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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 11  |  Issue : 4  |  Page : 226-228

Rare or rarely detected: Septic pulmonary embolism with tricuspid valve infective endocarditis after an unsafe abortion


Department of Cardiology, All India Institute of Medical Sciences (AIIMS), Rishikesh, India

Date of Submission05-Sep-2020
Date of Decision04-Oct-2020
Date of Acceptance04-Oct-2020
Date of Web Publication27-Nov-2020

Correspondence Address:
Dr. Shishir Soni
808, Building Number 85, All India Institute of Medical Sciences, Rishikesh Campus, Veerbhadra Road, Rishikesh, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/INJMS.INJMS_109_20

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  Abstract 


Septic pulmonary embolism (SPE) with isolated tricuspid valve infective endocarditis (TVIE) after an unsafe abortion is an uncommon condition. However, unsafe abortion is common among reproductive-age women, especially in underdeveloped and developing countries contributing significantly to increased maternal mortality. As infective endocarditis and SPE are likely to be missed in transthoracic echocardiography and chest X-ray, respectively, in its incipient stage, there is a possibility that many cases of SPE with TVIE following such a predisposing condition may remain undiagnosed. We report a case of 26-year-old female with recent unsafe abortion who was diagnosed to have SPE with TVIE. Her clinical course depicts the possibility of missing the diagnosis, especially if subtle findings are overlooked that are emphasized in this case report.

Keywords: Septic pulmonary embolism, tricuspid valve infective endocarditis, unsafe abortion


How to cite this article:
Kumar B, Chauhan G, Soni S, Singh A. Rare or rarely detected: Septic pulmonary embolism with tricuspid valve infective endocarditis after an unsafe abortion. Indian J Med Spec 2020;11:226-8

How to cite this URL:
Kumar B, Chauhan G, Soni S, Singh A. Rare or rarely detected: Septic pulmonary embolism with tricuspid valve infective endocarditis after an unsafe abortion. Indian J Med Spec [serial online] 2020 [cited 2021 Mar 4];11:226-8. Available from: http://www.ijms.in/text.asp?2020/11/4/226/301717




  Introduction Top


Septic pulmonary embolism (SPE) is a known complication after infective endocarditis (IE); however, its prevalence among patients with IE is <6%.[1] SPE in association with Tricuspid valve infective endocarditis (TVIE) after an unsafe abortion has been described in a few case-reports only.[2] IE with isolated involvement of tricuspid valve (TV) is rare in the absence of predisposing conditions such as intravenous drug abuse.[3] However, unlike SPE with TVIE, which is an uncommon condition, unsafe abortion is common among reproductive-aged women, especially in underdeveloped and developing countries contributing to around 13% of maternal mortality each year globally.[4] IE and SPE are likely to be missed in transthoracic echocardiography (TTE) and chest X-ray, respectively, in its incipient stage. We report such a case depicting the clinical course, diagnostic and therapeutic challenges encountered in managing TVIE with SPE after an unsafe abortion.


  Case Report Top


A 26-year-old female was referred from a peripheral hospital with complaints of amenorrhea for 3 months; fever, abdominal pain, and per vaginal discharge for 25 days, which had worsened for 7 days with breathlessness for 5 days. On further inquiring about the history of amenorrhea, it was found that she underwent urine-pregnancy test 2 months back, which came out to be positive following which she underwent an abortion at her home (unsafe abortion). At the peripheral hospital, she underwent cervical dilatation and curettage, 10 days back. There, she was diagnosed to have severe anemia (hemoglobin of 5 g/dL) with sepsis (total leukocyte count of 25,000/mm3) and was treated with blood transfusion and intravenous antibiotics for 10 days and then referred to a higher center for further management following lack of any improvement. At the time of presentation, she was febrile, with a respiratory rate of 28/min, the regular pulse at 122/min, blood pressure of 100/74 mmHg, and desaturated at room air with oxygen saturation of 85%. Immediate gynecological consultation and examination were done, which revealed bleeding per vaginum. Cardiovascular examination suggested findings of associated tricuspid regurgitation (TR) with grade 3/6 murmur at left parasternal border increasing on inspiration. She had a tender lower abdomen. The electrocardiogram showed sinus tachycardia. TEE showed a large mobile (10 mm) vegetation on the anterior tricuspid leaflet with severe TR [Figure 1]. On chest X-ray, bilateral infiltrates were present following which she underwent computed tomography (CT) chest with pulmonary angiography to rule out acute pulmonary thromboembolism. Her CT chest revealed diffuse bilateral infiltrates and airspace opacities with multiple cavitations in bilateral upper and lower lobes of the lung and moderate right pleural effusion with filling defect in the right inferior pulmonary artery extending into lower-order vessels suggesting pulmonary artery embolism of the right pulmonary artery and inferior division [Figure 1]a, [Figure 1]b, [Figure 1]c. On further workup, there was no evidence of venous thrombosis in ultrasonography with Doppler of the bilateral lower limb. Venous duplex did not show any evidence of deep venous thrombosis of lower extremities. Ultrasound abdomen and pelvis showed no free fluid in the pelvis and no retained product of conceptus. Three blood cultures were withdrawn from three different peripheral sites, at an interval of 30 min, before administration of antibiotic therapy and two subsequent blood cultures at 24 h and 48 h of therapy were negative for any growth. She was managed for TVIE and SPE with intravenous vancomycin for 6 weeks along with other supportive measures. She improved symptomatically and on repeated TTE, the size of vegetation reduced to 7 mm. She was discharged on the 45th day of hospitalization.and was asymptomatic at 1 month of follow-up postdischarge.
Figure 1: (a-d) An intraluminal filling defect in the right pulmonary artery and its inferior division detected in computed tomography pulmonary angiography as shown by red arrows (a and b), bilateral pulmonary nodules in computed tomography chest (c), large vegetation on the tricuspid valve leaflet found on transthoracic echocardiography as shown by yellow arrows (d)

