201Tl SPECT for suspected lung cancer in a case of a systemic arterial supply to the lung without sequestration

BACKGROUND: Q fever endocarditis is a life-threatening disease for which the diagnosis is usually based on serology. The major microbiologic criterion for the diagnosis of infectious endocarditis (two separate positive blood cultures) cannot be achieved in most routine laboratories because of the biohazard associated with the culture of Coxiella burnetii, the etiological agent of Q fever. PURPOSE: Recently, new criteria for the diagnosis of infectious endocarditis have been proposed, and in this study we attempted to assess the suitability of these criteria specifically for the diagnosis of Q fever endocarditis. PATIENTS AND METHODS: To achieve this aim, we first selected from our series 20 recent cases in whom endocarditis had been confirmed following valvular pathological examination, and for whom microbiological evidence for the involvement of C burnetii was available. Then, we applied the criteria proposed by the Duke Endocarditis Service (ie, C burnetii positive serology being considered a minor criterion) to this cohort of patients but excluding pathological findings. Although the Duke Endocarditis Service criteria confirmed diagnosis in 16 of the patients, 4 were misclassified as "possible" cases (20%). However, when the Q fever serological results (using an 1/800 antiphase I immunoglobulin G cut off) and single blood culture results were changed from minor to major diagnostic criteria, endocarditis was confirmed in them all. A second time, prospectively, we applied the Duke Endocarditis Service criteria to a further 5 patients affected with Q fever endocarditis. Strict application of these criteria resulted in 1 of the 5 being misdiagnosed. Applying the suggested modification for C burnetii results, all 5 were confirmed as having infectious endocarditis. CONCLUSION: We propose that the modifications discussed in this study be applied to the Duke Endocarditis Service criteria in order that the diagnosis of C burnetii induced endocarditis is improved.     

Why is there an analytical culture in a medical laboratory?]

During a seven-year period (1998-94) 68 patients with infectious endocarditis were diagnosed at a university hospital. Staphylococcus aureus was the most common etiological agent (38%), followed by Streptococcus viridans (21%). In seven patients the diagnosis infectious endocarditis was first made during autopsy, all seven of them had the clinical diagnosis septicaemia. Surgery was performed on 41% of the patients. Case fatality was 34%. Case fatality was significantly higher for S aureus endocarditis than for S viridans endocarditis, 48% vs. 7% (p = 0.01). The advantages of transthoracic and transoesophageal echocardiography in the diagnosis and follow up of patients with infectious endocarditis is emphasized. In spite of these new diagnostic tools a definitive clinical diagnosis of infectious endocarditis was not made for 23% of the patients.     

Immunoblotting in the diagnosis of culture negative endocarditis caused by streptococci and enterococci

AIM: To improve the diagnosis of culture negative endocarditis by diagnosing cases due to streptococci and enterococci. METHODS: Serum samples were immunoblotted against extracts of the commonest streptococci and enterococci. They were selected from patients with a cardiac murmur, persistent pyrexia and at least three negative blood cultures. The presence of patterns of endocarditis species specific antigenic bands was measured and correlated with clinical outcome. RESULTS: Negative serology was found in 28 patients where the diagnosis of endocarditis was rejected or, if proved, staphylococcal, yeast, Gram negative, systemic lupus erythematosus, due to Q fever or Chlamydia psittaci or nonbacterial thrombotic. Positive serology was found in 27 of the 34 patients where the response to antibiotics suggested streptococcal or enterococcal infection. In 22 of these there was objective evidence of endocarditis. Positive serology was also found in three of four further patients with vegetations at necropsy. CONCLUSION: The identification of patterns of antibody response on immunoblotting can be used to make a specific diagnosis of streptococcal or enterococcal endocarditis in the absence of positive blood cultures.     

Polypoid ulcerating endocarditis aortalis caused by Streptococcus viridans with perforation of the right atrium. Pathology and clinical aspects of 2 autopsy cases

We report two cases of patients (one 65 and one 43 years of age, respectively) who died of Streptococcus-viridans induced endocarditis of the aortic valve with perforation into the right atrium. Whereas perforation in Staphylococcus-induced endocarditis is a common complication, it occurs rarely in Streptococcus-induced endocarditis. Because of its uncharacteristic symptoms, the endocarditis was clinically unknown in both cases and was recognized to be the cause of death only at autopsy. To reduce the large number of complications in patients suffering from endocarditis, it is necessary to confirm the diagnosis as soon as possible if endocarditis might be suspected.     

