Letter to the Editor A “strange cough”: 3D-echocardiography for diagnosis of late tricuspid valve endocarditis in a former drug addict with septic pulmonary emboli Natale Daniele Brunetti a, ⁎, Luisa De Gennaro a,b , Domenica Paola Basile c , Emanuela De Cillis c , Tommaso Acquaviva c , Filippo Boscia b , Matteo Di Biase a , Alessandro Santo Bortone c a Cardiology Department, University of Foggia, Foggia, Italy b Cardiology Department, University of Foggia, “San Giacomo” Hospital, Monopoli, Bari, Italy c Cardiac Surgery Department, University of Bari, Bari, Italy article info Article history: Received 16 January 2011 Accepted 23 January 2011 Available online 25 February 2011 Keywords: 3D-Echocardiogram Tricuspid valve endocarditis Septic pulmonary emboli Tricuspid valve endocarditis (TVE) is not an uncommon finding in intravenous drug addicts [1]. TVE with pulmonary septic emboliza- tion, however, is a less common finding [2]. Even more rare is the diagnosis of TVE mainly led by pulmonary signs. We report the case of a 40-year-old man, a former intravenous drug addict, referred to our institution for recurrent episodes of cough and fever mimicking episodes of pneumonitis since a couple of months. The patient was affected by chronic hepatitis C, without history of heart disease. At previous hospitalization, chest radiograph showed 2 parenchy- ma nodules within left lung (basal and apical). A pneumonitis was therefore hypothesized and the patient was administrated with levofloxacin and ceftriaxone for 2 weeks, without any symptom relief. At present hospitalization, chest X-ray confirmed the presence of a single nodule in the basal segment of the left lung. Physical examination, however, was unremarkable. Rest ECG showed sinus rhythm at 78 bpm without significant ST anomalies (Fig. 1). Systolic blood pressure was 120/80 mm Hg. Troponin was 0.03 ng/ml and N-terminal pro-brain natriuretic peptide 20.6 pg/ml, while C-reactive protein was 3.9 mg/l. Urine assay was negative for cannabis, opioids and cocaine. However, trans-thoracic echocardiogram (TTE) finally showed right heart endocarditis with septic vegetation implanted on the anterior leaflet of the tricuspid valve (measuring 23 × 10 mm), protruding into the right ventricle, and mild tricuspid regurgitation (eccentric regurgitation jet). Tricuspid valve floating vegetations were particularly evident at 3D-TTE (Fig. 2, Video 1). The finding of TVE was then confirmed at trans-esophageal echocardiogram (TEE). A CT scan documented the presence of a basal nodule into the left lung (Fig. 3). We therefore hypothesize that pulmonary nodules may represent septic pulmonary emboli coming from TVE vegetations. The patient underwent blood cultures, and those, however, were negative. The patient was then administrated with a wide range of anti-biotic therapy with teicoplanin, amoxicillin, clavulanate, and fluconazole with progressive mild reduction of both vegetations (11 × 8 mm) (Fig. 4) and pulmonary nodule, and symptom relief. The patient remained in stable clinical and hemodynamic conditions during the entire hospitalization: 3-month follow up was uneventful. To our knowledge, this is one of the first cases reporting TVE with recurrent pulmonary embolization diagnosed with 3D echocardiog- raphy and CT scan. A “normal” physical examination without evidence of heart murmurs is often reported in this subset of patients [2]. According to some authors, the triad including intravenous drug addiction, septicemia and septic pulmonary embolism might be considered pathognomonic for TVE, and, consequently, patients fulfilling these criteria should be treated as suffering from endocar- ditis. Echocardiographic examination does not seem necessary in patients with a typical clinical picture but may be helpful when chest X-ray is inconclusive or complications are suspected. The most common organisms detected in TVE are Staphylococcus aureus, Streptococcus viridans and Pseudomonas aeruginosa, with pulmonary manifestations and septic pulmonary emboli present in 80% of patients [3]. About 40% of patients with TVE were reported as improving on medical treatment while 30% may require urgent valve replacement [3]. CT scan might sometimes be helpful in diagnosing both TVE and septic pulmonary embolism, [4,5]. In our case, 3D TTE was able to show the presence of an elongated hypodense mass implanted on tricuspid valve. International Journal of Cardiology 153 (2011) e15–e18 ⁎ Corresponding author. Tel.: +39 3389112358; fax +39 0881745424. E-mail addresses: nd.brunetti@unifg.it (N.D. Brunetti), luisadegennaro@hotmail.com (L. De Gennaro), nini.basile@yahoo.it (D.P. Basile), e.decillis@cardiochir.uniba.it (E. De Cillis), tommaso.acquaviva68@libero.it (T. Acquaviva), filippo.boscia@tin.it (F. Boscia), dibiama@tiscali.it (M. Di Biase), a.bortone@cardiochir.uniba.it (A.S. Bortone). 0167-5273/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2011.01.069 Contents lists available at ScienceDirect International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard