A 36-year-old man with a history of intravenous drug use developed fatal triple-valve endocarditis involving the aortic, mitral, and tricuspid valves caused by Enterococcus faecalis.
Case Report (n=1)
Triple-valve endocarditis is an extremely rare condition with high morbidity and mortality, requiring early recognition and multidisciplinary management.
Abstract Introduction Infective endocarditis (IE) typically involves a single cardiac valve, most often the mitral or aortic valves. Right-sided involvement, particularly of the tricuspid valve, is more common among individuals with intravenous drug use (IVDU). Multivalvular IE is uncommon, and triple-valve endocarditis (TVE) is extremely rare, with only limited cases reported. We present a case of TVE involving the aortic, mitral, and tricuspid valves, complicated by multiorgan failure and a fatal outcome. Case Presentation A 36-year-old man with a history of IVDU and prior methicillin-resistant Staphylococcus aureus (MRSA) tricuspid valve endocarditis eight months earlier, presented to the emergency department with dyspnea and altered mental status. On presentation, his temperature was 33.6 °C, heart rate 111 beats per minute, respiratory rate 31 breaths per minute, blood pressure 81/71 mmHg, and oxygen saturation 82% on room air. Physical examination showed jaundice, conjunctival hemorrhages, necrotic toes, splinter hemorrhages, and Janeway lesions. Treatment for septic shock with broad-spectrum antibiotics and vasopressors was initiated. Due to progressive respiratory failure, he required intubation and mechanical ventilation. Laboratory results revealed white blood cell count 21.4 × 10³/cumm, hemoglobin 9.5 g/dL, platelet count 35 × 10³/cumm, international normalized ratio 4.08, serum creatinine 1.75 mg/dL, blood urea nitrogen 71 mg/dL, total bilirubin 11.7 mg/dL, aspartate aminotransferase 250 U/L, alanine aminotransferase 169 U/L, ammonia 118 micromoles/L, and lactate 21 mmol/L. Coagulation studies indicated disseminated intravascular coagulation. Chest computed tomography (CT) demonstrated bilateral nodular and ground-glass opacities consistent with multifocal pneumonia. Abdominal CT revealed diffuse bowel wall edema, multifocal bilateral renal infarcts, and splenic infarcts. Head CT was unremarkable. Point-of-care ultrasound of the heart suggested vegetations on the aortic, mitral, and tricuspid valves, confirmed by formal transthoracic echocardiogram. Cardiothoracic surgery deemed the patient a poor surgical candidate due to severe multiorgan failure and coagulopathy. Despite maximal medical therapy, he deteriorated rapidly, and his family opted for comfort measures. He died within 24 hours of admission. Blood cultures later grew Enterococcus faecalis. Discussion TVE is extremely rare. Reported pathogens include Staphylococcus aureus, Streptococcus, and Enterococcus species. Risk factors include IVDU, congenital or acquired valvular disease, and prior IE. TVE carries a poor prognosis, with high morbidity and mortality despite aggressive antibiotic therapy. This case highlights the importance of early recognition, comprehensive echocardiographic evaluation, and multidisciplinary management. The prognosis remains poor, emphasizing the need for further research into this rare and serious condition. This abstract is funded by: None
Freihat et al. (Fri,) conducted a case report in Triple-valve endocarditis (n=1). A 36-year-old man with a history of intravenous drug use developed fatal triple-valve endocarditis involving the aortic, mitral, and tricuspid valves caused by Enterococcus faecalis.