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Pediatric Oncall Journal

Right-Sided Infective Endocarditis with Ventricular Septal Defect 01/09/2014 00:00:00

Right-Sided Infective Endocarditis with Ventricular Septal Defect

Amar Taksande.
Department of Pediatrics, Jawaharlal Nehru Medical College, Sawangi Meghe, Wardha, Maharashtra, India.

Dr. Amar M Taksande, Department of Pediatrics, Jawaharlal Nehru Medical College, Sawangi Meghe, Wardha, Maharashtra -442102.
Ventricular septal defect, Infective endocarditis, Tricuspid valve.
An 8 years old boy presented with fever, chest pain and palpitations for 1 month. There were no joint pains, hematuria, blurring of vision, convulsions or bleeding manifestations. On examination, he was febrile and had pallor. Heart rate was 110/min, blood pressure 90/70 mmHg and respiratory rate was 24/min. There was no clubbing, cyanosis, Osler nodes or Janeway lesions. Jugular venous pressure was not raised. Pedal edema was present. On cardiac auscultation, wide and variable split of the second heart sound and pansystolic murmur of grade 4/6 in the left parasternal area was present. Other systems were normal except for a mild splenomegaly. Investigations revealed hemoglobin 6g /dl, total leucocyte count 7000/cumm (neutrophils 70%,lymphocytes 25%, eosinophils 3%), platelet count 150,000/cumm and ESR of 45mm. Cardiothoracic ratio on X-ray chest was 0.5. Echocardiography revealed small size (4mm) perimembranous type of ventricular septal defect (VSD) (gradient 80mmHg) with left to right shunt. Apical four chamber view showed vegetations 5x5 mm in size on the leaflet of tricuspid valve. Blood culture was sterile. Injection crystalline penicillin and gentamycin therapy were started. Patient was discharged on day 12 because of persistent request. Oral Amoxycillin was continued for six weeks. On follow up, echocardiography revealed no change in the size of vegetation but the patient?s clinical condition had improved. Later on, patient was referred to higher center for surgical management.
Infective endocarditis (IE) includes acute and subacute bacterial endocarditis as well as nonbacterial endocarditis caused by fungi, and other microbiologic agents. Viridians type streptococci and staphylococcus aureus are the leading causative agent responsible for endocarditis in pediatrics patients. (1) Right-sided endocarditis usually occurs in intravenous drug abusers, patients receiving intensive care with peripheral and central venous catheters and other sources include pacemakers, skin or gynecologic infections, and rarely due to bacteremia in patients having congenital cardiac lesions such as left-to-right shunts. (2,3) Children with tetralogy of fallot, aortic stenosis, patent ductus arteriosus, transposition of great arteries and Blalock-Taussig shunts are the most frequent structural lesion associated with endocarditis. (3) Tricuspid valve is more often involved than the pulmonary valve and the principal responsible pathogen is S.aureus. In our patient with VSD, vegetations involving the tricuspid valve were seen. Among patients with VSD, Di Filippoet al found only 36 cases of infective endocarditis from 1966 to 2002 of which 26 had an isolated VSD and 10 had VSD associated with a minor lesion. (4) VSD is a benign cardiac lesion, the prognosis of which can be severely compromised by infectious endocarditis, surgical repair reduces the risk but does not totally exclude it because of minor associated abnormalities.The surgical treatment of infective endocarditis with VSD are closure of the defect and valve replacement, simple valve excision without valve replacement or resection of the vegetation ("vegetectomy"). (2-5) Prognosis of patients after VSD closure and vegetectomy is good.
Compliance with Ethical Standards
Funding None
Conflict of Interest None
  1. Acer J, Michel PL. Right-heart valve disease and endocarditis. In: Crawford MH, DiMarco JP, ed. Cardiology, 1st ed. London. Mosby; 2001: 14.1-14.15.
  2. Carrel T, Schaffner A, Vogt P, Laske A, Niederhauser U, Schneider J et al. Endocarditis in intravenous drug addicts and HIV infected patients: possibilities and limitations of surgical treatment. J Heart Valve Dis. 1993; 2: 140-147.  [PubMed]
  3. Renzulli A, De Feo M, Carozza A, Della Corte A, Gregorio R, Ismeno G et al. Surgery for tricuspid valve endocarditis: a selective approach. Heart Vessels.1999; 14: 163-169.  [CrossRef]  [PubMed]
  4. Di Filippo S, Semiond B, Celard M, Sassolas F, Vandenesch F, Ninet J et al. Characteristics of infectious endocarditis in ventricular septal defects in children and adults. Arch Mal Coeur Vaiss. 2004; 97: 507-514.  [PubMed]
  5. Hanada T, Yamauchi M, Sasaki T, Nosaka S, Ku K, Nakayama K. Tricuspid valvereplacement for infectious endocarditis associated with ventricular septal defect-report of three cases. Nippon Kyobu Geka Gakkai Zasshi 1997; 45: 1612-1615.  [PubMed]


Cite this article as:
Taksande A. RIGHT-SIDED INFECTIVE ENDOCARDITIS wITH VENTRICULAR SEPTAL DEFECT. Pediatr Oncall J. 2013;10: 122. doi: 10.7199/ped.oncall.2013.56
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