Acute endocarditis of the native aortic valve caused by Propionibacterium acnes

Propionibacterium acnes is often considered to be a contaminant but it has also been found to be the principal pathogen in serious infections. P. acnes is a rare cause of infective endocarditis. It has been suggested that aortic root abscesses are caused by bacteria that are particularly virulent. The strongest risk factor for serious infections by this bacteria is the presence of foreign bodies. A case is presented in which endocarditis of a native aortic valve caused by P. acnes was associated with an aortic root abscess. Transesophageal echocardiography is particularly helpful in the diagnosis of this severe complication of infective endocarditis. The literature for P. acnes endocarditis is reviewed.     

Q fever endocarditis and bicuspid aortic valve

Q fever is caused by the rickettsia Coxiella burnetti, an obligate intracellular bacterium acquired by inhalation of infected dust from subclinically infected animals. Q fever may be acute or chronic; the chronic form mostly presents as endocarditis. Immunocompromised states and underlying heart disease are the most important risk factors. Usually the symptoms of Q fever endocarditis are nonspecific and diagnosis is often established very late. New criteria for diagnosis include a single blood culture positive for Coxiella burnetti, positive Q fever serology and characteristic echocardiographic studies. We describe a 49-year-old man with bicuspid aortic valve admitted with fever, weight loss and a new heart murmur. The diagnosis of Q fever endocarditis was established by positive Q fever serology, and an echocardiogram showing vegetations and valvular dysfunction. This case suggests that Q fever endocarditis should be considered in patients with "sterile" endocarditis.     

Are the Duke criteria superior to the Beth Israel criteria for the diagnosis of infective endocarditis in children?

Accurate diagnosis of infective endocarditis may be difficult. The Beth Israel criteria and the newer Duke criteria assign probability to the diagnosis of infective endocarditis on the basis of the presence of common features and manifestations. We reviewed 111 cases of pediatric infective endocarditis diagnosed and treated over 19 years. Each case was classified by the two criteria, and the results were compared. Of 111 cases, 73 (66%) and 18 (16%) were classified as definite by the Duke criteria and the Beth Israel criteria, respectively. No cases were rejected by the Duke criteria, while 21 (19%) of 111 were rejected by the Beth Israel criteria. In 18 pathologically proven cases, reanalysis without pathological data showed that the Duke criteria had significantly greater sensitivity (83%) than the Beth Israel criteria (67%) (P < .03). Echocardiographic evidence was required in 22 cases for definite classification by the Duke criteria; none were rejected, however, when echocardiographic findings were ignored. Our results suggest that the Duke criteria are superior to the Beth Israel criteria for the diagnosis of pediatric infective endocarditis.     

Acute bacterial endocarditis: a silent source of sepsis in the burn patient

In the past six years, 35 patients with thermal injuries have died with a diagnosis of endocarditis. The cause of death in 21 of the 22 patients with acute bacterial endocarditis (ABE) was directly related to complications arising from the ongoing sepsis. In only three cases was the diagnosis considered pre-mortem. The endocarditis was located in the right heart in 18, left heart in 9, and both sides in 8 cases. Associated venous thrombi were present in 14 instances, and 10 of these were septic thrombi. Staphylococcus was the primary organism in the blood in 17 of 22 patients with ABE. Clinically audible murmurs were present in only two patients. In no instance was ABE superimposed upon previously existing valvular disease. ABE can serve as a silent source of sepsis in the burn patient. The diagnosis should be suspected with persistantly positive blood cultures, especially for Staphylococcus aureus, in any burn patient in whom no other foci of sepsis can be identified. Vigorous methods of diagnosis and specific treatment are recommended.     

