Uncommon Cardiac Manifestations of Left-sided Pseudomonas Endocarditis in an Intravenous Drug Abuser with an Undiagnosed Atrial Septal Defect

Abstract

A 56-year-old male, who is an active intravenous drug abuser (IVDA) (heroin) with a history of diabetes, hypertension, chronic kidney disease, and hepatitis C-related liver cirrhosis, presented with generalized anasarca, bilateral pneumonic infiltrations, and heart failure. His blood cultures were positive for Pseudomonas aeruginosa and were treated with antibiotics. Echocardiogram showed multiple uncommon manifestations of left-sided endocarditis. Surprisingly, he did not have right-sided involvement. Furthermore, echocardiogram revealed undiagnosed large atrial septal defect suggesting a paradoxical seeding of infective vegetation. This case illustrates the uncommon manifestations of Pseudomonas endocarditis in an IVDA and indicates that it is very important to check comprehensively for an atrial septal defect or patent foramen ovale or any shunt in such high-risk patients who may be at risk for left-sided endocarditis which is catastrophic when compared to right-sided endocarditis. If detected early in IVDA patients, these shunts need to be closed to prevent paradoxical embolism of vegetation.

Keywords: Echocardiography; Pseudomonas endocarditis; intravenous drug abuser.

Figure 1

Transesophageal echocardiographic examination showing a large atrial septal defect (a, arrowheads), a large parachute-shaped mass attached to aortic valve (b, right arrowheads), and a large mass in the left atrial appendage (b, left arrowheads, Video 1), suggestive of vegetation in a patient with intravenous drug abuse and Pseudomonas endocarditis.

Figure 2

Transesophageal echocardiographic examination demonstrating multiple vegetation attached to mitral valve leaflets (a, arrowheads) with a large fluttering saccular mass (1.4 cm × 4 cm) in the left atrium attached to the posterior mitral valve leaflet bulging into the left atrium suggesting mitral valve aneurysm (a and b, arrowheads, Video 1) in a patient with intravenous drug abuse and Pseudomonas endocarditis.

Figure 3

Transesophageal echocardiographic examination showing a large left atrial vegetation intermittently resembling a “cat” face with prominent eyes, nose, and mouth (Video 2) measuring 4.9 cm × 1.9 cm in a patient with intravenous drug abuse and Pseudomonas endocarditis.