infective endocarditis assume increasing importance in adolescents and adults with congenital heart disease, operated or not.

Active infective endocarditis observed in an Indian hospital 1981-1991

Clinical data from 186 patients (133 males and 53 females) with 190 episodes of infective endocarditis (IE) occurring between January 1981 and July 1991 were studied retrospectively at a large referral hospital in Northern India with the intention of highlighting certain essential differences from those reported in the West. The mean age was much lower (25 +/- SD 12 years, range 2 to 75 years). Rheumatic heart disease was the most frequent underlying heart lesion accounting for 79 patients (42%). This was followed by congenital heart disease in 62 (33%) and normal valve endocarditis in 17 (9%). Twenty-four patients had either aortic regurgitation (n = 15) or mitral regurgitation (n = 9) of uncertain etiology. Prosthetic valve infection and mitral valve prolapse were present in only 2 patients each. A definite predisposing factor could be identified in only 28 patients (15%). Postabortal sepsis and sepsis related to childbirth accounted for 6 and 5 cases, respectively. Only 1 patient had history of intravenous drug abuse. Two-dimensional echocardiography showed vegetations in 121 patients (64%). Blood cultures were positive in only 87 (47%), with a total of 90 microbial isolates. Commonest infecting organisms were staphylococci (37 cases) and streptococci (34 cases). Except for a significantly higher number of patients with neurologic complications in the culture-negative group, there were no differences between patients with culture-positive and culture-negative IE. Of the 190 episodes of IE, the patients had received antibiotics before admission in 110 (58%) instances. A significantly greater number of culture-negative patients had received antibiotics than did culture-positive patients (87 vs 23, p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)