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  Discussion Top


SPE is an uncommon condition in which micro-organisms implant in the vascular system of the lungs as a result of embolization from infectious nidus such as TV vegetation, infected venous catheter, septic thrombophlebitis, or rarely from periodontal disease.[5],[6] This case demonstrates that reluctance to seek medical attention has led to SPE with isolated TVIE in a patient following unsafe abortion. This clinical entity of SPE with isolated TVIE is rare in literature, unlike unsafe abortion. This patient underwent echocardiography following clinical suspicion of TR and underwent CT of the chest and pulmonary angiography after finding large vegetation on TTE. CT chest to look for an embolic phenomenon is part of the standard workup for IE with large vegetation.[7] However, in other situations, this patient would have been managed as a case of sepsis only as there were subtle findings on chest X-ray that would not warrant immediate CT. Blood cultures were also negative; thus, it was timely done TTE which revealed the underlying disease. Such cases are likely to have two consequences if underlying IE remains unrevealed. One is the worsening of the underlying condition with the worst outcomes. Another is an improvement (partial or complete) following the administration of higher antibiotics for sepsis. The latter condition has two major implications. First is the underreporting of such a clinical entity. Second is the unrevealed candidacy of such patients to receive IE prophylaxis when indicated. As per the latest recommendation, patients with a prior history of IE are candidates for IE prophylaxis. Considering the limited availability of TTE and CT at peripheral health-care centers, along with subtle findings on other investigations, such a condition may remain unnoticed. Another important aspect was the finding of large vegetation on TTE; however, if vegetation would have been smaller enough to be neglected on TTE then again this condition would have been missed until a strong suspicion for IE warranted transesophageal echocardiography (TEE). Chest CT is important in the diagnosis of SPE. Multiple peripheral nodules with predominantly basilar distribution with or without cavitation are common findings in SPE reported in previous studies.[5],[8] However, the facility of TEE and CT is not available widely, especially in developing and underdeveloped countries. This patient was improved after the administration of intravenous vancomycin for 6 weeks, which is one of the recommended regimens to manage a case of IE with the background of unsafe abortion and negative blood cultures. The patient was not given any anticoagulant therapy as anticoagulation for SPE is not indicated.[9] This case clearly emphasizes the role of clinical acumen and timely done investigation in managing such a rare clinical entity which might be a rarely detected condition as well.

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 initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

None.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Song XY, Li S, Cao J, Xu K, Huang H, Xu ZJ. Cardiac septic pulmonary embolism: A retrospective analysis of 20 cases in a Chinese population. Medicine (Baltimore) 2016;95:e3846.  Back to cited text no. 1
    
2.
Piedimonte S, Almohammadi M, Lee TC. Group B Streptococcus tricuspid valve endocarditis with subsequent septic embolization to the pulmonary artery: A case report following elective abortion. Obstet Med 2018;11:39-44.  Back to cited text no. 2
    
3.
Georges H, Leroy O, Airapetian N, Lamblin N, Zogheib E, Devos P, et al. Outcome and prognostic factors of patients with right-sided infective endocarditis requiring intensive care unit admission. BMC Infect Dis 2018;18:85.  Back to cited text no. 3
    
4.
WHO Database. Preventing Unsafe Abortion. Available from: https://www.who.int/news-room/fact-sheets/detail/preventing-un\safe-abortion. Last accessed on 2020 Sep 01.  Back to cited text no. 4
    
5.
Cook RJ, Ashton RW, Aughenbaugh GL, Ryu JH. Septic pulmonary embolism: Presenting features and clinical course of 14 patients. Chest 2005;128:162-6.  Back to cited text no. 5
    
6.
Shiota Y, Arikita H, Horita N, Hiyama J, Ono T, Ohkawa S, et al. Septic pulmonary embolism associated with periodontal disease: Reports of two cases and review of the literature. Chest 2002;121:652-4.  Back to cited text no. 6
    
7.
Habib G, Lancellotti P, Antunes MJ, Bongiorni MG, Casalta JP, Del Zotti F, et al. ESC Scientific Document Group. 2015 ESC Guidelines for the management of infective endocarditis. Eur Heart J 2015;36:3075-128.  Back to cited text no. 7
    
8.
Kuhlman JE, Fishman EK, Teigen C. Pulmonary septic emboli: Diagnosis with CT. Radiology 1990;174:211-3.  Back to cited text no. 8
    
9.
Aslam AF, Aslam AK, Thakur AC, Vasavada BC, Khan IA. Staphylococcus aureus infective endocarditis and septic pulmonary embolism after septic abortion. Int J Cardiol 2005;105:233-5.  Back to cited text no. 9
    


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