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PubMed2001

Gram-Negative anaerobic endocarditis: two case reports and review of the literature.

The rarity of anaerobic gram-negative endocarditis limits the ability of physicians to define its prognosis. Two cases of endocarditis due to Bacteroidesfragilis are described, and a review of the English literature for all cases of anaerobic gram-negative endocarditis reported since 1940 is presented. The disease predominantly affects males. Clinical features are similar to those of endocarditis due to nonanaerobic organisms, but underlying heart disease is less common and the rate of thromboembolic complications is high. All deaths reported were due to Bacteroides spp.; no deaths due to Fusobacterium spp. have been reported. Treatment with metronidazole has dramatically improved the prognosis of patients with endocarditis due to anaerobic gram-negative bacilli.

Aged↗
PubMed2005

Tricuspid endocarditis in an adult patient with Ebstein's anomaly who has a residual pacemaker lead.

Ebstein's anomaly is defined as an apical displacement of the attachment of the septal tricuspid valve leaflet from the right atrioventricular annulus that exceeded 1.2 cm in length. Patients with Ebstein's anomaly are known to have a high potential for developing arrhythmia, in the vast majority, of the tachycardia type. Infective endocarditis is characterized by ulcerovegetational lesions that result from the graft of a microorganism, usually bacterial, on the valvuler endocardium (native valve endocarditis) or on a prosthesis (prosthetic valve endocarditis). Ebstein's anomaly with tricuspid regurgitation is also thought to be a predisposing condition for infective endocarditis. In this case, we report a patient who presented with atrial flutter and infective endocarditis due to residual pacemaker lead and Ebstein's anomaly.

Device Removal↗
PubMed2005

Performance of the Fontan procedure using extra-cardiac direct anastomosis on patients treated for penicillin-resistant Streptococcus pneumoniae endocarditis.

Streptococcus pneumoniae is now a rare cause of endocarditis in humans. We report a patient with a double outlet right ventricle and mitral atresia, who underwent the Fontan procedure without prosthetic materials after treatment for penicillin-resistant Streptococcus pneumoniae endocarditis. Postoperative infectious endocarditis was not found. In patients with a history of infectious endocarditis, direct anastomosis of the main pulmonary artery and inferior vena cava would reduce the risk of recurrent infectious endocarditis.

Abnormalities, Multiple↗
PubMed1975

Bacterial endocarditis in idiopathic hypertrophic subaortic stenosis.

Bacterial endocarditis complicating idiopathic hypertrophic subaortic stenosis (IHSS) is uncommon but endocarditis may be the first clinical manifestation of IHSS. In this report of such a case, the aortic and the mitral valves were the sites of the bacterial infection. Many chordae tendineae to the mitral valve were ruptured from the extension of the infectious process. The endothelial lesions, which served as the seat for the bacterial infection on the anterior mitral leaflet, likely resulted from its abutting action against the septal prominence. Damage to the aortic valve leaflet may have resulted from abnormal valve motion caused by IHSS and created an environment conducive to endocarditis. This patient developed aortic insufficiency during the course of bacterial endocarditis, suggesting that the occasional association of aortic insufficiency in patients with IHSS may be secondary to healed endocarditis of the aortic valve.

Adult↗
PubMed1978

Infective endocarditis in heroin addicts: epidemiological observations and some unusual cases.

The total number of cases of heroin-induced endocarditis occurring over a four-year period were reviewed in order to explain an increase in the number of cases in the last year studied (1975). Brown heroin was noted to be used more frequently by addicts during the period of increased incidence. Cultures of "street samples" of brown and white heroin as well as cocaine were obtained in order to elucidate a possible relationship between the increased use of brown heroin and the increased number of endocarditis cases. Despite frequent contamination of both white and brown heroin, none of the common endocarditis-causing pathogens were isolated from the samples. Staphylococcus aureus, the most common etiological agent, frequently resulted in tricuspid endocarditis. That the accepted criteria for tricuspid endocarditis may be present without actual cardiac valve involvement is demonstrated by a most unusual case of hepatic vasculature infection.

Adolescent↗
PubMed1983

Immune reactions in infective endocarditis. I. Clinical data and diagnostic relevance of antimyocardial antibodies.

