A Rare Case of Quadrivalvular Infective Endocarditis

Abstract

Infective endocarditis is a devastating disease with high morbidity and mortality. Infective endocarditis affecting all four valves is rarely encountered. Even rarer is the involvement of all four valves by nutritionally variant streptococci, Granulicatella. The case describes a female in her 40s, known case of small perimembranous ventricular septal defect, who presented with symptoms of fever and congestive cardiac failure, with severe anemia, glomerulonephritis, and pain abdomen, who was found to have vegetations on pulmonary, tricuspid, mitral, and aortic valves, with pulmonary regurgitation, tricuspid regurgitation, mitral, and aortic regurgitations. Blood culture grew Granulicatella adiacens species. She improved clinically after intravenous antibiotics, decongestive measures, and blood transfusion. Causation of quadrivalvular infective endocarditis is rare and previously has not been documented in Granulicatella infection, a fastidious species. Interestingly, the patient remained quite stable despite involvement of all four heart valves, likely due to the predominant involvement of the pulmonary valve. This case report discusses the factors predisposing to infective endocarditis in a known case of congenital heart disease and the importance of timely diagnosis and treatment.

Keywords: Granulicatella adiacens infective endocarditis; infective endocarditis in congenital heart diseases; quadrivalvular infective endocarditis; quadrivalvular vegetations.

Figure 1

(a): Tricuspid valve vegetation, (b) pulmonary valve vegetation, (c) mitral valve vegetation, (d) aortic RCC vegetation, (e) small perimembranous VSD, and (f) mitral valve vegetation on TEE.