Presenter: Jacob Cecil, MD, Resident
University of California, San Francisco
Authors: Jacob Cecil, MD
Martin Stechert, MD (Faculty Mentor)
Background:
Isolated pulmonic valve endocarditis is rare; approximately 90 cases have been reported. Risk factors include sepsis, congenital heart disease, pulmonic valve lesions, central venous catheters, and ESRD requiring dialysis. Low index of suspicion, subtle, nonspecific presentation, and difficulty visualizing the pulmonic valve with echocardiography make diagnosis challenging.
Case Description:
A 71 year old male with a past medical history significant for DMII, CAD s/p CABG, Afib, ESRD on hemodialysis, and severe lower extremity peripheral vascular disease with previous bypass surgery complicated by chronic lower extremity wounds and recurrent bacteremia presented to the hospital with findings concerning for angioedema. During his admission, he was found to have VRE bacteremia. He was taken to the operating room for below-knee amputation given concern for vascular graft infection as a source of his recurrent bacteremia. During intraoperative TEE, an oscillating hyperechoic structure was visualized in multiple views adjacent to the pulmonic valve. This hyperechoic structure was not seen previously on TTE or TEE, and it was not visualized on postoperative TTE. After Cardiology and Infectious Disease consultations, this patient was not diagnosed with endocarditis.
Discussion:
This study highlights that pulmonic valve endocarditis is a clinical diagnosis, although often supported by echocardiographic evidence. In rare or atypical presentations, repeat echocardiography or alternative modalities such as Cardiac CT can be useful in further characterizing suspicious findings as vegetation, thrombus, soft tissue mass, calcification, artifact, or even air.
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