Clinical data from 72 patients with infective endocarditis (41 with defined pathogen, 31 with no pathogen isolated) were analyzed with respect to the diagnostic relevance of immunologic parameters. In our patients from a rural area, no significant changes in the epidemiology and pathogenesis of infective endocarditis were observed. Antiendocardial and antisarcolemmal (ASA) antibodies were demonstrated in 60% to 100% of cases. Their frequency depended on the endocarditic pathogen and on the clinical course: in subacute or chronic endocarditis these antibodies were found regularly, in acute lethal cases their occurrence was diminished. Whereas antiendocardial antibodies are diagnostic markers of endocarditis, ASA and antimyolemmal antibodies in particular most likely indicate myocardial involvement in endocarditis. Only complement fixing antimyolemmal antibodies induced cytolysis of vital, adult, heterologous cardiac cells. Our data suggest that antibody-mediated cytolysis in vitro may also play a pathogenetic role in vivo.

Adult↗
PubMed1992

Improved detection of infective endocarditis with transesophageal echocardiography.

The incremental advantage of transesophageal echocardiography was determined by comparing results of paired transthoracic and transesophageal echocardiographic examinations performed in 61 patients for evaluation of suspected infective endocarditis. According to clinical and pathologic data, 31 of 61 (51%) patients had finding that were positive for infective endocarditis. Studies were graded as positive or negative for vegetations and were also graded for image quality. The sensitivity of transesophageal echocardiography in detecting vegetations was 88% versus 30% for transthoracic studies (p less than 0.01). For patients with aortic valve infective endocarditis, transesophageal sensitivity was 88% versus 25% for transthoracic sensitivity, because transesophageal echocardiography successfully separated vegetations from chronic valve disease caused by sclerosis or calcification (p less than 0.01). For patients with mitral valve infective endocarditis, transesophageal sensitivity was 100% versus 50% for transthoracic sensitivity, because transesophageal echocardiography distinguished vegetations from myxomatous changes or detected vegetations on prosthetic valves (p less than 0.01). Thus transesophageal echocardiography improves recognition of infective endocarditis, particularly in the presence of underlying valvular disease.

Aortic Valve↗
PubMed1992

A comparison of hospital and community-acquired infective endocarditis.

The epidemiology, clinical features, microbiology and outcome of 30 episodes of nosocomial endocarditis occurring over a 13-year period were reviewed and compared with 148 cases of community-acquired endocarditis. Twenty-eight patients (93%) had been in hospital for > 1 week and 10 patients (33%) for > 1 month when they developed endocarditis. Left-sided infection was most frequent; only 3 cases involved the tricuspid valve. Compared with community-acquired infection, patients tended to be older, had a greater incidence of congestive cardiac failure (p = 0.001) or hypotension (p = 0.0008) at presentation and were more likely to have bacteremia after an invasive procedure (83 vs 31%; p < 0.00001). Intravascular devices were the presumed source of bacteremia in 11 cases (37%); the same organism was isolated from both the blood and the suspected source of infection. Staphylococcus aureus was the most frequent causative organism, accounting for 17 episodes (57%), including 4 (13%) due to methicillin-resistant strains. Nosocomial endocarditis had a significantly higher mortality than did community-acquired infection (40 vs 18%; p = 0.02). Eight patients (27%) needed valve replacement. Proper adherence to protocols for management of intravascular devices and appropriate antimicrobial prophylaxis before procedures may have prevented endocarditis in 15 of 30 patients.

Adult↗
PubMed1982

Staphylococcus aureus bacteremia in diabetic patients. Endocarditis and mortality.

The presentation and course of Staphylococcus aureus bacteremia in 27 diabetic patients (18 insulin-dependent) were compared with those in 34 nondiabetic patients. The groups were comparable in age, proportion with pre-existing cardiac valvular disease, community-acquired bacteremia, fever, and leukocytosis. Endocarditis (vegetation or new regurgitant murmur) was present in eight (30 percent) diabetics and four (12 percent) nondiabetics (p = 0.16). A primary focus of infection was present in 67 percent of diabetics and 65 percent of nondiabetics. Among those with a focus, six of 18 diabetics and none of 22 nondiabetics had endocarditis (p less than 0.005). Fifteen of 54 (28 percent) patients who received appropriate antibiotic therapy died. After stratificaton for underlying illness, there was no mortality difference between those with and without endocarditis (three endocarditis deaths versus 1.78 expected), or between those with and without diabetes (four diabetic deaths versus 4.8 expected). Diabetics with staphylococcal bacteremia were more likely than nondiabetics to have endocarditis in the presence of a primary focus. They had no increase in mortality.

