Case Presentation: A 65-year-old man presented to outside hospital post-fall with weakness, back pain and fever. He had sinus tachycardia, leukocytosis, and a meth-positive urine drug screen (UDS). Chest x-ray and CT abdomen/pelvis were unremarkable. Blood and urine cultures grew MRSA. Empiric antibiotics and infectious disease (ID) consult ordered. Transthoracic (TTE) and transesophageal (TEE) echocardiogram did not reveal vegetations. Blood cultures remained persistently positive until patient left against medical advice on day 12.He presented 4 days later afebrile with sinus tachycardia, leukocytosis, and a meth-positive UDS. CT showed a 5×4 cm left pelvic mass, contiguous with the prostate, consistent with prostatic abscess (PA). Blood cultures grew MRSA; ID recommended daptomycin and ceftaroline. Urology performed urgent transurethral resection of the prostate (TURP) with unroofing, draining copious purulent material. TTE was inconclusive. TEE revealed 1.7×0.8 cm echodense mass attached to the pulmonic valve’s anterior leaflet indicating native pulmonic valve endocarditis (PVE). Blood cultures cleared on day 6, and the patient was discharged with 6 weeks total of IV antibiotics. He remained asymptomatic at recent follow-up.
Discussion: Infective endocarditis (IE) incidence is 3-9 cases per 100,000. Right-sided IE is rare (5-10%) and isolated PVE causes less than 2%. PA is rare in the post-antibiotic era, commonly caused by gram-negative organisms or Enterococcus. Less than 50 MRSA PA cases are reported. Acute bacterial IE due to bacteremia from PA has only a few reported cases. The patient had two risk factors for PA: diabetes and IV drug use. His fever and back pain were non-specific, as PA and PVE often present. PA diagnosis is by transrectal US or CT/MRI. PVE diagnosis is challenging due to visualizing limitations. TEE is more sensitive than TTE except for large vegetations (>10mm), necessitating TEE in cases of suspicion despite negative TTE. The patient’s diabetes, IVDU, and delayed treatment predisposed PVE. Management of PA involves antibiotics and drainage, preferably with TURP to unroof the abscess. No surgical intervention was indicated for PVE, and patient improved after PA drainage with appropriate antibiotics.
Conclusions: PVE is rare and unaddressed in ACC/AHA guidelines. The rarity of MRSA bacteremia causing PA, coupled with the infrequency of isolated PVE, highlights the diagnostic complexity of dual pathologies. TURP and appropriate antibiotic therapy were pivotal in achieving a favorable outcome for the patient.