Nature’s balancing act: Infective endocarditis of pulmonary valve with ventricular septal defect in fifth decade; a rare and unusual presentation

It is unusual for a moderate-size ventricular septal defect (VSD) to remain asymptomatic and complication-free until the age of 45 years. Similarly, infective endocarditis of anatomically normal pulmonary valve is also rare. Here we report a case in which nature created a protection for VSD, i.e. right ventricular outflow tract (RVOT) obstruction, which led to a complication, i.e. pulmonary valve endocarditis. A 45-year-old sick-looking man presented in medical emergency with fever and progressively increasing breathlessness for the previous 2 weeks. He had no significant past history. The patient was febrile and on cardiovascular (CVS) examination, ejection systolic murmur in left upper parasternal region was heard, suggesting a diagnosis of infective endocarditis. Echocardiography revealed subaortic VSD of 1.2cm size with left to right shunt. There was moderator band hypertrophy in sub-infundibular right ventricle (RVOT obstruction) creating obstruction to blood flow, thus preventing development of pulmonary artery hypertension. There were two large vegetations (4×3mm) on each leaflet of pulmonary valve. High speed turbulent jet of blood generated from right ventricle obstruction was striking the pulmonary valve leaflets which led to injury and subsequent development of infective endocarditis of pulmonary valve. The patient improved on intravenous antibiotics. The plan was to give 6 weeks of antibiotics followed by surgical closure of VSD and resection of moderator band.