Eustachian valve endocarditis caused by Actinomyces species is extremely rare. A literature review revealed only one reported case—caused by Actinomyces israelii in an intravenous drug abuser.

Our patient, a 30-year-old woman who at first appeared to be in good health, presented with fever, a large mobile mass on the eustachian valve, and extensive intra-abdominal and pelvic masses that looked malignant. Histopathologic examination of tissue found in association with an intrauterine contraceptive device revealed filamentous, branching microorganisms consistent with Actinomyces turicensis. This patient was treated successfully with antibiotic agents.

In addition to presenting a new case of a rare condition, we discuss cardiac actinomycotic infections in general and eustachian valve endocarditis in particular: its predisposing factors, clinical course, sequelae, and our approaches to its management.

Actinomyces species are anaerobic-to-microaerophilic bacteria that survive as normal flora within the mouth, bronchi, gastrointestinal tract, and female genital tract. These organisms are rarely associated with chronic pyogenic or granulomatous infections in the general population.1  Actinomycotic infections are generally limited to the cervicofacial (50%), pulmonary (15%), and intra-abdominal (20%) areas. Cardiac involvement is relatively rare; most infections occur by contiguous metastasis to the pericardium and very rarely by hematogenous metastasis to the cardiac valves.2  Infection of the eustachian valve (EV) by Actinomyces species is extremely rare, having (to our knowledge) been reported only once before.3  We report a case of EV endocarditis caused by Actinomyces turicensis in an apparently healthy young woman, possibly transmitted by an intrauterine contraceptive device (IUD). In our accompanying review of the relevant literature, we discuss the predisposing factors, the clinical course, and the treatment of various actinomycotic and EV endocarditis.

In September 2011, a 30-year-old woman was admitted with right upper quadrant pain and swelling of one week's duration. Her medical history included no recent dental work, no human immunodeficiency viral infection, and no history of intravenous drug use. She had undergone a cesarean section 2 years before presentation, after which an IUD had been placed. Physical examination at admission revealed a firm mass, slightly painful to the touch, in the right upper quadrant. Laboratory results showed marked leukocytosis. A transvaginal ultrasonogram and a computed tomogram revealed multiple large masses in the ovaries, pelvis, and liver that were suspect for extensive metastatic disease, presumably ovarian in origin. Histopathologic studies of tubo-ovarian (Fig. 1A) and liver (Fig. 1B) biopsy samples failed to reveal any malignant cells. Instead, they showed microabscesses with branching filamentous microorganisms consistent with Actinomyces species. The patient subsequently underwent an exploratory laparotomy, which revealed multiple pockets of pus with extensive inflammatory changes and fibrinous adhesions. Evacuation of pus was performed, along with total abdominal hysterectomy, right salpingo-oophorectomy, appendectomy, and lysis of adhesions. Cultures of fluid from both the abdominal cavity and the IUD grew A. turicensis. Multiple sets of blood cultures performed on the day of admission and during the patient's hospital course failed to reveal any growth of microorganisms.

Fig. 1

A) Photomicrograph of tubo-ovarian section shows colonies of Actinomyces with a branching filamentous appearance (H & E, orig. ×200). B) Photomicrograph of liver biopsy specimen shows branching filamentous bacteria, surrounded by liver parenchyma (Grocott-Gomori methenamine-silver stain, orig. ×400). C) Computed tomogram performed with intravenous and oral contrast medium reveals a large abscess of the liver (arrow) eroding into the anterior abdominal wall.

Fig. 1

A) Photomicrograph of tubo-ovarian section shows colonies of Actinomyces with a branching filamentous appearance (H & E, orig. ×200). B) Photomicrograph of liver biopsy specimen shows branching filamentous bacteria, surrounded by liver parenchyma (Grocott-Gomori methenamine-silver stain, orig. ×400). C) Computed tomogram performed with intravenous and oral contrast medium reveals a large abscess of the liver (arrow) eroding into the anterior abdominal wall.

