Gizaw Abera Wondie, Tadesse Abilo, Alemu Hailemaryam, Worku Abebe, Chanie Samuel Dereje, Muluken Getasew
Department of Internal Medicine, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
Clin Med Insights Case Rep. 2024 Aug 26;17:11795476241277329. doi: 10.1177/11795476241277329. eCollection 2024.
Isolated pulmonic valve endocarditis is a rare heart valve infection, and constitutes about 1% to 2% of all infective endocarditis cases. Modified Duke's criteria were used to diagnose culture negative pulmonic valve endocarditis.
A 52-year-old male patient presented with generalized body swelling of 1 month duration associated with prolonged fever, malaise, fatigue, and lassitude. He had productive cough, dyspnea on mild exertion, and reddish discoloration of urine. Upon physical examination, blood pressure (BP) = 140/90 mmHg, pulse rate (PR) = 104 beats per minute, respiratory rate (RR) = 26 breaths per minute, temperature (T) = 38.3°C, and Sp0 = 90% at ambient air. He had signs of bilateral pleural effusion. Cardiovascular examination revealed tachycardia, raised jugular venous pressure, murmurs of pulmonic regurgitation, and tricuspid regurgitation. There was grade 2 ascites and bilateral leg edema. On laboratory investigation, there were normochromic, normocytic anemia; raised ESR; positive Rheumatoid factor, elevated serum creatinine; and active urinary sediments on urinalysis. Two sets of blood culture were negative on days 1, 5, and 7. Chest-X-ray showed cardiomegaly with bilateral pleural effusion. ECG revealed sinus tachycardia with regular P-waves and QRS complexes. 2D Transthoracic echo showed vegetation on pulmonic valves, pulmonary valve lesions, dilated right atrium and right ventricle, and elevated right ventricular systolic pressure. Abdominal ultrasound revealed enlarged and echogenic kidneys, and ascites. Definitive diagnosis of PVE was made using modified Duke's criteria which was evidenced by 1 major (echo-proven vegetation on pulmonic valve), and 3 minors (suspected congenital pulmonic stenosis, fever, and immunologic phenomena [acute glomerulonephritis, positive rheumatoid factor]). The patient's clinical condition markedly improved after 2 weeks of intravenous antibiotics and loop diuretics, and discharged home after completing 6 weeks of parenteral antibiotics.
Modified Duke's criteria could play a major role in the management decision about diagnosis and empiric treatment of infective endocarditis in the absence of positive bacterial cultures.
孤立性肺动脉瓣心内膜炎是一种罕见的心脏瓣膜感染，约占所有感染性心内膜炎病例的1%至2%。改良的杜克标准用于诊断血培养阴性的肺动脉瓣心内膜炎。
一名52岁男性患者出现全身肿胀1个月，伴有持续发热、不适、乏力和倦怠。他有咳痰、轻度活动时呼吸困难以及尿液呈红色。体格检查时，血压（BP）=140/90mmHg，脉搏率（PR）=每分钟104次，呼吸频率（RR）=每分钟26次，体温（T）=38.3°C，在室内空气中Sp0=90%。他有双侧胸腔积液的体征。心血管检查显示心动过速、颈静脉压升高、肺动脉瓣反流和三尖瓣反流杂音。有2级腹水和双侧腿部水肿。实验室检查发现有正色素正细胞性贫血；血沉升高；类风湿因子阳性、血清肌酐升高；尿液分析显示有活动性尿沉渣。在第1、5和7天两组血培养均为阴性。胸部X线显示心脏扩大伴双侧胸腔积液。心电图显示窦性心动过速，P波和QRS波群规则。二维经胸超声心动图显示肺动脉瓣上有赘生物、肺动脉瓣病变、右心房和右心室扩大以及右心室收缩压升高。腹部超声显示肾脏增大且回声增强以及腹水。使用改良的杜克标准对感染性心内膜炎进行了明确诊断，证据为1项主要标准（经超声证实肺动脉瓣上有赘生物）和3项次要标准（疑似先天性肺动脉狭窄、发热和免疫现象[急性肾小球肾炎、类风湿因子阳性]）。患者在静脉使用抗生素和袢利尿剂2周后临床状况明显改善，并在完成6周的肠外抗生素治疗后出院回家。
在没有阳性细菌培养结果的情况下，改良的杜克标准在感染性心内膜炎的诊断和经验性治疗的管理决策中可发挥重要作用。
