Mycobacterium Tuberculosis Endocarditis Infective at Pulmonary Valve in a Pediatric Patient with Ventricular Septal Defect.
Author : P. Suci, A. Priyatno
Upload Date : 19-04-2018
Background: Infective endocarditis (IE) is one of congenital heart disease complication frequently seen in ventricular septal defect (VSD). The Duke criteria is diagnostic criteria for IE. Vegetation in VSD is frequently found on the opening defect, right ventricular side, tricuspid valve and less frequently found on pulmonary valve (PV). PV IE is extremely rare, 2% of IE total cases. Although isolated right sided endocarditis is benign prognosis with low in-hospital mortality, but dreadfull complication still ahead.
Case Presentation: A 14-year-old boy presented as prolonged fever, dyspnea, severe chronic malnutrition and on fourth month tuberculosis treatment. After 2 weeks treatment at previous hospital, reffered to Kariadi Hospital. Transthoracic echocardiograms revealed severe pulmonary regurgitation with large pulmonary valve vegetation with subarterial VSD. The laboratory showed negative blood culture. Emergency operation was done because large size vegetation and severe pulmonary regurgitation, after 6 weeks of antibiotics coverage. Durante operation found pericardial effusion, 15 mm subarterial VSD is repaired by gortex, excision vegetation of atretic pulmonal and replaced by pericardium. The histopathology result showed granulomatous chronic inflammation and datia langhans cell leading to tuberculosis.
Discussion: Intravenous antibiotic therapy started when IE diagnosis established, administered at least 4 weeks and may be continue 6-8 weeks. Continuing antimicrobial treatment despite negative blood culture is reasonable as prophylactic against reinfection. Mycobacterial tuberculosis endocarditis could be confirmed by histopathology. This case leads to extracardiac tuberculosis then therapy had been given as protocol. Surgical intervention is secondary therapy in IE. The right timing surgery in right sided infective endocarditis are organism type, secondary heart failure, severe valvular dysfunction, response appropriate antibiotic therapy, local invasion, pulmonary involvement, systemic involvement. Pulmonary regurgitation (PR) and right heart failure after excision pulmonary valve should be considered. Pulmonary valce replacement could be another way to treat volume overload caused by PR.
KEYWORDS : Pulmonary Valve, Mycobacterium Tuberculosis Endocarditis, Ventricular Septal Defect