Eustachian valve endocarditis in patients with Fournier's gangrene and septic shock: A rare case and a literature review.

Abstract

Introduction: The eustachian valve (EV) is a remnant of the right sinus venosus valve. It remains different in size and shape without much impact on adult life. In 5% to 10% of all endocarditis, are seen in the right side of the heart is involved, which is rare compared to the left side of the heart. Bacteremia, central venous catheter, heart implants, and drug abuse increase the risk of EV vegetation and right heart endocarditis. We are reporting a case of EV endocarditis in patients with Fournier's gangrene and septic shock.

Case presentation: A 45-year-old male patient was admitted into the surgical intensive care unit with Fournier's gangrene, septic shock, and acute kidney injury (AKI). The patient was managed by invasive ventilation, noradrenaline, vasopressin, and renal replacement therapy. He developed Escherichia coli bacteremia and candidemia. We added meropenem and antifungal to the therapy. The transthoracic echocardiography showed EV vegetation and thread-like vegetation in the right coronary sinus, which was confirmed with transesophageal echocardiography. With aggressive therapies, the patient recovered from septic shock, organ dysfunction and was successfully liberated from invasive ventilation. The patient was discharged home on day 27. The antibiotics and antifungal were continued for 6 weeks. Two weeks after discharge, the follow-up echocardiogram was normal, and he was doing well.

Discussion: Eustachian valve endocarditis is rare, and should be treated with appropriate, culture- and sensitivity-guided antibiotics and or antifungal therapy for 6 weeks. The outcome of EV vegetations of endocarditis is good. The reported mortality is up to 17%. The independent risk factors associated with mortality are AKI, the Charlson comorbidity index, congestive heart failure, larger vegetation, and central nervous system involvement.

Conclusion: The presence of larger EV, along with E. coli (ESBL) bacteremia and fungemia, increases the risk of right-sided endocarditis, which is rarely reported. Our patient was diagnosed early, received appropriate antimicrobial treatment for a sufficient duration, resulting in a better outcome. A high index of suspicion, along with early diagnosis and culture-guided 6-week antimicrobial therapy, will improve the patient's outcomes.