Pulmonary valve endocarditis in a postpartum patient: a case report of unconventional risk

Infective endocarditis is a critical and fatal condition characterized by infection of the endocardium, including the heart valves, cardiac devices, central catheters, and nonfunctional embryonic remnants of the right atrium, such as the Eustachian valve. Intravenous drug users, people with intracardiac devices and central venous catheters are significantly more likely to develop right-sided endocarditis.

A 35-year para 3 woman, on her 40th postpartum day after normal vaginal delivery at home, was referred to our center with symptoms of headache, fever, shortness of breath, palpitation manifested on the 5th postpartum day and conservatively managed in a peripheral institute until being referred. She was initially managed symptomatically but again presented with worsening symptoms, and on CECT, acute pulmonary thromboembolism with pulmonary infarcts was seen. Similarly, the echocardiographic finding showed hypoechoic oscillating structure of 32 mm × 9 mm attached to pulmonary valve (probably clot) with severe pulmonary regurgitation, mild eccentric tricuspid regurgitation, dilated right atrium and right ventricle. Hence, a diagnosis of right-sided infective endocarditis was made and the patient was managed accordingly.

This case report presents a rare instance of right-sided infective endocarditis involving the pulmonary valve in a postpartum patient without any associated risk factors. Postpartum progesterone suppression, physiological stress, and uterine healing create a temporary immunocompromised state with weeks-long infection vulnerability after delivery. Initially, the patient was misdiagnosed as a case of postpartum cardiomyopathy. The corrected diagnosis of infective endocarditis was confirmed via echocardiography despite negative blood cultures. Severe anemia (Hb 5.2 g/dl) and postpartum immune alterations likely predisposed to infection. The patient improved on empirical antibiotics (clindamycin/linezolid) and rivaroxaban. This case highlights the importance of considering right sided infective endocarditis in postpartum fever presenting with shortness of breath and the challenges of diagnosis in resource-limited settings.

This case highlights right-sided infective endocarditis (RSIE) as a rare but serious complication in the postpartum period, even in patients without traditional risk factors. The postpartum state marked by progesterone-driven immunosuppression, hemodynamic stress, and anemia-induced immune dysfunction, may predispose women to atypical infections, including culture-negative endocarditis.