APCU25CR7 The murmur that spoke twice: VSD and reccurent endocarditis in the military

Introduction Infective endocarditis (IE) is a serious illness often associated with structural heart disease. In young, active servicemen, it is uncommon and can be easily overlooked even when initial treatment appears successful. However, a small congenital defect may remain the silent culprit, setting the stage for recurrence.Case Report A 36-year-old serviceman with young-onset hypertension was first admitted in 2022 with fever and malaise. Echocardiography reported a 2 × 1.1 cm mitral valve (MV) vegetation, mild LV systolic dysfunction (EF 45%), and mild mitral regurgitation. Blood cultures grew Streptococcus mitis, sensitive to penicillin. He completed six weeks of IV therapy, blood cultures cleared, and repeat imaging showed improved LV function (EF 67%) and reduction in vegetation size. He was discharged with routine follow-up, his life returning to normal military duties. Two years later, during routine medical assessment, a medical officer detected a new pansystolic murmur. The patient admitted to months of reduced effort tolerance. This finding reopened an old story. Repeat echocardiography revealed a small perimembranous Ventricular Septal Defect (0.3 cm) with left-to-right shunting, and a 2.2 × 1.2 cm calcified vegetation on the tricuspid valve (TV). Moderate tricuspid regurgitation (TR) was noted; the NT-proBNP level was mildly elevated at 190 pg/mL with preserved LV function. He was then referred and underwent TV replacement and VSD closure.Discussion This case highlights the previously unrecognized role of a small, congenital VSD in recurrent endocarditis. Congenital heart disease such as VSD is the most common risk factor for right sided IE occurring 19.6% of cases. The first episode involved the MV and appeared to resolve after antibiotic treatment. Unfortunately, there was no further echo evaluation for the cause of the MV vegetation despite no other identifiable risk factors for IE. We hypothesize that the extension of the vegetation into the VSD leading to unnoticed chronic vegetation on the TV.Conclussion A murmur may speak once, but when it speaks twice, it demands deeper listening. Recurrent IE in young adults should always raise suspicion of congenital heart disease. Early recognition and surgical repair are key to preserve the fighting strength.