Mitral Valve Endocarditis Secondary to Nasal Irrigation Use in Chronic Allergic Rhinitis

Streptococcus mitis (S. mitis) is a common colonizer of the teeth, nasopharynx, and oropharynx. S. mitis has been reported in several cases of streptococcal infective endocarditis (IE). Streptococcal IE is most associated with dental procedures and diseases of the mouth. There are fewer reports of diseases of the nasopharynx leading to endocarditis secondary to nasal irrigation systems, and that is why we present a unique case of mitral valve IE secondary to nasal irrigation. We report a case of a 49-year-old African American woman with a history of chronic allergic rhinitis who presented with chest pain and subjective fevers. Transthoracic echocardiogram (TTE) failed to show valvular vegetation, but high clinical suspicion led to transesophageal echocardiogram (TEE) imaging that demonstrated a mobile echo density with a size of 5mm by 3mm attached to the atrial side of the anterior mitral valve leaflet with thickening of the anterior mitral leaflet tip as well as moderate mitral valve regurgitation. Findings on TTE were consistent with IE. The patient still has organized/nodular vegetation after three months of appropriate antibiotic therapy. We highlight how poor nasal hygiene is low on the differential for a cause of valvular endocarditis. This case will help clinicians in determining appropriate therapy for chronic allergic rhinitis. This will also help clinicians to inform patients to stop using nasal irrigation systems if epistaxis is present.