In view of the extensive actinomycotic infection and consequent risk of abdominal-wall fistula formation, we started her on broad-spectrum antibiotics, including penicillin G, ceftriaxone, and metronidazole. Despite the abdominal surgery and antibiotic therapy, the patient continued to be febrile and hypotensive over the next few days. A 2nd computed tomogram of the abdomen showed a right hepatic lobe abscess, which eroded the anterior abdominal wall and extended into the subcutaneous fat of the epigastrium (Fig. 1C). A transthoracic echocardiogram (TTE), performed for the evaluation of any cardiac cause of hypotension, showed a 2.7 × 2-cm mobile and multilobulated echogenic mass attached to a congenitally complete EV in the right atrium. This mass was consistent with a large EV vegetation, probably the product of hematogenous actinomycotic seeding from the liver abscess (Figs. 2A–B). The tricuspid valve was free of any vegetation and displayed minimal tricuspid regurgitation. The patient underwent surgical drainage of the liver abscess, and the course of antimicrobial therapy was continued.

Fig. 2

Transthoracic echocardiograms. A) The apical 4-chamber view reveals a mobile, multilobulated vegetation (arrow) attached to the mid portion of a complete eustachian valve. B) The parasternal short-axis view reveals a mobile vegetation (arrow) attached to the eustachian valve. C) After 3 weeks of antibiotic therapy, the apical 4-chamber view reveals complete resolution of the vegetation.

Fig. 2

Transthoracic echocardiograms. A) The apical 4-chamber view reveals a mobile, multilobulated vegetation (arrow) attached to the mid portion of a complete eustachian valve. B) The parasternal short-axis view reveals a mobile vegetation (arrow) attached to the eustachian valve. C) After 3 weeks of antibiotic therapy, the apical 4-chamber view reveals complete resolution of the vegetation.

Postoperatively, she showed gradual clinical improvement, along with resolution of her fever and leukocytosis. In order to reevaluate the extent of cardiac involvement, we repeated TTE on day 20 after the patient's initial presentation, and this showed near-complete resolution of the vegetation (Fig. 2C). After a month-long hospital course on the previously mentioned antibiotic agents, the patient was discharged from the hospital on penicillin G and imipenem. She received these 2 agents for an additional 30 days, which concluded 8 weeks of therapy in total. During the next 16 months of follow-up at our infectious diseases clinic, complete clinical and radiographic recovery was documented.

In the fetal circulation, the eustachian valve directs oxygenated blood from the inferior vena cava through the foramen ovale, and into the left atrium. In adults, it is usually a rudimentary and benign nonfunctional structure. Eustachian valve endocarditis, first described in 1986 by Edwards and colleagues4  in a patient who died of staphylococcal septicemia and lung abscesses, is distinctly rare. Since 1986, only 29 additional cases of EV endocarditis have been reported (Table I).424  The usual predisposing factor for EV endocarditis is intravenous drug use. Other causes include indwelling catheters, rheumatic heart disease, pacemaker wires, and immunologic compromise (such as that caused by chronic alcoholism or the human immunodeficiency virus).12,15,18 

TABLE I.

Reports of Eustachian Valve Endocarditis

Reports of Eustachian Valve Endocarditis
Reports of Eustachian Valve Endocarditis

In the presence of intravenous drug use, the usual causative pathogen is Staphylococcus aureus.14  Other organisms, not specifically associated with intravenous drug use, include Staphylococcus hominis,6  Enterobacter cloacae,10  Escherichia coli,14  Proteus vulgaris,14  Streptococcus viridans,12  Klebsiella pneumonia,16,19  and Actinomyces israelii.3  Pericardial actinomycotic infections are known to occur by contiguous spread from adjacent thoracic structures. In patients with underlying rheumatic heart disease or a history of intravenous drug use,25,26  Actinomyces species are also a reported cause of aortic, mitral, and (rarely) tricuspid valve endocarditis (Table II2745 ). Kennedy and colleagues3  reported a case of EV endocarditis caused by A. israelii in an intravenous drug user who had a history of treatment for staphylococcal tricuspid valve endocarditis. Because of persistent fever, the patient underwent surgical excision of the vegetation.

TABLE II.

Reports of Actinomycotic Endocarditis

Reports of Actinomycotic Endocarditis
Reports of Actinomycotic Endocarditis

For the diagnosis of EV endocarditis, TTE is usually the test of choice for initial imaging. Although transesophageal echocardiography might yield relatively better images of the EV, its use as an initial diagnostic tool in all patients suspected to have EV endocarditis remains controversial.46,47  We recommend a transesophageal echocardiogram in patients with a high clinical suspicion of endocarditis, in whom a TTE fails to accurately define cardiac structures, including the EV.

