Propionibacterium acnes infectious endocarditis

BACKGROUND: Propionibacterium acnes, a Gram positive microaerophilic bacteria is considered to have a low level of virulence. Nevertheless, it can be associated with infective endocarditis. We report 2 cases and a review of the literature. CASE REPORTS: The first man developed an acute prosthetic valve infective endocarditis and died. The second case was also a prosthetic valve infective endocarditis in a patient who developed infectious spondylitis. DISCUSSION: P. acnes is an uncommon causal agent in infective endocarditis and appears to have a predilectio for prosthetic valves. A prior history of skin infection is rare. P. acnes grow quite slowly, often requiring 7 to 14 days for identification. All isolates of P. acnes from blood or valve do not necessarily mean contamination.     

Replacement of aortic root with valved tubular prosthesis in a ten-year-old child with infective endocarditis--a case report

Aortic root abscess, aneurysm of sinus Valsalva, severe aortic valve insufficiency, and a fragile aortic wall caused by infective endocarditis were found in a 10-year-old child. Aortic valve replacement was intended as a preoperative strategy, but one of modifications of Cabrol had to be used urgently because of aortic root rupture between right atrial and aortic connection just after pericardiotomy.     

Value and limitations of transesophageal echocardiography in infective endocarditis

Echocardiography has contributed considerably to the evolution in the management of patients with infective endocarditis. There is a clear hierarchy with respect to sensitivity of the different methods is superior when compared to 2-D and M-mode echocardiography in identifying both vegetations and perivalvular complications e.g. abscess formation, aneurysms, mural endocardial lesions. For patients with suspected endocarditis, in whom vegetations can not be clearly identified or in whom abscess formation is suspected with transthoracic echocardiography (TTE), transesophageal echocardiography (TEE) with mono- or multiplane scans has become the standard diagnostic procedure. For the examination of prosthetic valves it is the method of choice. It has even been suggested that it is employed as routine measure in all patients with suspected infective endocarditis. TEE is a safe semi-invasive technique with an extremely low complication rate and high sensitivity. Its specificity depends largely on the patient group which is examined. In patients with indicative clinical symptoms the specificity and the predictive value of vegetations are high. When used as screening method to assess echodense formations at cardiac valves particularly in the elderly, in whom degenerative changes prevail, its specificity and positive predictive value of vegetation-like structures are much lower. The negative predictive value of a negative transesophageal echocardiogram remains high, however. Valve abscesses are detected rarely by transthoracic echocardiography. It is the domain of TEE to assess them particularly in the aortic and mitral valve area. For them the specificity and positive predictive value of TEE in the diagnosis of infective endocarditis is high again. Of further importance was the observation that patients with vegetations of > 10 mm were more likely to suffer embolic complications. It should be noted, however, that infective endocarditis remains a clinical diagnosis: neither is the demonstration of a vegetation already the equivalent of endocarditis, nor does missing vegetations completely rule out the possibility of it. But without doubt, the presence of vegetations, of abscess formation or a concomitant pericardial effusion add valuable information to clinical diagnosis of infective endocarditis, which still needs a "high index of suspicion".     

A case report of infective endocarditis with total rupture of the posterior papillary muscle after aortic valve replacement

We reported a case with severe mitral regurgitation caused by total rupture of the posterior papillary muscle two days after aortic valve replacement. A 62-year-old man was transferred to our hospital with high fever and dyspnea with severe aortic regurgitation caused by infective endocarditis. The left heart failure occurred suddenly two days after the initial operation. Echocardiogram revealed massive mitral regurgitation and rupture of the posterior papillary muscle. He underwent emergent mitral valve replacement. Histological examination of the papillary muscle showed typical ischemic necrosis without inflammation. The postoperative course was uneventful. We suggested the papillary muscle rupture in this case may be due to coronary artery emboli occurred in association with infective endocarditis.     

Intramuscular clindamycin for therapy of infective endocarditis. Report of 23 cases and review of the literature

Twenty-three patients with infective endocarditis received intramuscular clindamycin (Cleocin) for treatment. Thirteen had acute Staphylococcus (S.) aureus endocarditis but none had involvement of the aortic valve. Eleven of these 13 infections were heroin-related and involved the tricuspid valve.Twenty-one patients were successfully treated. Two patients with heroin-related S. aureus infection failed to respond to intramuscularly administered clindamycin, but responded to retreatment with methicillin. There have been 34 reported cases of endocarditis treated with clindamycin. Although 80 percent of all cases due to staphylococci responded favorably, almost all were heroin-related tricuspid valve infections. In addition 91 percent of cases due to aerobic streptococci responded but, surpisingly, treatment failed in three of four cases of anaerobic endocarditis. Although clindamycin can be useful in streptococcal endocarditis and in some cases of heroin-related S. aureus tricuspid endocarditis, caution should be exercised in its use. It is "less" bactericidal than the penicillins or cephalosporins, and organisms have become resistant during treatment. Furthermore, patients with anaerobic endocarditis have not responded well, and data are not available to recommend administration of clindamycin for acute S. aureus infections engrafted on the aortic or mitral valve.     

