School of Medicine and Health Sciences Poster Presentations

Title

Tricuspid Pseudomonas Endocarditis with Rare Sequelae of Left-Sided Endocarditis: Subarachnoid Hemorrhage

Poster Number

275

Document Type

Poster

Status

Medical Resident

Abstract Category

Immunology/Infectious Diseases

Keywords

Pseudomonas Endocarditis, Subarachnoid Hemorrhage, Tricuspid Endocarditis, Pseudomonas Aeruginosa

Publication Date

Spring 2018

Abstract

Case: A 60 year-old female with recent intravenous drug use (IDVU), presented with a week of cough, shortness of breath, orthopnea, and lower extremity edema. On physical examination the patient was afebrile, tachycardic, and tachypneic. She had lower extremity edema and bibasilar crackles but a normal cardiac examination without murmur. Labs were significant for leukocytosis to 18,000, acute kidney injury (AKI) with creatinine of 2.9, and an elevated BNP to 11,000. CT chest revealed innumerable septic pulmonary emboli. Subsequent transthoracic echocardiograms (TTE) revealed multiple vegetations on the tricuspid valve (largest >1cm), mild tricuspid regurgitation, mild thickening of aortic valve with moderate aortic regurgitation, and no patent foramen ovale. Due to altered mental status, CT head and MRI was performed and revealed a subarachnoid hemorrhage (SAH). MRA was negative for aneurysm but showed reduced flow in the V4 segment of the left vertebral artery. Treatment for infective endocarditis (IE) was started with vancomycin and piperacillin/tazobactam. Blood cultures returned positive for P. aeruginosa with antibiotics adjusted to meropenem and ceftazidine. Cultures cleared after gentamicin was added after renal function improved.

Discussion: Pseudomonas Aeruginosa is a rare cause of IE seen most often with concomitant IVDU. Prior case studies have reported left-sided pseudomonas endocarditis. This, however, is the first reported case of tricuspid involvement. TTE showed possible left sided involvement, which has a higher mortality rate than right sided endocarditis though a transesophageal echocardiogram was unable to be performed for confirmation. IE may have multiple neurological sequelae, but SAH is certainly a rarer complication and commonly results from mycotic aneurysm rupture or left sided cardiac vegetations. A review of the literature does not reveal any case reports of tricuspid valve pseudomonal endocarditis associated with SAH, further raising the suspicion of undiagnosed left-sided involvement. Typical treatment for pseudomonas endocarditis includes an aminoglycoside and a secondary pseudomonal agent in combination with surgery. While our patient met multiple criteria for early surgical intervention such as signs and symptoms of heart failure, difficult-to-treat pathogen, and persistent infection, this was unable to be performed due to her SAH. Despite this our patient improved steadily with medical therapy alone. This case highlights SAH as a rare neurological complication of IE with a first report of its association with pseudomonal endocarditis secondary to IVDU, which generally predisposes to right-sided involvement though our patient likely also had left-sided involvement that may have precipitated her neurological sequelae.

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Tricuspid Pseudomonas Endocarditis with Rare Sequelae of Left-Sided Endocarditis: Subarachnoid Hemorrhage

Case: A 60 year-old female with recent intravenous drug use (IDVU), presented with a week of cough, shortness of breath, orthopnea, and lower extremity edema. On physical examination the patient was afebrile, tachycardic, and tachypneic. She had lower extremity edema and bibasilar crackles but a normal cardiac examination without murmur. Labs were significant for leukocytosis to 18,000, acute kidney injury (AKI) with creatinine of 2.9, and an elevated BNP to 11,000. CT chest revealed innumerable septic pulmonary emboli. Subsequent transthoracic echocardiograms (TTE) revealed multiple vegetations on the tricuspid valve (largest >1cm), mild tricuspid regurgitation, mild thickening of aortic valve with moderate aortic regurgitation, and no patent foramen ovale. Due to altered mental status, CT head and MRI was performed and revealed a subarachnoid hemorrhage (SAH). MRA was negative for aneurysm but showed reduced flow in the V4 segment of the left vertebral artery. Treatment for infective endocarditis (IE) was started with vancomycin and piperacillin/tazobactam. Blood cultures returned positive for P. aeruginosa with antibiotics adjusted to meropenem and ceftazidine. Cultures cleared after gentamicin was added after renal function improved.

Discussion: Pseudomonas Aeruginosa is a rare cause of IE seen most often with concomitant IVDU. Prior case studies have reported left-sided pseudomonas endocarditis. This, however, is the first reported case of tricuspid involvement. TTE showed possible left sided involvement, which has a higher mortality rate than right sided endocarditis though a transesophageal echocardiogram was unable to be performed for confirmation. IE may have multiple neurological sequelae, but SAH is certainly a rarer complication and commonly results from mycotic aneurysm rupture or left sided cardiac vegetations. A review of the literature does not reveal any case reports of tricuspid valve pseudomonal endocarditis associated with SAH, further raising the suspicion of undiagnosed left-sided involvement. Typical treatment for pseudomonas endocarditis includes an aminoglycoside and a secondary pseudomonal agent in combination with surgery. While our patient met multiple criteria for early surgical intervention such as signs and symptoms of heart failure, difficult-to-treat pathogen, and persistent infection, this was unable to be performed due to her SAH. Despite this our patient improved steadily with medical therapy alone. This case highlights SAH as a rare neurological complication of IE with a first report of its association with pseudomonal endocarditis secondary to IVDU, which generally predisposes to right-sided involvement though our patient likely also had left-sided involvement that may have precipitated her neurological sequelae.