In most cases of EV endocarditis reported to date, medical therapy with appropriate antibiotics has shown resolution of the vegetations. Surgery is reserved for nonresponders or for patients with evidence of septic emboli or symptoms of congestive heart failure. Penicillin G remains the mainstay of treatment for actinomycosis. Alternative regimens for patients with allergy to penicillin include 3rd-generation cephalosporin (ceftriaxone), clindamycin, erythromycin, and doxycycline.48 

Our patient with EV endocarditis was a previously healthy young woman who acquired extensive A. turicensis infection of her intra-abdominal and pelvic structures mimicking malignancy, although its most likely cause was an infected IUD. Despite the absence of a cardiac histologic diagnosis in this case, several factors support the diagnosis of actinomycotic EV endocarditis: a high degree of suspicion for cardiac involvement of Actinomyces, a lack of evidence to support an alternative diagnosis, and successful resolution of the vegetation with antibiotic treatment. We conclude that endocarditis, particularly of the eustachian valve, should be suspected in patients who have such extensive actinomycotic infection. Prompt diagnosis and appropriate intervention is recommended to reduce the risk of such sequelae as septic emboli, congestive heart failure, and death.

1.
Burden
P
.
Actinomycosis
.
J Infect
1989
;
19
(
2
):
95
9
.
2.
Brown
JR
.
Human actinomycosis. A study of 181 subjects
.
Hum Pathol
1973
;
4
(
3
):
319
30
.
3.
Kennedy
JL
,
Chua
DC
,
Brix
WK
,
Dent
JM
.
Actinomycotic endocarditis of the eustachian valve
.
Echocardiography
2008
;
25
(
5
):
540
2
.
4.
Edwards
AD
,
Vickers
MA
,
Morgan
CJ
.
Infective endocarditis affecting the eustachian valve
.
Br Heart J
1986
;
56
(
6
):
561
2
.
5.
Vilacosta
I
,
San Roman
JA
,
Roca
V
.
Eustachian valve endocarditis
.
Br Heart J
1990
;
64
(
5
):
340
1
.
6.
Navarro
V
,
Martinez-Alfaro
E
,
Sanz
P
,
Solera
J
.
Eustachian valve endocarditis produced by Staphylococcus hominis in a patient with HIV infection [in Spanish]
.
Rev Clin Esp
1996
;
196
(
8
):
572
3
.
7.
Georgeson
R
,
Liu
M
,
Bansal
RC
.
Transesophageal echocardiographic diagnosis of eustachian valve endocarditis
.
J Am Soc Echocardiogr
1996
;
9
(
2
):
206
8
.
8.
Palakodeti
V
,
Keen
WD
Jr
,
Rickman
LS
,
Blanchard
DG
.
Eustachian valve endocarditis: detection with multiplane transesophageal echocardiography
.
Clin Cardiol
1997
;
20
(
6
):
579
80
.
9.
Punzo
F
,
Guarini
P
,
De Michele
M
,
Accadia
M
,
Irace
L
,
Caruso
A
,
Granato Corigliano
G
.
Eustachian valve endocarditis in an elderly woman
.
Echocardiography
1999
;
16
(
3
):
259
61
.
10.
James
PR
,
Dawson
D
,
Hardman
SM
.
Eustachian valve endocarditis diagnosed by transoesophageal echocardiography
.
Heart
1999
;
81
(
1
):
91
.
11.
Bowers
J
,
Krimsky
W
,
Gradon
JD
.
The pitfalls of transthoracic echocardiography. A case of eustachian valve endocarditis
.
Tex Heart Inst J
2001
;
28
(
1
):
57
9
.
12.
Schmidt
MA
,
Nigbor
D
,
Eitzman
DT
.
Eustachian valve endocarditis caused by Streptococcus viridans
.
J Am Soc Echocardiogr
2001
;
14
(
10