Surgery of infectious endocarditis

Thirty to fifty percent of patients with infective endocarditis are operated on during the active phase of the disease; this percentage is higher in case of some valvular localizations (aortic), in case of early prosthetic valve endocarditis, in case of some microorganisms (Staphylococcus aureus, gram-negative, fungus, intracellular microorganism). Operative death (at 30 days) is below 10% in native valve endocarditis, close to 50% in early prosthetic valve endocarditis, and below 20% in late prosthetic valve endocarditis. When active infective disease has been healed by medical treatment alone, half the patients need surgery in the first 2 years of follow-up; the indications for surgery are the functional status, the degree of valvular leaks and other lesions, the degree of ventricular dilatation.     

Ischemia of the lower limbs as the initial manifestation of Candida albicans endocarditis in a parenteral drug addict

BACKGROUND: Multiple infective complications have been described in injection drug users (IDUs). Infective endocarditis, most frequently caused by Gram positive bacteria, with classical features, is one of the most dangerous. In a few patients fungi are the cause (less than 5%), and these develop an unusual clinical picture. METHODS: An IDUs patient was admitted in our Hospital for subacute arterial ischemia at the inferior limbs. A mass inside the abdominal aorta was detected by echography and arteriography, which was removed surgically a few hours later. RESULTS: The pathologic evaluation of the surgical specimen revealed its fungal composition; the culture of this material was characteristic of Candida albicans. The clinical suspicion of aortic endocarditis, as the emboligenic source responsible of the inferior limbs ischemia, was confirmed with the performance of an echocardiography. A few hours after surgery the patient got worse; 24 hours later he died due to uncontrolled bleeding of the surgical suture in the aorta. CONCLUSIONS: Fungal endocarditis should be thought in IDUs patients presenting inferior limbs ischemia. Due to the high mortality of this disease, as soon as the diagnosis is suspected, urgent medical and surgical therapy should be started.     

Infective endocarditis: a complication of idiopathic hypertrophic subaortic stenosis (author's transl)

The idiopathic hypertrophic subaortic stenosis (IHSS) is thought to be infrequently complicated by infective endocarditis. Because IHSS is a disorder of the myocardium and not endocardium is not generally considered to have increased risk of infective endocarditis. Some Authors found, however, that approximately 5% of patients with IHSS develop bacterial endocarditis, because hemodynamically IHSS is like to valvular diseases. Therefore the incidence of endocarditis in IHSS is the same of valvular diseases. The vegetations can be found on anterior mitral valve leaflet, aortic cusps and subaortic endocardium. Some patients have dental surgery prior to the onset of endocarditis and others are infected with oral streptococci. For these reasons prophylactic antibiotics should be administered to patients with IHSS undergoing dental manipulation and in other settings where the risk of developing bacteremia is high. We describe one case of IHSS complicated with streptococcus viridans endocarditis. Vegetations, determined with echocardiography, were present on anterior mitral valve leaflet, aortic right coronary cusp and interventricular septum. In a review of literature we are been able to find twenty-seven cases of IHSS complicated with endocarditis.     

Expression of nuclear hormone receptors in Escherichia coli

If streptococci and staphylococci remain the main bacteria responsible for infective endocarditis (80%), the emergence of Streptococcus bovis associated with intestinal lesions, the confirmation of the role of Coxiella burnetii, and the discovery of the responsibility of Bartonella sp in case of negative blood culture endocarditis have been the principal microbiological modifications during the last few years. Blood cultures performed under the best technical conditions and the examination and culture of the valve after surgery remain the better means for diagnosing infective endocarditis. In case of negative blood culture (11% of the infective endocarditis), the serologic tests against C. burnetii and Bartonella should decrease the rate of diagnostic uncertainty. The development of bacteriological techniques, particularly molecular methods, should improve the microbiology of infective endocarditis lead to the discovery new aetiological agents.     

Molecular genetics of small bowel cancer

Streptococcus adjacens has never previously been reported as an etiologic organism of infective endocarditis in Taiwan. We describe a case of severe native valve endocarditis caused by S. adjacens, involving the mitral valve, the aortic valve, and the left atrium, in a 29-year-old woman with nephrotic syndrome on steroid therapy. Blood cultures yielded gram-positive cocci that grew poorly on blood agar but strongly on chocolate agar. Despite aggressive antibiotic treatment, the patients continued to have high fever and progressive congestive heart failure, which necessitated surgical intervention. Symptoms were alleviated after surgery; teicoplanin was continued for 4 weeks and the patient remained symptom-free at the 6 month follow up. To our knowledge, this is the first reported case of bacterial endocarditis involving the left atrium without preexisting myxoma.     

