Pulmonary embolism and fever: when should right-sided infective endocarditis be considered?

Case presentation: A 39-year-old woman with chronic alcoholism became febrile (38.8°C) and markedly dyspneic on the fourth postoperative day of gastric surgery. Laboratory evaluation revealed anemia (hemoglobin 8.5 g/dL), thrombocytopenia (platelet count 30 000/mm), and elevation of inflammatory markers (white blood cell count 18 000/mm, C-reactive protein 187 mg/dL, and erythrocyte sedimentation rate 50 mm/s). Limb venous ultrasonography was negative for deep vein thrombosis, but pulmonary embolism (PE) was diagnosed on the basis of contrast-enhanced multidetector-row spiral computed tomography (MSCT; Figure 1A). Anticoagulation therapy was considered to be contraindicated because of recent surgery and thrombocytopenia, and a retrievable inferior vena cava filter was placed. With persistent high-grade fever and dyspnea and with the finding of Streptococcus agalactiae bacteremia, the patient underwent a transthoracic echocardiography examination on the sixth postoperative day that showed a large, mobile vegetation attached to the pulmonary valve (Figure 1B). A diagnosis of infective endocarditis (IE) of the pulmonary valve complicated by septic PE was then made, and the patient was referred for vena cava filter removal and pulmonary valve replacement. During vena cava filter removal, an acute thromboembolic stroke occurred, and transesophageal echocardiography documented a patent foramen ovale with right-to-left shunt. Ten days later, the patient underwent successful pulmonary valve replacement and surgical closure of the patent foramen ovale.