Tricuspid Valve Endocarditis with Large Vegetations on Two Leaflets in an Intravenous Drug User

Infective endocarditis in individuals who inject drugs often involves the right side of the heart, particularly the tricuspid valve. Large vegetations spanning multiple leaflets increase the risk of severe tricuspid regurgitation, septic pulmonary embolism, and right heart dysfunction, creating a therapeutic challenge. We present a 28-year-old male with a history of IV drug use, admitted with fever and chest pain. Blood cultures confirmed methicillin-resistant Staphylococcus aureus . Echocardiography revealed large, mobile vegetations on the anterior and septal leaflets of the tricuspid valve, causing severe regurgitation and right ventricular overload. Despite appropriate antibiotics, the patient’s condition worsened. Surgery was advised, but the patient declined. He was managed conservatively in the intensive care unit with a tailored antibiotic regimen. This case highlights the aggressive nature of tricuspid endocarditis in this population. Echocardiographic assessment is vital for diagnosis, risk stratification, and guiding surgical timing. A multidisciplinary team consisting of cardiology, infectious diseases, and surgery is essential for optimizing the outcomes, especially when surgery is indicated.