A Series of Frustrations of Fever for Congenital Heart Disease: Case Report

Background: Fever, dry cough and fatigue are the most common symptoms of the coronavirus disease-2019 (COVID-19). During the COVID-19 pandemic in China, we treated a patient with fever and nally diagnosed congenital heart disease. Case presentation: An 18-year-old lady came to the fever clinic with a complaint about the symptoms of fever, dry cough and dyspnea for 15 days. She had a travel history of epidemic area two weeks ago. She had a low fever and dry cough accompanied with chest tightness and fatigue. Eventually she diagnosed ventricular septal defect complicated by infective endocarditis. Two months after surgery, the patient returned to normal social life and physical activity. Conclusion: Early surgical treatment is an effective strategy for ventricular septal defect patients complicated with IE, which can improve the early survival rate of patients.


Introduction
Fever, dry cough and fatigue are the most common symptoms of the coronavirus disease-2019 . In the early stage of lung imaging, multiple small plaques and interstitial changes were frequently observed, and the outer lung area was obvious. We treated a suspected COVID-19 patient and eventually diagnosed congenital heart disease. The report is as follows.

Case Presentation
An 18-year-old lady came to the fever clinic with a complaint about the symptoms of fever, dry cough and dyspnea for 15 days. She had a travel history of epidemic area two weeks ago. She had a low fever and dry cough accompanied with chest tightness and fatigue. There were no other concomitant symptoms. Physical examination showed her body temperature was 37.5℃, coarse respiratory and moist rales were found in her both lungs. The pulmonary valve auscultation area could be heard a loud systolic wind-like murmur of grade 4 up to 6. Biochemical examination indicated that the white blood cells (WBC), hemoglobin (HB) and platelets PLT were 15.36 × 10^9 / L, 69g / L and 6610^9/L, respectively. The percentage of lymphocytes was 8%, and c-reactive protein (CRP) was 185.66mg/L. Lung CT scan displayed multiple infections and consolidation occurred in both lungs, presenting frosted hyaline changes, peripheral ground-glass opacities, and pericardial effusion (Figure 1 A). Primary cardiac ultrasound revealed the enlarged right atrium and ventricle. There seemed to be a slightly hyperechoic mass on the right ventricular out ow tract and pulmonary valve. Ultrasonic cardiogram indicated pulmonary valve stenosis and pulmonary artery enlargement with moderate pulmonary hypertension. Admission was considered as a suspected case of COVID-19 and was treated in isolation ward. Some kinds of antibiotic and antivirus therapy were prescribed. The second lung CT scan displayed an aggravation of the infection several days later (Figure 1 B). The patient's condition continued to deteriorate with fever, dyspnea, and hypoxemia. CRP increased progressively, HB decreased to 57g/ L, and PLT decreased to 7×10 9 /L. While multiple pharyngeal swabs of the patient were negative for COVID-19. The second ultrasonic cardiogram revealed enlarged right atria and ventricle, pulmonary stenosis and multiple neoplasm ( Figure   2A and 2B). Blood culture of this patient collected a kind of streptococcal infection. Pulmonary artery CTA showed multi-location pulmonary embolisms and pulmonary infarction ( Figure 1C 1 , 1C 2 and 1C 3 ). The diagnosis was amended with congenital heart disease, pulmonary valve stenosis, infective endocarditis, sepsis, and pulmonary infection. High doses of penicillin, levo oxacin, vancomycin was prescribed according to sensitivity. Platelet suspension was infused to decrease the possibility of spontaneous hemorrhage. The patient still had fever, chest tightness, and dyspnea symptoms. So, surgical operation was decided to perform thoracotomy for pulmonary valvuloplasty and resection of neoplasm. A large neoplasm was seen on the pulmonary valve, which caused to the severe pulmonary valve stenosis ( Figure 2D). An intra-cristae ventricular septal defect with a size of 1.5*1.8cm 2 was found by cardiac exploration. Due to being blocked by the thick muscle bundles nearby, the ventricular septal defect could not be detected by conventional echocardiography. Pathological examination showed the neoplasm lled with denatured and necrotic tissue, cellulose, lymphocytes and plasma cells, focal calci cation, a small amount of myocardial and endocardial tissue ( Figure 2E and 2F). The patient was re-amended with congenital ventricular septal defect (VSD), infective endocarditis, secondary pulmonary valve stenosis.
She received tissue patch repair for VSD, right ventricular out ow tract dredging, and tricuspid valvuloplasty. Two months later, the patient had no any special discomfort, and no valvular neoplasm was found by echocardiography ( Figure 2C). Pulmonary artery CT scan did not show obvious embolism, and the in ammation of lung was obviously absorbed ( Figure 1D 1 , 1D 2 and 1D 3 ). The patient backed to normal social life and physical activity.

Discussion And Conclusions
During the COVID-19 pandemic in China, the patient characterized by fever, cough, and dyspnea was initially diagnosed as COVID-19 suspected case comorbidity with congenital pulmonary stenosis. She was amended with congenital ventricular septal defect with the right heart infective endocarditis nally.
Due to the low pressure of right heart system, the neoplasm of infective endocarditis was always large, crisp, and easy to fall off to form multiple pulmonary embolisms. That would lead to bacterial pulmonary small artery embolism and pulmonary infection [1]. Similar symptoms and lung image change in CT scan with COVID-19 caused to the initially diagnosis in this patient. Following up the patient's medical history, she had a history of tooth extraction 4 months ago the onset of the disease, which may be the inducing factor causing to the infective endocarditis (IE).
Infective endocarditis with high morbidity and mortality is one of the most serious and destructive complication of valvular heart disease [2]. Congenital heart disease is a common cause of infective endocarditis [3], and studies have shown that the incidence can reach 10% to 14%, which is more common in VSD, congenital bicuspid aortic valve, patent ductus arteriosus (PDA), and tetralogy of Fallot. Furthermore, VSD is the most common intracardiac malformation resulting in IE. From this case, it was suggested that a diagnosis of pulmonary stenosis with IE should be more cautious in evaluation of VSD.
Endocarditis of the right heart system mainly involved the tricuspid valve and pulmonary valve, which were relatively rare in clinic. They were mainly seen in injecting drug abuser, patients with intracardiac implantation and congenital heart disease [4]. Compared with endocarditis in left heart system, right heart system of endocarditis not only showed infection symptoms, such as fever of unknown origin, anemia, bacteremia and so on, but also showed complications caused by pulmonary infection and right heart system function damage. In this case, pulmonary valve stenosis and the formation of neoplasm were initially diagnosed, and it was nally amended with congenital ventricular septal defect complicated with infective endocarditis.
Early surgical treatment is an effective strategy for ventricular septal defect patients complicated with IE, which can improve the early survival rate of patients. Some studies have also shown that surgery should be actively considered for patients with congestive failure, severe valvular dysfunction, perivalvular abscess, recurrent systemic embolism, large neoplasm and persistent sepsis [5,6]. Although the preoperative general condition of this patient was extremely poor with HB 65 g/L, PLT 28×10 9 /L, we decided to take the risk of surgical treatment and nally achieved a good result, considering that the pulmonary valve neoplasm of the patient was too large and she had multiple pulmonary embolisms. This case gave a positive feedback.  CAREchecklistEnglish2013.pdf