Iatrogenic Right Sided Infective Endocarditis in Children with CHD

Background: Right sided endocarditis (IE) occurs predominantly in intravenous drug abusers, and occasionally acquired in hospital as a result of contaminated intravascular devices. The iatrogenic IE of tricuspid valve in children treated with intravenous (IV) injections for various unrelated conditions is not reported in literature. Objective: Aim is to report clinical outcome, microbiological and echocardiographic presentation of iatrogenic right sided IE in 4 children. Materials and methods: In a span of 3 months four children, age ranging from 1 month to 5 years, three females and one male, who presented with prolonged history of fever formed the material for this study. Two cases had ventricular septal defect (VSD), one had a small atrial septal defect (ASD) and one patient had tetralogy of Fallot (TOF). The blood culture grew coagulase negative staphylococcus in two patients and gram negative bacilli in the one month infant. The diagnosis of tricuspid valve endocarditis was established by transthoracic echocardiography (TTE) in all the four patients. In addition to vegetation on tricuspid valve, the vegetation was also detected in inferior vena cava (IVC) in one case and in another case a large vegetation was seen closing the VSD. Discussion: Right sided endocarditis accounts for only 5 - 10% of cases of IE. It has been estimated that up to 76% of cases of endocarditis among IV drug abusers involve the right heart, compared with only 9% in non-addict patients. The bacterial endocarditis is extremely rare in cases of ASD and TOF. This series of four cases is notable for the iatrogenic IE of tricuspid valve in children treated in the reputed hospitals with IV injections and IV fluids for various unrelated non cardiac conditions. The infection in this series occurred upon previously normal tricuspid valve. Three patients died (75%) and only one survived. Conclusions: Right sided endocarditis can occur in CHD patients when proper aseptic precautions are not taken while treating with IV injections. The blood culture and TTE play an important role in diagnosis and management of right sided IE.