P0876 - Bilateral Multivalvaular Infective Endocarditis in a Pediatric Patient with Native Valves

Background:
Infective endocarditis (IE) is exceedingly rare in pediatric patients. Although prolonged life expectancy for patients with congenital heart disease has increased the prevalence, the incidence remains 0.43 in every 100,000 patients. Of these cases, multivalvular disease or abscess formation, particularly in pediatric patients, is even more rare.

Case Presentation:
An 8-year-old previously healthy male presented with fever, rash, myalgias, and headache. He had been seen in the ED, where an ultrasound for appendicitis was negative, and by his pediatrician, where he tested positive for strep and was given a dose of IM Penicillin. Despite these interventions and other supportive care measures, he remained febrile, became somnolent, and developed a painful rash on his legs with an inability to bear weight.

His admission physical exam was significant for altered mental status, irritability, and slow response to stimuli. His oropharynx was erythematous, he had a petechial rash on his palms and feet from the soles to the shins, and he had diffuse tenderness to palpation of the lower extremities. Cardiac and abdominal exams were normal. Laboratory work was significant for serum leukocytosis with 23% bandemia, elevated CRP, and CSF leukocytosis. Blood cultures were positive for gram positive cocci in clusters within 12 hours. Echocardiogram was negative for vegetations. MRI of the brain showed multiple infarcts consistent with septic emboli. MRI of the lower extremities showed bilateral myositis and fasciitis. He was started on Vancomycin and then narrowed to Nafcillin once cultures showed susceptible MSSA.

Despite appropriate therapy, he continued to be febrile and his bacteremia failed to resolve. On day three of admission, repeat echocardiogram revealed tricuspid valve (TV) and aortic valve (AV) vegetations. On day eight of admission, after having been afebrile for greater than 48 hours, he again spiked a fever. This prompted another echocardiogram, which showed enlargement of the TV vegetation and a mass at the aortic root. In the OR the TV was debrided, the aortic valve was replaced with a homograft, and the LVOT was reconstructed. Following the procedure, he failed multiple attempts to transition off ECMO and was subsequently transferred to a nearby transplant center. After first receiving an LVAD, a heart became available and the patient is now status post successful heart transplantation.

Discussion/

Conclusion:
To our knowledge, this is the first reported case of multivalvular infective endocarditis with development of an aortic root abscess in a pediatric patient with native valves. This case highlights the fact that infective endocarditis should remain a consideration when multiple septic emboli occur even in the setting of normal echocardiogram findings. In adult literature, only 15% of IE cases are multivalvular and Staphylococcal IE with aortic root abscess is most commonly seen in IV drug use.