):
1042
3
.
13.
San Roman
JA
,
Vilacosta
I
,
Sarria
C
,
Garcimartin
I
,
Rollan
MJ
,
Fernandez-Aviles
F
.
Eustachian valve endocarditis: is it worth searching for?
Am Heart J
2001
;
142
(
6
):
1037
40
.
14.
Sawhney
N
,
Palakodeti
V
,
Raisinghani
A
,
Rickman
LS
,
De-Maria
AN
,
Blanchard
DG
.
Eustachian valve endocarditis: a case series and analysis of the literature
.
J Am Soc Echocardiogr
2001
;
14
(
11
):
1139
42
.
15.
Pellicelli
AM
,
Pino
P
,
Terranova
A
,
D'Ambrosio
C
,
Soccorsi
F
.
Eustachian valve endocarditis: a rare localization of right side endocarditis. A case report and review of the literature
.
Cardiovasc Ultrasound
2005
;
3
:
30
.
16.
Wong
RC
,
Teo
SG
,
Yeo
TC
.
An unusual right-sided endocarditis: a case report of eustachian valve endocarditis
.
Int J Cardiol
2006
;
109
(
3
):
406
7
.
17.
Skubas
N
,
Slepian
RL
,
Lee
LY
,
Tortolani
AJ
.
Tricuspid regurgitation caused by eustachian valve endocarditis
.
Anesth Analg
2006
;
103
(
6
):
1410
1
.
18.
Gill
DS
,
Birchley
S
.
Eustachian valve endocarditis
.
Echocardiography
2006
;
23
(
3
):
256
7
.
19.
Veiga
VC
,
Molinari
AC
,
Farias
CM
,
Silva
A
Jr
,
Marum
EC
,
Rojas
SO
,
et al
.
Eustachian valve endocarditis [in Portuguese]
.
Arq Bras Cardiol
2007
;
88
(
4
):
e79
80
.
20.
Jagernauth
S
,
Patel
A
,
Baig
K
,
De Souza
A
.
Fungal endocarditis of the eustachian valve in carcinoid heart disease: a case report
.
J Heart Valve Dis
2007
;
16
(
6
):
631
3
.
21.
Deluca
G
,
Correale
M
,
Ieva
R
,
Di Biase
M
.
Voluminous mass adherent to the eustachian valve
.
Echocardiography
2008
;
25
(
1
):
100
1
.
22.
Lopes
A
,
de Morais
GP
,
Dourado
R
,
Pacheco
M
,
Martins
D
.
Eustachian valve bacterial endocarditis--a rare location [in Portuguese]
.
Rev Port Cardiol
2008
;
27
(
10
):
1335
8
.
23.
Andres
AS
,
Moreno
JI
.
Endocarditis sobre valvula de Eustaquio redundante: diagnostico neonatal [in Spanish]
.
Rev Esp Cardiol
2009
;
62
(
10
):
1200
2
.
24.
Venkatram
M
,
Kommuri
NV
,
Kollepara
SL
,
Krishnamurthy
VN
,
Rajagopal
R
,
Munasinghe
R
.
Eustachian valve endocarditis: a rare complication of automatic implantable cardioverter defibrillator placement
.
J Heart Valve Dis
2009
;
18
(
6
):
723
5
.
25.
Janoskuti
L
,
Lengyel
M
,
Fenyvesi
T
.
Cardiac actinomycosis in a patient presenting with acute cardiac tamponade and a mass mimicking pericardial tumour
.
Heart
2004
;
90
(
5
):
e27
.
26.
Slutzker
AD
,
Claypool
WD
.
Pericardial actinomycosis with cardiac tamponade from a contiguous thoracic lesion
.
Thorax
1989
;
44
(
5
):
442
3
.
27.
Uhr
N
.
Bacterial endocarditis: report of a case in which the cause was Actinomyces bovis
.
Arch Intern Med (Chic)
1939
;
64
(
1
):
84
90
.
28.
Beamer
PR
,
Reinhard
EN
,
Goodof
II
.
Vegetative endocarditis caused by higher bacteria and fungi: review of previous cases and report of two cases with autopsies
.
Am Heart J
1945
;
29
(
1
):
99
112
.
29.
Mac Neal
WJ
,
Blevins
A
,
Duryee
AW
.
Clinical arrest of endocardial actinomycosis after 44 million units of penicillin
.
Am Heart J
1946
;
31
(
6
):
668
76
.
30.
Wedding
ES
.
Actinomycotic endocarditis; report of two cases with a review of the literature
