A 26-year-old woman presented with a 2-month history of fever, rashes on both legs, shortness of breath for the past 10 days, swelling of both legs and abdomen and face for 7 days, weakness and weight loss. On examination, she was ill-appearing and breathless with a rapid pulse, low blood pressure, elevated jugular venous pressure, murmur at the pulmonary area, and crackles in both lungs. Tests showed vegetation on the pulmonary valve, pulmonary regurgitation, enlarged right ventricle and atrium, and pulmonary hypertension. She was diagnosed with infective endocarditis of the pulmonary valve with pulmonary regurgitation and heart failure, and was started on intravenous antibiotics and

1. A 26-Year-Woman with Fever
And Breathlessness
Presented by
Dr.Md.Sajjad Safi
MD phase –B,Resident
UCC,BSMMU

2. Case summary
Mrs.Ambia,26yrs,housewife presented with fever for 2
months, low grade, intermittent, chills and rigor, with
profuse sweating, associated with both legs rashes ,highest
recorded 103F,subsided by paracetamol. She also
complaints of SOB for 10 days, insidious, progressive,
aggravated with lying and also suddenly getup from sleep
with dry cough and improves with sitting. She also noticed
both legs swelling for 7 days, progressive, involving
abdomen and face. She also experiences malaise,
generalized weakness, arthralgia, myalgia, anorexia and
wt.loss during this period. There is no h/o contact sputum
+TB, burning micturition, loc, dental procedure,change in
urine color. On query she gives h/o 2 pint blood
transfusion 3 months ago after delivery.

3. • On examination,she looks ill and below average
with dyspnoeic(NYHA-IV) and propped up,anaemic
and edematous
• On both legs rashes
• Pulse=120/min,regular,low vol.,BP:90/60mmHg,
Temp:99F,Resp.rate:32/min,
• JVP raised ,No thyromegaly.
• On systemic exam revealed S1 and S2(P2 loud)
diastolic murmur at pulmonary area with b/l basal
crepts and no organomegaly.

4. Investigation

5. ECG

6. CHEST X-RAY P/A VIEW

7. Echo finding
• RA & RV are dilated
• Vegetation at the tips of pulmonary valve
• Pulmonary regurgitation(Gr-II)
• TR(Gr-I)
• PASP=50 mmHg
• Good LV systolic function(EF=64%)
• No regional wall motion abnormality present

8. ROUTINE LAB
Hemoglobin 8.9 %
Total count 8.0*109/L
Differential N66L25M6E0
ESR=65
URINE R/M/E Protein +
RBS 5.2 mmol/L
S.ELECTROLYTES Normal
S.creatinine 0.56mg/dL
ANA Negative
Blood culture 3 samples Negative
CRP 57.0mg/L

9. Final diagnosis
• Infective endocarditis(IE)involving Pul.Valve
with pulmonary regurgitation(PR)
• Pulmonary hypertension(PASP=50)
• Heart failure(HF)

10. Treatment
• Intravenous antibiotics
• Injectable diuretics
• Antipyretics

11. PLAN
• Cause for pulmonary valve involvement(IE)?
• Why left heart failure?
• Any change in treatment plan and duration.

12. Thank you…..