37 yo female presents with complaints of increasing generalized malaise over the past 2 weeks as well as a fever and nausea. She endorses a history of intravenous drug use (IVDU). On physical exam, you appreciate a faint systolic murmur. Before any lab tests or other imaging have been done, you obtain the following echo:
Answer: Infective endocarditis
This bedside echocardiograms demonstrates a normal ejection fraction, no pericardial effusion or evidence of right ventricular strain. Additionally, a large mass adherent to the tricpuspid valve is visible on multiple views, consistent with endocarditis. Significant tricuspid regurgitation is seen when color doppler is applied across this valve.
- Endocarditis is a disease that carries significant morbidity and mortality, especially if not recognized early.1 The mortality rate of endocarditis has been reported to be as high as 18%.2
- Typical physical exam findings of a fever, murmur and various physical exam findings can be present. However, they are often absent, especially early in the course of the disease.1
- Transesophageal echocardiography (TEE) is considered the gold standard for direct visualization of endocarditis, but transthoracic echocardiography (TTE) can be used as well.3
- The accuracy of TTE increases with increasing size of the vegetation.3
- One study reported that TTE had a sensitivity of 84% for detecting vegetations larger than 10mm.4
- This becomes important due to the fact that mortality increases along with the size of the lesion. One study found that the size of the vegetation was the only independent predictor of in-hospital mortality.5
- If using TTE, the typical view used to detect endocarditis on the tricuspid valve is the apical 4 chamber view. RV inflow views or the subxiphoid view may be helpful as well. Color Doppler may also be helpful to assess for valve regurgitation.
- Seif D, Meeks A, Mailhot T, Perera P. Emergency department diagnosis of infective endocarditis using bedside emergency ultrasound. Critical ultrasound journal. 5(1):1. 2013. [pubmed]
- Murdoch DR, Corey GR, Hoen B. Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century: the International Collaboration on Endocarditis-Prospective Cohort Study. Archives of internal medicine. 169(5):463-73. 2009. [pubmed]
- Erbel R, Rohmann S, Drexler M. Improved diagnostic value of echocardiography in patients with infective endocarditis by transoesophageal approach. A prospective study. European heart journal. 9(1):43-53. 1988. [pubmed]
- Reynolds HR, Jagen MA, Tunick PA, Kronzon I. Sensitivity of transthoracic versus transesophageal echocardiography for the detection of native valve vegetations in the modern era. Journal of the American Society of Echocardiography 16(1):67-70. 2003. [pubmed]
- Nunes MC, Gelape CL, Ferrari TC. Profile of infective endocarditis at a tertiary care center in Brazil during a seven-year period: prognostic factors and in-hospital outcome. International journal of infectious diseases : IJID : official publication of the International Society for Infectious Diseases. 14(5):e394-8. 2010. [pubmed]
