Adult patent ductus arteriosus complicated by pulmonary infective endocarditis

We report the case of a 32 year-old male with Down Syndrome and a medical history of Immune thrombocytopenia (ITP) under corticosteroids, who was admitted to the cardiology department for prolonged fever and asthenia. On inspection, the conjunctivae were anemic and physical examination found a febrile patient (38.9&#176;C) and a 3/6 continuous murmur in the pulmonary area. Blood tests revealed a normocystic, normochromic anemia (Hemoglobin 8.6 g/dL) and severe thrombocytopenia (9000/mm³), a leukocyte count of 12,500 cells/mm³, and high C-reactive protein and erythrocyte sedimentation rates. Thoracic X-ray showed cardiomegaly with normal lung area. Transthoracic Echocardiography (TEE) was immediately performed and showed a 7 mm Patent Ductus Arteriosus (PDA) associated to a large oscillating mobile vegetation attached to the pulmonic valve measuring 32 x 15 mm (A,B,C,D) with a dilated pulmonary artery and a severe pulmonary insufficiency. Right chambers were dilated (<i>RV infundibulum= 37mm, RV basal diameter= 46 mm, RA surface= 24 cm²<i>) with moderate tricuspid regurgitation and a transvalvular gradient of 68 mmHg, left valves were normal. Repeated blood cultures were sterile, empirical anbitiotherapy including Vancomycin and gentamycin was started with no significant improvement after 2 weeks. The patient underwent surgical vegectomy with pulmonic and tricuspid valves&acute; repair, and closure of PDA was not considered. Post-operative period was uneventful, after 2 additional weeks of antibiotherapy, the evolution was favorable with apyrexia, inflammation markors normalization and no residual vegetation in the post-operative TTE. The patient was discharged from hospital as he was asymptomatic and was advised regular follow up.