Characteristics and treatment of Staphylococcus aureus endocarditis

In order to evaluate whether there were changes of the clinical features of Staphylococcus (Staph.) aureus endocarditis in recent years, the data of 21 cases of Staph. aureus endocarditis diagnosed from 1977 to 1994 were analyzed and compared with those of 11 cases of Staph. aureus endocarditis from 1957 to 1977. The results showed the following changes in recent years. The incidence of Staph. aureus endocarditis cases has been increasing. Cases of right-sided endocarditis increased in the recent two decades and this increase was related to intravenous drug abuse and increased use of vascular intervention. Right-sided endocarditis was different from left-sided endocarditis in their risk factors, underlying heart diseases, clinical manifestations and prognosis. The clinical manifestations of ventricular-wall endocarditis were atypical and it could be definitely diagnosed only with echocardiogram. Complications of Staph. aureus endocarditis became more common and serious, in recent decades but hospital mortality decreased markedly due to effective antibiotic management. The authors believe that sound knowledge of Staph. aureus endocarditis is essential for the proper diagnosis and treatment of Staph. aureus endocarditis.     

Development of animal models for the chronobiotics of melatonin analogs

We reviewed the records of patients admitted to our centre with the diagnosis of isolated tricuspid valve infective endocarditis and analysed the clinical presentation, etiopathogenic agent, echocardiographic features and therapeutic approach, namely the indication for cardiac surgery. Between 1988 and 1996, 11 cases of confirmed tricuspid valve endocarditis were identified, corresponding to 5% of the cases of endocarditis admitted to our centre in the same period. A predisposing factor was found in ten of the patients, half of them intravenous drug addicts and Staphylococcus aureus was the most frequent agent isolated. Fever and pleuro-pulmonary manifestations were predominant clinical features. Transthoracic echocardiography had a crucial role in the diagnosis and transesophageal echocardiography was important to characterize vegetations. Four patients underwent cardiac surgery, for persistent infection. In two cases, excision of the vegetations and ring annuloplasty was performed. In two patients not addicted to drugs, the tricuspid valve was replaced with a bioprosthesis, since the extension of the damage to the valve did not allow repair. One patient, with early endocarditis of a tricuspid bioprosthesis died before surgery was attempted.     

Infective endocarditis of the tricuspid valve in an orthotopic heart transplant recipient

A 43-year-old orthotopic heart transplant recipient had coagulase-negative staphylococcus endocarditis 26 weeks after the operation. A diagnosis of endocarditis was confirmed and followed up by serial transoesophageal echocardiography. Treatment with intravenous gentamycin and vancomycin cured her endocarditis, and a 2.5 cm vegetation regressed significantly. She has been well since and, at 14 months after transplantation, was back to her normal activities. Although repeated blood culture yielded only intermittent light growths of coagulase-negative staphylococci, there were several positive samples. In a setting of infective features, light growths of coagulase-negative staphylococcus should be taken seriously if repeatedly positive in heart transplant recipients or other immunocompromised patients. Transesophageal echocardiography offers significant advantages over the transthoracic modality in suspected endocarditis.     

Treated bacterial endocarditis as a histological mimic of fungal infection

Histological assessment of cardiac valve tissue contributes to the diagnosis of infective endocarditis and is of particular importance in cases in which no organism is cultured. Antibiotic treatment of bacterial endocarditis may lead to abnormal bacterial morphology and staining characteristics. Although in many cases the presence of some residual bacteria of normal appearance makes the diagnosis straightforward, in some only abnormal bacteria may be seen. Unless the appearances of these are interpreted with caution, the presence of larger spherical organisms with the staining properties of a yeast may lead to an erroneous diagnosis of fungal infection.     

Transesophageal echocardiography diagnosis of perforation of the mitral valve secondary to infective endocarditis

We report on a patient with infective endocarditis and severe mitral regurgitation secondary to perforation in the base of the posterior mitral leaflet. Transthoracic echocardiography was inconclusive. Only transesophageal echocardiography could confirm the presence of vegetations, their characteristics and the existence of valvular perforation. We also review the literature on the contribution of transesophageal echocardiography to the diagnosis of infective endocarditis and its complications.     

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".     

N-acetylcysteine prevents development of the hyperdynamic circulation in the portal hypertensive rat

Infective endocarditis, defined as pathologically or clinically definite by the Duke criteria, was observed in 14 transplant recipients at our institutions. In addition, we reviewed 32 previously reported cases in solid organ transplant recipients. The spectrum of organisms causing infective endocarditis was clearly different in transplant recipients than in the general population; 50% of the infections were due to Aspergillus fumigatus or Staphylococcus aureus, but only 4% were due to viridans streptococci. Fungal infections predominated early (accounting for six of 10 cases of endocarditis within 30 days of transplantation), while bacterial infections caused most cases (80%) after this time. In 80% (37) of the 46 cases in transplant recipients, there was no underlying valvular disease. Seventy-four percent (34) of the 46 cases were associated with previous hospital-acquired infection, notably venous access device and wound infections. Three patients with S. aureus endocarditis had had an episode of S. aureus bacteremia > 3 weeks prior to the diagnosis of endocarditis and had received treatment for the initial bacteremia of < 14 days' duration. The overall mortality rate was 57% (26 of 46 patients died), with 58% (15) of the 26 fatal cases not being suspected during life. Endocarditis is an underappreciated sequela of hospital-acquired infection in transplant recipients.     

