SCIENTIFIC LETTER TO THE EDITOR

Delayed Diagnosis of Infective Endocarditis in a Childwith a Normal Heart

Malika Minocha & Tanu Singhal & Suresh Rao &

Snehal Kulkarni

Received: 12 May 2011 /Accepted: 24 May 2012 /Published online: 15 June 2012# Dr. K C Chaudhuri Foundation 2012

Sir,A 12 y- old boy was admitted with high fever, and poor oralintake of 1 wk duration. Enteric fever was suspected andtreatment with ceftriaxone initiated. Fever continued withrise in WBC count and CRP and fall in platelets. The bloodculture was sterile and WIDAL was negative. Repeat ma-larial smears were negative and an abdominal ultrasoundshowed mild hepatosplenomegaly. Fever persisted and fea-tures of pneumonia appeared with tachypnea, hypoxemiaand left sided consolidation on CXR. CT scan chest showedbilateral pneumonia with mild effusion. In view of nonresponse to standard therapy, other unusual etiologies suchas mycoplasma, scrub typhus, community acquired MRSAwere considered and antibiotics upgraded to imipenem, line-zolid, doxycycline and levofloxacin. The repeat blood cul-ture grew methicillin sensitive S. aureus (MSSA). Owing toisolation of S. aureus and appearance of a soft systolicmurmur on the precordium, a 2- D ECHO was done whichshowed large pedunculated freely mobile vegetation at-tached to the septal leaflet of the tricuspid valve with milddilatation of right atrium and moderate tricuspid regurgita-tion. This clinched the diagnosis of staphylococcal infectiveendocarditis with septic pulmonary embolism.

Antibiotics cloxacillin and gentamycin were started asper standard recommendations. Over the next 1 wk, the

fever completely resolved but the vegetation became morefriable and mobile. Hence, vegetectomy and tricuspid valverepair was performed. Culture from tricuspid vegetation wassterile. IV cloxacillin was given for 4 wks. At 3 mo followup the child is asymptomatic with a near normal ECHO.

The absence of classical risk factors, the faint murmur oftricuspid regurgitation and failure to auscultate on a dailybasis possibly led to delay in the diagnosis in the index case.The usual risk factors for TVE (Tricuspid Valve Endocarditis)include intravenous drug use, intracardiac catheterization, car-diac anomalies, immunodeficiency and indwelling centralvenous lines [1]. However TVE in children and adults withnormal hearts and no risk factors have been reported with ahigh incidence of pulmonary embolism, sudden death, needfor surgical intervention and poor surgical outcome [2-4]. Theclassical indications for surgical intervention in right sidedendocarditis are persistent sepsis (intractable right heart failureor recurrent pulmonary embolism [5]. In the index case clin-ical and microbiologic cure had been achieved. However, inview of the largemobile and friable vegetation and in light of aprevious case reports wherein children died suddenly due topulmonary embolism, a decision to surgically intervene wastaken.

Infective endocarditis should be considered as a differentialdiagnosis in patients with prolonged pyrexia even if classicalrisk factors are absent. Meticulous and daily clinical cardio-vascular evaluation is a must in all patients.

References

1. Nandakumar R, Raju G. Isolated tricuspid valve endocarditis innonaddicted patients: a diagnostic challenge. Am J Med Sci.1997;314:207–12.

M. Minocha : T. Singhal (*)Department of Pediatrics, Kokilaben Dhirubhai Ambani Hospitaland Medical Research Institute,Andheri (W), Mumbai 400056, Indiae-mail: tanusinghal@yahoo.com

S. Rao : S. KulkarniDepartment of Pediatric Cardiology and Cardiothoracic Surgery,Kokilaben Dhirubhai Ambani Hospital and Medical ResearchInstitute,Andheri (W), Mumbai, India

Indian J Pediatr (February 2013) 80(2):173–174DOI 10.1007/s12098-012-0803-z

2. Levin SE, Dansky R, Benatar A, Milner S. Tricuspid valve endo-carditis on a healthy valve—potentially lethal in infants and youngchildren. Cardiol Young. 1992;2:191–5.

3. Karthikeyan G, Nalini P, Sethuraman KR. Tricuspid valve endocar-ditis in a child with structurally normal heart. Indian Pediatr.1996;33:692–4.

4. Clifford CP, Eykyn SJ, Oakley CM. Staphylococcal tricuspid valveendocarditis in patients with structurally normal hearts and noevidence of narcotic abuse. QJM. 1994;87:755–7.

5. Barbosa Filho J, Castier MB, AlBanesi Filho FM, Christiani LA,Jazbik W, Meier MA. Surgical treatment of high-risk valvularendocarditis. Arq Bras Cardiol. 1989;53:211–5.

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