.
Arch Intern Med (Chic)
1947
;
79
(
2
):
203
27
.
31.
Walters
EW
,
Romansky
MJ
,
Johnson
AC
,
Conway
SJ
.
Actinomyces bovis endocarditis: an uncommon and complex problem
.
Antimicrob Agents Chemother
1962
;
2
(
5
):
517
25
.
32.
Dutton
WP
,
Inclan
AP
.
Cardiac actinomycosis
.
Dis Chest
1968
;
54
(
5
):
463
7
.
33.
Gutschik
E
.
Endocarditis caused by Actinomyces viscosus
.
Scand J Infect Dis
1976
;
8
(
4
):
271
4
.
34.
O'Sullivan
RA
,
Armstrong
JG
,
Rivers
JT
,
Mitchell
CA
.
Pulmonary actinomycosis complicated by effusive constrictive pericarditis
.
Aust N Z J Med
1991
;
21
(
6
):
879
80
.
35.
Lam
S
,
Samraj
J
,
Rahman
S
,
Hilton
E
.
Primary actinomycotic endocarditis: case report and review
.
Clin Infect Dis
1993
;
16
(
4
):
481
5
.
36.
Moffatt
S
,
Ahmen
AR
,
Forward
K
.
First reported case of bacterial endocarditis attributable to Actinomyces meyeri
.
Can J Infect Dis
1996
;
7
(
1
):
71
3
.
37.
Reddy
I
,
Ferguson
DA
Jr
,
Sarubbi
FA
.
Endocarditis due to Actinomyces pyogenes
.
Clin Infect Dis
1997
;
25
(
6
):
1476
7
.
38.
Hamed
KA
.
Successful treatment of primary Actinomyces viscosus endocarditis with third-generation cephalosporins
.
Clin Infect Dis
1998
;
26
(
1
):
211
2
.
39.
Huang
KL
,
Beutler
SM
,
Wang
C
.
Endocarditis due to Actinomyces meyeri
.
Clin Infect Dis
1998
;
27
(
4
):
909
10
.
40.
Mardis
JS
,
Many
WJ
Jr.
Endocarditis due to Actinomyces viscosus
.
South Med J
2001
;
94
(
2
):
240
3
.
41.
Westling
K
,
Lidman
C
,
Thalme
A
.
Tricuspid valve endocarditis caused by a new species of actinomyces: Actinomyces funkei
.
Scand J Infect Dis
2002
;
34
(
3
):
206
7
.
42.
Julian
KG
,
de Flesco
L
,
Clarke
LE
,
Parent
LJ
.
Actinomyces viscosus endocarditis requiring aortic valve replacement
.
J Infect
2005
;
50
(
4
):
359
62
.
43.
Oh
S
,
Havlen
PR
,
Hussain
N
.
A case of polymicrobial endocarditis caused by anaerobic organisms in an injection drug user
.
J Gen Intern Med
2005
;
20
(
10
):
C1
2
.
44.
Oddo
BD
,
Ayala
RF
.
Actinomycotic infective endocarditis of the mitral valve. Anatomoclinical case and review of literature [in Spanish]
.
Rev Chilena Infectol
2007
;
24
(
3
):
232
5
.
45.
Grundmann
S
,
Huebner
J
,
Stuplich
J
,
Koch
A
,
Wu
K
,
Geibel-Zehender
A
,
et al
.
Prosthetic valve endocarditis due to Actinomyces neuii successfully treated with antibiotic therapy
.
J Clin Microbiol
2010
;
48
(
3
):
1008
11
.
46.
Shively
BK
,
Gurule
FT
,
Roldan
CA
,
Leggett
JH
,
Schiller
NB
.
Diagnostic value of transesophageal compared with transthoracic echocardiography in infective endocarditis
.
J Am Coll Cardiol
1991
;
18
(
2
):
391
7
.
47.
Seto
TB
,
Manning
WJ
.
The role of echocardiography in suspected endocarditis: where's the beef?
Am J Med
1999
;
107
(
3
):
281
2
.
48.
Sudhakar
SS
,
Ross
JJ
.
Short-term treatment of actinomycosis: two cases and a review
.
Clin Infect Dis
2004
;
38
(
3
):
444
7
.

Author notes

From: Division of Cardiology (Drs. Afonso, Bhandare, Kottam, and Zmily), and Departments of Internal Medicine (Drs. Bheemreddy, Brar, and Kaur) and Clinical Pathology (Dr. Herawi), Harper University Hospital, Wayne State University, Detroit, Michigan 48201