Adult↗
PubMed1984

Endocarditis prophylaxis for patients with mitral valve prolapse. A quantitative analysis.

Antimicrobial prophylaxis of bacterial endocarditis is widely recommended for patients with mitral valve prolapse who undergo procedures that may cause bacteremia. The benefits and risks of this practice have been analyzed on the basis of published data and response to a questionnaire survey of leading authorities on bacterial endocarditis. Among 10 million patients with mitral valve prolapse undergoing a dental procedure, an estimated 47 nonfatal cases and two fatal cases of bacterial endocarditis would occur if no prophylaxis were given, five cases of bacterial endocarditis and 175 deaths due to drug reactions would occur if all patients were given prophylaxis with a penicillin, and 12 nonfatal cases and one fatal case of bacterial endocarditis would be expected if a policy of prophylaxis with erythromycin were adopted. Even using assumptions most favorable to the penicillin regimen, this analysis predicts that no prophylaxis and penicillin prophylaxis would result in a similar number of deaths. No prophylaxis or prophylaxis with erythromycin appears preferable to prophylaxis with a penicillin.

Anaphylaxis↗
PubMed1984

Glomerulonephritis in bacterial endocarditis.

The introduction of antibiotic therapy and changing epidemiologic patterns have altered the nature of glomerulonephritis as it occurs during the course of bacterial endocarditis. Observations made predominantly in the pre-antibiotic era suggested that infections with less virulent organisms, by virtue of their indolent subacute course, favored an antibody response predisposing to immune complex glomerulonephritis. Although antibiotic prophylaxis and therapy have reduced the incidence of both Streptococcus viridans bacterial endocarditis and concomitant glomerulonephritis, Staphylococcus aureus has become a major cause of acute bacterial endocarditis with a high incidence of glomerulonephritis. Parenteral drug abuse itself, which has emerged as a major factor predisposing to endocarditis, may also favor the development of glomerulonephritis. The course of glomerulonephritis has been altered in association with these changes in etiology and epidemiology. This review summarizes the clinical and morphologic features of glomerulonephritis as it currently occurs during the course of bacterial endocarditis.

Antigen-Antibody Complex↗
PubMed1987

Underlying cardiac lesions in adults with infective endocarditis. The changing spectrum.

The spectrum of recognized cardiac lesions underlying infective endocarditis has been changing as a result of the decline in incidence of rheumatic heart disease, the recognition of the entity of mitral valve prolapse, and the improvement in cardiac diagnostic techniques. Sixty-three cases of native valve endocarditis diagnosed in Memphis hospitals between 1980 and 1984 were reviewed. All diagnoses of underlying cardiac lesions were confirmed by two-dimensional echocardiography, cardiac catheterization, and/or histopathologic examination of valve tissues. Major categories of underlying lesions were as follows: mitral valve prolapse, 29 percent; no underlying disease, 27 percent; degenerative lesions of the aortic or mitral valve, 21 percent; congenital heart disease, 13 percent; rheumatic heart disease, 6 percent. Thus, mitral valve prolapse and, in the elderly, degenerative lesions have displaced rheumatic and congenital heart diseases as the major conditions underlying endocarditis. Redundancy of the mitral valve leaflets was noted in 17 of 18 patients in whom endocarditis was superimposed upon mitral valve prolapse. The risk of infective endocarditis appears to be substantially increased in the subset of patients with mitral valve prolapse who exhibit valvular redundancy.

Adolescent↗
PubMed1990

Influence of referral bias on the apparent clinical spectrum of infective endocarditis.

