When three is not a magic number : a case of native triple-valve endocarditis caused by Streptococcus agalactiae

Abstract

We present a case of a 47-year-old female who presented with septic shock and a hyperosmolar hyperketotic state, accompanied by episodes of unresponsiveness. As part of the extensive investigations which took place, a trans-oesophageal echocardiogram (TOE) revealed the presence of infective endocarditis in three native valves – the tricuspid valve, pulmonary valve and the aortic valve. Blood cultures showed evidence of bacteraemia with Streptococcus agalactiae. The hyperosmolar hyperketotic state was controlled after optimisation of insulin treatment and the patient’s condition was relatively stable for weeks with intravenous antibiotics.

The patient’s condition started deteriorating after multiple episodes of septic embolisation from the pulmonary valve vegetation, leading to urgent mechanical aortic, tissue pulmonary and tricuspid valve replacements in a tertiary centre in the United Kingdom; as well as a dual-chamber pacemaker implantation for post-operative complete heart block (CHB).

After arrival back to Malta, the postoperative sternotomy wound was becoming recurrently infected, eventually leading to wound breakdown and overwhelming sepsis. Despite optimal medical treatment, wound care and intensive care support, the patient suffered from multi-organ failure and then passed away.