A 58‐year‐old man was admitted with a 5‐day history of shortness of breath, cough, and weakness. His medical history was remarkable for an 8‐month course of recurrent pneumonia and intermittent fevers He had been treated with multiple courses of antibiotics for presumed pneumonia. His symptoms continued to wax and wane and thus presented to the emergency department. The patient denied any history of recent dental work, IV drug abuse, or heart disease. He was afebrile but hypoxic. Pertinent physical exam findings were: lungs revealed bilateral crackles, whereas the cardiovascular exam was pertinent for a soft ll/VI systolic murmur best heard in the left upper parasternal border, with no radiation to the carotids There were no Osier's nodes or subungual hemorrhages. On laboratory data, WBC was 34 K/uL with 92% PMN, platelet count 40 K/μL, hemoglobin 8.3 mg/dL, creatinine 1 .8 mg/dL. CXR showed nodular opacities and pulmonary infiltrates bilaterally. CT of the chest revealed bilateral patchy infiltrative densities suggestive of an infectious process. Blood cultures were repeatedly negative. A transthoracic echocardiogram disclosed a large, mobile mass in Ihe right ventricular outflow tract (RVOT) which was attached to the right ventricular side of the medial leaflet of the pulmonic valve. The mass was partially calcified. A transesophageal echocardiogram confirmed a mass measuring 5.4 × 1.5 cm attached to the pulmonic valve. A diagnosis of isolated pulmonic valve endocarditis was made. Patient underwent pulmonary valve replacement and was discharge home soon Thereafter.
When infective endocarditis (IE) afflicts the pulmonic valve, it does so in conjunction with the tricuspid valve, but less commonly the mitral or aortic valve. Isolated pulmonic valve infective endocarditis (IPVIEJ, in the absence of risk factors, is a rare diagnosis that is often overlooked. Because of variability in clinical presentation, IPVIE poses a diagnostic challenge. Although the clinical features of left‐sided endocarditis are easier to identify, the constellation of symptoms of right‐sided endocarditis are nonspecific. Fever and respiratory manifestations are the most commonly observec symptoms in right‐sided endocarditis. The predominance of respiratory manifestations with subsequent clinical improvement with antibiotics allows these patients to be misdiagnosed as pneumonia. These patients are often treated initially as recurrent pneumonias before a diagnosis of infective endocarditis is entertained. Diagnosis is Ihus often missed or delayed and may take a year before it is made.
Isolated pulmonic valve endocarditis may be a more frequently encountered entity than commonly reported. This case serves to increase hospitalists awareness of the constellation of symptoms of IPVIE. Keeping a high index of suspicion in this potentially life threatening condition will help avoid undue delay in diagnosis and decrease morbidity and mortality.
T. Hamieh, none; M. Saha, none; V. Dimov, none; A. Kumar, none