A rare case of community-acquired native quadruple-valve endocarditis
We herein report the case of a 58-year-old man who was relatively well and healthy up to 1 month prior to his admission to our hospital (Rajaie Heart Center, Tehran, Iran, 2011), when he developed generalized edema with malaise, dyspnea, anorexia, and vomiting without fever. He sought medical treatment elsewhere; and after incomplete treatment, he referred to Rajaie Cardiovascular, Medical and Research Center with renal dysfunction and suspicious infective endocarditis.\nOn admission, the initial vital sign assessment revealed a blood pressure of 147/90 mmHg, pulse rate of 84/min, respiratory rate of 16/min, and temperature of 37.1°C. The patient was then subjected to cardiorespiratory examination, which showed soft S1, systolic murmur III/VI at the left sternal border and left ventricular apex, and fine rales in the lower third of both lung fields. The EKG findings included left axis deviation, left atrial enlargement, incomplete right bundle branch block, and high voltage QRS with ST-T change, suggestive of left ventricular volume overload.\nAdmission laboratory findings demonstrated white blood cells = 12000/ml (4000-1,00,000), hemoglobin = 8.2 g/dl (12-16), platelets = 84,000/ml (150,000-450,000), creatinine = 3.4 mg/dl (0.5-1.4), serum sodium = 141 meq/l (132-145), and serum potassium = 3.4 meq/l (3.5-5.5). In addition, during the patient's stay in our center, his blood cultures were negative five times.\nImaging revealed splenomegaly and most probably paranchymal renal disease (abdominal sonography). Additionally, Doppler sonography of the renal arteries demonstrated atherosclerotic change without significant stenosis.\nTransthoracic and transesophageal echocardiographic examinations [Figures –] showed two highly mobile masses on both anterior and posterior mitral valve leaflets (max size = 0.5 × 1.5 cm2) with severe mitral regurgitation due to malcoapted mitral leaflets, three highly mobile masses on the ventricular side of the aortic cusps (max size = 1 × 0.5 cm2) with mild-to-moderate aortic regurgitation, highly mobile masses on all the three leaflets of the tricuspid valve (max size = 2.2 × 0.75 cm2) with mild tricuspid regurgitation, semi-mobile vegetation on the medial, and lateral pulmonary valve cusps (max size = 1.75 × 0.9 cm2) with mild-to-moderate pulmonary regurgitation, moderate-sized perimembranous ventricular septal defect (0.7 cm) with a left-to-right shunt (QP/QS = 1.5, peak pressure gradient = 188 mmHg, and mean pressure gradient = 88 mmHg) with large highly mobile vegetation in the orifice of the ventricular septal defect on the right ventricular side, and moderate pulmonary artery hypertension (pulmonary artery pressure = 50 mmHg).\nThe patient's antibiotic treatment for infective endocarditis[] was continued for another 18 days, and he was dialyzed five times due to symptomatic uremia. He was also scheduled for surgery; however, his refusal to undergo operation and even to continue his treatment at the intensive care unit led to his consensual discharge from the hospital. We followed the patient through phone, and he told triple valve replacement was done for him in another center.