Native tricuspid valve endocarditis in a young woman.

Accepted 23 April 1998 A 30-year-old woman was admitted having suffered from fever and malaise for about a month. During this period no drugs were taken, except antipyretics. On examination she was febrile (37.8°C) and a systolic ejection type murmur was heard along the left sternal border. Haemoglobin was 9.4 g/dl, white cell count 6.03 x109/l (80% neutrophils), erythrocyte sedimentation rate 111 mmnh and C-reactive protein 52 mg/l. Chest X-ray was normal. The patient underwent transthoracic and transoesophageal echocardiography, revealing a vegetation of 1.36 x 1.13 cm on the anterior tricuspid leaflet, which prolapsed freely between the atrium and ventricle (figure). The leaflet coaptation point was lost, resulting in a moderate to severe valve regurgitation. Nine blood cultures were obtained and all yielded Staphylococcus epidermidis sensitive to methicilline. The patient was neither a drug abuser nor an alcoholic. Serological tests for HIV and viral hepatitis were negative. She had no history of rheumatic fever and had no dental treatment, abortion or genital infection in the last six months. She had pierced her ears a few weeks prior to the appearance of the symptoms. Her left ear lobe around the hole was erythematous with local swelling and painful when pressed and there was a small fistula on the back of the ear lobe. Three separate cultures of fistula contents yielded the same strain of S epidermidis. Dicloxacilline, 2 g six times daily, was administered for 6 weeks, resulting in rapid improvement of the patient's general condition. During hospitalisation, no symptoms or signs of right heart failure or septic pulmonary embolism were present. Perfusion and ventilation lung scanning were normal. On discharge the patient had negative blood cultures. A repeat echocardiography was unchanged. On the basis of the size of the vegetation and the severe regurgitation, vegectomy and reconstruction of the valve were recommended, but the patient declined.