Attention deficit hyperactivity disorder: focus on genetics

BACKGROUND: Leuconostoc spp. are gram-positive coccobacilli, catalase and oxidase negative, vancomycin resistant, with a not clearly defined role in human infectious. Cases of infection have been reported previously but it has not been described confirmed infective endocarditis due to Leuconostoc mesenteroides. METHODS: We describe a case of prosthetic valve endocarditis in a 72-years-old woman with a long previous history of cardiac disease but without other immunological disorders. She developed a heart failure because of prosthetic aortic valve dysfunction. CONCLUSIONS: Leuconostoc mesenteroides should be considered as a potential cause of infective endocarditis and listed in the group of vancomycin-resistant microorganism.     

A brimmed valved conduit in repair of fibrous skeleton abscess

Aortomitral common annular involvement, which is not uncommon in infective endocarditis, necessitates deliberate surgical procedures. To repair fibrous skeleton abscess accompanied with annuloaortic ectasia, we used a brimmed valved conduit. Tension-free reconstruction of the aortic root and aortomitral common annulus was easily performed with this method.     

Assessment of the role and reliability of sonographic post-prandial flow response in grading Crohn''s disease activity

CONTEXT: The incidence of infective endocarditis after surgical repair of congenital heart defects is unknown. OBJECTIVE: To determine the long-term incidence of endocarditis after repair of any of 12 congenital heart defects in childhood. DESIGN: Population-based registry started in 1982. SETTING: State of Oregon. PARTICIPANTS: All Oregon residents who underwent surgical repair for 1 of 12 major congenital defects at the age of 18 years or younger from 1958 to the present. MAIN OUTCOME MEASURE: Diagnosis of infective endocarditis confirmed by hospital or autopsy records. RESULTS: Follow-up data were obtained from 88% of this cohort of 3860 individuals through 1993. At 25 years after surgery, the cumulative incidence of infective endocarditis was 1.3% for tetralogy of Fallot, 2.7% for isolated ventricular septal defect, 3.5% for coarctation of the aorta, 13.3% for valvular aortic stenosis, and 2.8% for primum atrial septal defect. In the cohorts with shorter follow-up, at 20 years after surgery the cumulative incidence was 4.0% for dextrotransposition of the great arteries; at 10 years, the cumulative incidence was 1.1% for complete atrioventricular septal defect, 5.3% for pulmonary atresia with an intact ventricular septum, and 6.4% for pulmonary atresia with ventricular septal defect. No children with secundum atrial septal defect, patent ductus arteriosus, or pulmonic stenosis have had infective endocarditis after surgery. CONCLUSION: The continuing incidence of endocarditis after surgery for congenital heart defect, particularly valvular aortic stenosis, merits education about endocarditis prophylaxis for children and adults with repaired congenital heart defects.     

Ceftriaxone and outpatient treatment of infective endocarditis

There are a total of 8000 cases of infective endocarditis yearly in the United States. Central nervous system metastatic infections are not uncommon in infective endocarditis. Because ceftriaxone is highly bound to serum proteins, there is concern that the drug is highly bound to serum proteins, there is concern that the drug might not penetrate well in the core of an infected vegetation. To date, there are two published studies on the treatment of nonenterococcal streptococcal endocarditis by ceftriaxone in humans. Ceftriaxone appears to be an attractive alternative antibiotic therapy to conventional regimens in the treatment of streptococcal endocarditis.     

Molecular identification of Gemella species from three patients with endocarditis

Gemella morbillorum and Gemella haemolysans are opportunistic pathogens which cause endocarditis and other severe infections. We report on three patients with endocarditis, one with endocarditis caused by G. haemolysans and two with endocarditis caused by G. morbillorum. The paucity of reports concerning these bacteria is probably related to the difficulties associated with their identification. For example, one of the strains reported in this study was originally sent to our laboratory with a preliminary characterization as a short "gram-negative" coccobacillus, highlighting the specific problem associated with Gram staining of these bacteria. The usefulness of 16S rRNA gene amplification, partial sequencing, and comparison of the nucleotide sequence to those in databases when standard phenotypic identification schemes are not helpful is emphasized. We also suggest that the use of simple tests, such as testing susceptibility to vancomycin for gram-negative bacteria and colistin for gram-positive bacteria, could prevent misinterpretation of Gram staining in gram-variable bacteria such as Gemella spp.     

