A Challenging Case of Isolated Pulmonic Valve Endocarditis With Septic Embolic and High-Grade Bacteremia

Isolated pulmonic valve endocarditis is a rare entity attributed to multiple factors, including lower pressures on the right side of the heart, as well as lower oxygen content of venous blood. Herein, we present a challenging case of isolated pulmonic valve endocarditis complicated with septic emboli and high-grade methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia. A 31-year-old female presented to the emergency department with fever, chills, fatigue, left-sided pleuritic pain, shortness of breath, and an 8-pound weight loss for the past two weeks. She is an active intravenous drug user. Notable was a grade four diastolic murmur most prominent on the upper left sternal border. Chest CT with contrast showed multiple pulmonary emboli with cavitating nodules suspicious of a septic etiology. Transthoracic echo revealed an isolated large irregularly shaped (3.0 cm x 1.5 cm) vegetation on the pulmonic valve with moderate-to-severe pulmonary regurgitation. The course was notable for persistent high-grade MSSA bacteremia for a total of 10 days, which was treated with ertapenem and cefazolin. The patient did not undergo valve replacement. Close outpatient follow-up was established with a recommendation to treat with an additional two doses of dalbavancin 1,500 mg one week apart. Isolated pulmonic valve endocarditis is a very rare entity. Prompt recognition of isolated pulmonic valve endocarditis and multidisciplinary management is key to improving outcomes among patients with this extremely rare condition.