A 25-year-old female with uncomplicated ventricular septal defect presented to our casualty medical ward with the complaint of intermittent low-grade fever of 3-month duration. She had generalized malaise, loss of appetite, and weight loss over the same period. There was no history suggestive of chronic respiratory illnesses, tuberculosis, or connective tissue disorders. She was diagnosed to have small ventricular septal defect (VSD) since childhood and was on regular echocardiographic evaluation. She did not have history or peripheral evidence of intravenous drug abuse. On examination, she was thin built, pale, and febrile. There was no lymphadenopathy or features of autoimmune connective tissue disorders. She did not have finger clubbing. Her pulse rate was 90 beats per minute and blood pressure was 110/70 mmHg. There was no cardiomegaly. She had a left parasternal thrill and a harsh pan systolic murmur over the left lower sternal edge. There were no features of heart failure. Other systems' examination was unremarkable.
Her investigations revealed white blood cell count 14 x 103/microl, neutrophils 75%, lymphocytes 18%, hemoglobin 8.8 g/dl, platelets 224 x 103/microl, erythrocyte sedimentation rate (ESR) 40 mm in 1st hour, C-reactive protein (CRP) 75 mg/l, alanine transaminase (ALT) 26 IU/l, and aspartate transaminase (AST) 30 IU/l. Anti-nuclear antibodies (ANA) were negative. The electrocardiogram (ECG) showed sinus tachycardia. Chest radiograph was normal. The 2D echocardiogram (2DE) revealed a perimembranous VSD, left to right shunt with a maximum pressure gradient of 105 mmHg. There was moderate tricuspid regurgitation with a maximum tricuspid pressure gradient of 36 mmHg. There was 7 mm x 4 mm-sized vegetation attached to the posterior leaflet of the tricuspid valve. The pulmonary valve was free of vegetations. There was moderate pulmonary hypertension. Her transoesophageal echocardiogram (TOE) confirmed the tricuspid valve vegetation (Figures 1 and 2). There were no abnormalities seen in other cardiac valves. Her blood culture was positive for Streptococcus bovis in two samples. She was diagnosed to have infective endocarditis based on fulfilling modified Duke's criteria and empirically started on intravenous ceftriaxone and gentamicin. Subsequent culture confirmed that the organism was sensitive to empirical antibiotics, hence continued. She also underwent detailed colonoscopy and upper gastrointestinal endoscopy, and both were normal. Her ultrasound scan of the abdomen did not reveal any abnormality. She was given intravenous gentamicin for 2 weeks and ceftriaxone for 6 weeks and made an uneventful recovery. The patient was referred to the cardiology department for further assessment for closure of VSD.