Infective endocarditis as a complication of heroin use

Infective endocarditis in heroin addicts has been reported to have a mortality as high as 85% and reports have varied widely regarding predominant valvular involvement and infecting microorganisms. A retrspective study was done and 61 cases of heroin-associated infective endocarditis were identified at Freedmen's Hospital and the District of Columbia General Hospital, Washington, DC between January 1969 and January 1973. Our results indicate that staphylococcal infection of the tricuspid valve has a much higher incidence in this population than has generally been believed and that it is the predominant presentation of infective endocarditis in these patients. The outcome of patients in our series compares favorably with previous reports and suggests that early diagnosis and prompt institution of appropriate antimicrobial therapy are important and may lead to improved survival in addicts with tricuspid endocarditis.     

Coxiella burnetti infectious endocarditis. Apropos of a case

Chronic forms of Q fever (endocarditis) are rare, but are responsible for severe and desperately recurrent infections, resulting in multiple valve replacements with a reserved prognosis. The authors report the case of a 35-year-old patient with a known history of rheumatic fever, who developed blood culture negative infectious endocarditis on a mitral bioprosthesis. The diagnosis of Q fever was based on serological arguments. Despite long-term antibiotic therapy, serology remained strongly positive and was associated with repeated mitral valve disinsertion. The patient died immediately after the fourth operation in a context of haemodynamic failure. This clinical case emphasizes the importance of performing Q fever serology in any case of culture negative endocarditis and the therapeutic difficulties encountered in chronic recurrent endocarditis.     

Did pneumococcal endocarditis come back?

Endocarditis caused by pneumococci represents 1-5% of all cases of endocarditis according to publications from different western countries. Necropsy studies show frequencies of up to 14% of all cases of endocarditis. It usually occurs as a complication to a pneumococcal pneumonia but other foci might be seen. Concomitant meningitis is seen in 20-85% of patients suffering from pneumococcal endocarditis. By knowing this disease entity there is a good possibility for treatment with antibiotics and valve replacement, but if overlooked the mortality is high. The frequency of pneumococcal endocarditis might be underestimated. Careful stethoscopic examination for heart murmurs should be a part of the clinical examination in case of invasive pneumococcal disease, especially with concomitant meningitis. Since bacteriaemia due to pneumococci is diagnosed with increasing frequency in many Northern European countries, special attention should be paid to pneumococcal endocarditis. The literature is reviewed with reference to pathology, pathogenesis, frequency, clinical presentation, diagnosis, treatment and prognosis.     

Outpatient intravenous antibiotic therapy for endocarditis

The clinical spectrum of endocarditis continues to evolve, as does its diagnosis and management. Outpatient parenteral antimicrobial therapy has been demonstrated to be safe and effective for medically stable patients with viridans streptococcal endocarditis. Other carefully selected and monitored patients with infective endocarditis may also be considered for completion of therapy outside the hospital setting.     

Mid-diastolic aortic valve opening in bacterial endocarditis of aortic valve

Echocardiographic features of acute aortic regurgitation resulting from bacterial endocarditis have been well documented (Nathan et al., 1980; Weaver et al., 1977; Wray, 1975a), and include thick shaggy echoes from aortic valve in diastole, fine diastolic flutter of aortic valves suggestive of rupture of cusps, and premature closure of mitral valves. Echocardiography being a sensitive noninvasive technique for detecting aortic valve vegetations is heavily relied on for earlier diagnosis and prompt therapy of these patients. Prognosis of echocardiographically positive endocarditis is known to be worse than for echo-negative patients. The following case is being presented because of an unusual echocardiographic manifestation with mid-diastolic aortic valve opening secondary to flail aortic valve from staphylococcal endocarditis of the aortic valve.