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A 28-year-old woman presented with fever and chills for 2 months and features of congestive heart failure for 20 days. She had undergone a medical termination of pregnancy of 8 weeks gestation 4 days prior to the onset of fever. Clinical examination revealed marked pallor, tachycardia, raised jugular vein pressure, long rumbling diastolic murmur in the tricuspid area, hepatosplenomegaly and fundal haemorrhage. She had normocytic anaemia with marked leucocytosis. Echocardiography demonstrated large mass in the right atrium (figure 1) which was reported as atrial myxoma by the radiologist.
- What is the probable diagnosis and the relevant method of diagnosis ?
- What will happen to the right atrial mass if the patient responds to medical treatment ?
The most probable diagnosis is tricuspid valve endocarditis with congestive heart failure. The history of septic abortion with clinical features including diastolic murmur without tumour plop in tricuspid area, Roth's spots, and microscopic haematuria with right atrial mass, favoured the diagnosis of tricuspid valve endocarditis. Almost all the major and minor criteria1 for a diagnosis of infective endocarditis were present. Right atrial myxoma should be considered an alternative diagnosis. However, it was less likely in this case as (a) constitutional symptoms are less frequent in right atrial myxoma,2 and (b) the background history and clinical features were suggestive of tricuspid valve endocarditis.
Blood culture and response to suitable antibiotic therapy (figure 2) for 4–6 weeks will be the most reliable confirmation of diagnosis in this case.
In spite of good antibiotic treatment and amelioration in clinical features, vegetation may persist on leaflets of the a-v valve and may increase the risk of re-infection in one third of patients. It is for this reason that penicillin prophylaxis of infective endocarditis is recommended3 if residual vegetation continues to be seen on echocardiography.
Infective endocarditis involving right heart valves is more common in intravenous drug abusers.4 Bacteraemia preceding endocarditis varies with the healthcare procedure, being highest after dental procedures, intermediate after genitourinary procedures, and low after gastrointestinal diagnostic procedures.
Tricuspid valve endocarditis following septic abortion has been previously reported.5 The causative organism in that case was group B β-haemolytic streptococci which was treated with vancomycin. The risk of bacteraemia following elective abortion is considered too low for antibiotic prophylaxis of infective endocarditis to be recommended.6
Staphylococcus aureus may cause right-sided endocarditis with large vegetation and it may follow septic abortion
right-sided myxoma on the basis of echocardiography should be suspected only if right-sided endocarditis has been excluded by clinical presentation and blood isolate
In the present case the isolate was Staphylococcus aureus and the patient was successfully treated with gentamycin and crystalline penicillin. This case report highlights the fact that, although the incidence of this complication of elective abortion is uncommon, it remains a risk to be remembered.
Tricuspid valve endocarditis with congestive heart failure following septic abortion.