Diagnostically Complex Case of Trivalvular Infectious Endocarditis Complicated by HIV, HCV, Pulmonary Septic Emboli, and Epidural Abscess

Background: Infective endocarditis (IE) can be visualized on echocardiograms. However, there is a significant discrepancy between transthoracic and transesophageal echocardiograms. This imaging modality is also impacted by operator dependent factors. The risk of right sided endocarditis is elevated in people who inject drugs (PWID). In individuals with human immunodeficiency virus (HIV), there is an increased risk of IE, and there is also a relationship that has yet to be fully established between hepatitis C virus (HCV) and IE. This report describes a woman with a history of IVDU who was diagnosed with HIV/AIDS, HCV, and sepsis secondary to methicillin-resistant Staphylococcus aureus (MRSA) bacteremia complicated by trivalvular infective endocarditis, pulmonary septic emboli, and an epidural abscess. The three involved valves were the pulmonic, the aortic, and the tricuspid. In this patient, there were vegetations on three valves seen on transesophageal echocardiogram, none of which were visible on transthoracic echocardiogram. She was managed medically with daptomycin with resolution of all three vegetations. This patient underscores the importance of a full imaging workup in patients with a high pretest probability of endocarditis given that none of her three vegetations were visible on the transthoracic imaging.