Document Type

Conference Proceeding

Publication Date

5-2-2025

Abstract

Background: Right-sided infective endocarditis (RSIE), commonly associated with intravenous drug use (IVDU), primarily affects the tricuspid valve (TV). With sustained bacteremia, the pulmonic valve may also become involved. Staphylococcus aureus remains the leading cause of tricuspid valve infective endocarditis (TVIE), diagnosed using Duke’s criteria, which integrate clinical findings, blood culture results, and echocardiographic evidence. The management of TVIE poses unique challenges, particularly in patients with IVDU, who often face barriers to surgical intervention despite severe complications like tricuspid regurgitation (TR), which normally carries a poor prognosis if left untreated. Case Presentation: We describe the case of a 39-year-old female with a history of IVDU who presented with recurrent MRSA bacteremia and endocarditis involving both tricuspid and pulmonic valves. Her clinical course was complicated by severe TR, septic emboli, necrotizing fasciitis, and intracranial hemorrhages. During her previous hospital admission, despite evidence of worsening valvular dysfunction and systemic complications, she was deemed ineligible for surgical intervention due to active IVDU and was therefore managed with prolonged antimicrobial therapy, wound debridement, and multidisciplinary care. However, during her most recent hospital admission, despite having a flail leaflet and no surgical intervention during her previous admission, she was relatively asymptomatic from a cardiac standpoint and able to function well despite persistent severe TR and right atrial dilatation. Discussion: While early antimicrobial therapy can reverse some valvular damage, structural complications such as severe TR and ruptured chordae tendineae typically necessitate surgical intervention. However, in patients who are bacteremic, or who have active IVDU, surgical options are often limited, and these patients typically fare poorly. This case, however, highlights the remarkable adaptability of the right heart in severe TR and flail leaflet despite not receiving surgical intervention. Notably, the right heart's resilience allowed our patient to avoid significant symptomatic decline despite persistent severe TR. In contrast, severe mitral valve regurgitation in such a scenario would likely have resulted in extensive pulmonary edema and a significantly worsened clinical course. Nonetheless, the risk of progressive heart failure and recurrent infections remains a concern for patients with severe tricuspid valve endocarditis who do not undergo surgical intervention. In our patient, septic emboli contributed to extensive systemic complications, including pulmonary cavitations, pleural effusions, and neurologic sequelae, underscoring the importance of comprehensive multidisciplinary care. Addressing underlying IVDU through addiction treatment is also crucial to improving long-term outcomes and candidacy for surgical repair. Conclusion: This case illustrates the remarkable adaptability of the right heart in managing severe TR and a flail leaflet without surgical intervention. It also emphasizes the importance of early diagnosis and targeted treatment in RSIE and highlights the intricate relationship between infection, valvular dysfunction, and substance use. A multidisciplinary approach that integrates infection control with addiction management is essential for optimizing outcomes in this vulnerable population.

Comments

American College of Physicians Michigan Chapter and Society of Hospital Medicine Michigan Chapter 2025 Resident and Medical Student Day, May 2, 2025, Troy, MI

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