Streptococcus viridans Endocarditis Affecting All Four Valves

Infective endocarditis (IE) affecting all four valves is rare. We describe an interesting clinical scenario of a 47-year-old female, with an underlying, unrepaired atrial septal defect (ASD) and hypertrophic obstructive cardiomyopathy (HOCM), who presented with a five-week history of worsening lower extremity rash and New York Heart Association (NYHA) class IV symptoms. She was febrile to 101.3 degrees F at the time of presentation. Examination revealed dental caries and track mark on hands. Her extremities demonstrated palpable purpura and pitting edema. Chest auscultation revealed bibasilar crackles and a grade III pan-systolic murmur, best heard over the apex, with radiation to the axilla. The blood gram stain resulted positive for gram-positive cocci in chains, prompting the initiation of ceftriaxone. Transthoracic echocardiography (TTE) did not reveal any new valvular regurgitation or vegetation. Transesophageal echocardiography (TEE) showed vegetation on all four valves and underlying ASD with HOCM. Blood cultures grew Streptococcus viridians. She had evidence of extensive septic emboli to the brain, lungs, spleen, and intestines. Given the extent of valvular involvement, intracranial hemorrhage, and tenuous hemodynamic status, a decision was taken to manage her conservatively followed by elective surgical management. She, however, went into cardiogenic shock further complicated by lower gastrointestinal bleed and passed away.