Mobile string-like thrombus on the calcified aortic valve in cardioembolic stroke--a case report

The calcified aortic valve has been associated with being a possible source of emboli in cardioembolic stroke. However, thrombus on the calcified aortic valve has not been identified with two-dimensional echocardiography. A seventy-two-year-old woman with calcified aortic stenosis was admitted with brain embolism. She had not previously received any platelet antiaggregant or anticoagulant. At admission, two-dimensional echocardiography demonstrated a mobile string-like abnormal echo attached to the calcified aortic valve, which showed regression and enlargement repeatedly during admission. No symptoms or clinical data suggested infective endocarditis or nonbacterial thrombotic endocarditis. After commencement of antiplatelet therapy, the abnormal echo regressed and disappeared. She continued to take the medication for seven months and then discontinued. Three months later, she developed recurrence of stroke, and an abnormal echo on the calcified aortic valve was again detected by two-dimensional echocardiography. The authors believe that the abnormal echo on the calcified aortic valve was thrombus and that it was the embolic source. Calcified aortic valve may thus be a causative lesion for mobile string-like thrombus. Two-dimensional echocardiography should be performed repeatedly in patients with calcified aortic valve and brain embolism.     

Purification and properties of the alpha-acetolactate decarboxylase from Lactococcus lactis subsp. lactis NCDO 2118

The authors report the case of a very large deterged aortic valve ring abscess detected at long-term after infective endocarditis during investigation of symptomatic consequent aortic regurgitation. The different imaging methods of diagnostic import are reviewed with special emphasis on the role of transoesophageal echocardiography during infective endocarditis.     

Rupture of asymptomatic mycotic aneurysm after valve replacement in infective endocarditis

Mycotic cerebral aneurysms (MCA) are one of the most serious complications of infective endocarditis. The rupture of MCA in patients under anticoagulant therapy following valve replacement carries high mortality. We encountered this serious complication in a patient who had no neurologic symptoms. A 12-year-old girl was scheduled for mitral valve replacement (MVR) 5 weeks after antibiotic therapy for infective endocarditis caused by Staphylococcus aureus. Before the surgery, she did not have any neurologic symptoms or abnormal findings in CT scanning examination. The surgery to remove her mitral valve with bacterial vegetations and replace it with an artificial valve proceeded smoothly and she appeared to begin an uneventful postoperative recovery. However, she suddenly began to complain of severe headache and became unconscious on the fifth days after MVR. A CT scan showed cerebral herniation due to a major subdural hematoma. A ruptured MCA was detected in the orbito-frontal artery and clipped in an emergency operation. She was transferred to the intensive care unit and given continuous infusion of barbiturate to prevent increase of her intracranial pressure. CT scanning and arteriography 10 days after the MCA clipping, revealed a new subdural hematoma and MCA just proximal to the previous clip. It is important to bear in mind that patients with infective endocarditis can have mycotic cerebral aneurysms without any clinical neurologic symptoms.     

Infectious endocarditis, risk factors, prevention. Research group for infectious endocarditis and jury of the consensus conference

Infective endocarditis, resulting from deposition of circulating microorganisms during a period of bacteremia on damaged endothelial heart valves, remains a serious disease. Its overall incidence did not decline in recent years, 24 cases/year/million inhabitants, in France. This can be explained by a modification of the type of underlying cardiac conditions with regression of rheumatic fever and increase of degenerative heart diseases, prosthetic valves and mitral valve prolapse. The risk of bacterial seeding on a damaged valve remains difficult to evaluate, the highest risk being for patients with prosthetic valve, previous infective endocarditis and cyanotic congenital heart disease. A case-control study, done in 1991, confirmed that procedures are risk factors for infective endocarditis and that the multiplicity of procedures increases the risk. A French consensus conference on the prophylaxis of infective endocarditis has updated the recommendations for antibiotic prophylaxis. Two groups of cardiac patients were identified, based on the incidence and the severity of endocarditis occurring in patients with these conditions, 1) patients considered at risk which require specific prophylaxis, and 2) patients considered non at risk which do not require antibiotic prophylaxis. Procedures which require antibiotic prophylaxis are dental procedures and specific gastrointestinal and urologic procedures. As complex protocols are associated with poor compliance by practitioners and patients, the jury has aimed for simplicity and feasibility.     

Enterococcal infective endocarditis on native aortic valve

Enterococcal endocarditis accounts for 10% of all bacterial endocardits. The infection progresses in a subacute way and when localized on the aortic valve it has a very poor prognosis since the valve is usually destroyed being death the fatal outcome. We report a case of a patient with infective endocarditis resulting from the implantion of the Enterococcus on the native aortic valve. Nor visk factors or an apparent main gate could be found. The patient was hospitalized after several months of a non especific febrile syndrome. The literature is reviewed. Diagnostic tests and clinical signs are discussed making emphasis on the refractoriness to chemotherapy.