PURPOSE: To assess the effect of referral bias on the clinical spectrum of infective endocarditis. PATIENTS AND METHODS: We performed a retrospective study comparing a population-based cohort of incidence cases from Olmsted County, Minnesota, with a cohort of referred cases from the practice of the Mayo Clinic during the period from 1970 to 1987. RESULTS: In the community cohort, age was an important risk factor for acquiring endocarditis (incidence rate ratio 8.8:1 for age 65 years or older versus age less than 65 years), but episodes in elderly patients were underrepresented in the referral practice. The proportion of cases due to Staphylococcus aureus was greater in the community than in the referral practice (p less than 0.02), while a trend toward overrepresentation of enterococcal endocarditis was seen in the referral population (p = 0.057). Symptom duration prior to diagnosis was significantly shorter in the community. Overall, measures of in-hospital morbidity and mortality were similar in the two populations, but advanced age was associated with adverse outcome in the community cohort. CONCLUSION: The clinical spectrum of infective endocarditis may be distorted by referral. The increased risk of endocarditis in the elderly underscores the importance of adherence to recommendations for prophylaxis in this patient population.

Adolescent↗
PubMed1994

Immunohistologic demonstration of Coxiella burnetii in the valves of patients with Q fever endocarditis.

PURPOSE: Cardiac valves that were resected from patients with Q fever endocarditis were examined by immunohistologic methods to correlate the presence of Coxiella burnetii in the valves with the histopathologic, serologic, microbiologic, and clinical findings. PATIENTS: Seventeen patients with serologic and microbiologic or clinical evidence of Q fever endocarditis who presented with cardiac failure secondary to valvular dysfunction and required valve replacement surgery were selected from the clinical records of the Unité des Rickettsies, Marseille, France. METHODS: Clinical data were collected by questionnaire. Serologic characterization was performed by indirect immunofluorescent antibody testing; shell vial cultivation of C burnetii was performed from resected valves and blood when available; and pathologic and immunohistologic testing for localization of C burnetti in resected valves were performed by standard methods using both polyclonal and monoclonal C burnetti antibodies. RESULTS: Demographic and clinical findings were typical of patients with Q fever endocarditis. Pure chronic inflammation or mixtures of acute and chronic inflammation were the most frequent inflammatory patterns present and were associated with fibrin deposition, necrosis, and fibrosis. Well-formed granulomas were not present, but the granulomatous inflammation observed in 6 of these 17 patients was associated with foreign body reactions or with valvular calcifications secondary to preexisting valvular damage and could not be directly attributed to infection. C burnetii were present nearly exclusively in macrophages in sites of inflammation and valvular injury and only in the vegetations. Immunohistologic results confirmed the valve culture results in 10 of 14 cases. CONCLUSION: The pathologic findings in the valves of patients with Q fever endocarditis are nonspecific. The presence of empty or foamy macrophages is suggestive of infection by C burnetii; however, definitive identification rests upon the demonstration of the organism in the tissue by immunohistology. Q fever endocarditis probably results from infection of previously damaged heart valves. The finding of the absence of granulomas in these cases contrasts with the pathologic findings in patients with acute, self-limited Q fever and suggests an aberrant host immune response that permits persistence of the bacterium and chronic, prolonged valvular infection and injury. The pathologic findings and distribution of C burnetii in the damaged valve tissues explain the clinical findings of valve failure and occasional embolic episodes, as well as the frequent ability to isolate C burnetii from the peripheral blood of infected patients. Immunohistology may be a valuable diagnostic tool in places where serology and culture are not available.

Acute Disease↗
PubMed1990

Heart valve operations in patients with active infective endocarditis.

Sixty-two consecutive patients underwent heart valve operation for active infective endocarditis. There were 42 men and 20 women whose mean age was 49 years (range, 21 to 79 years). The infection was in the aortic valve in 37 patients, the mitral valve in 18, the aortic and mitral valves in 5, and the tricuspid valve in 2. Twenty-four patients had prosthetic valve endocarditis. Staphylococcus and Streptococcus were responsible for 86% of the infections. Annular abscess was encountered in 33 patients. Complex valve procedures involving reconstruction of the left ventricular inflow or outflow tract or both were performed in 31 patients. There were three operative deaths (4.8%). Predictors of operative mortality were prosthetic valve endocarditis, preoperative shock, and annular abscess. Patients were followed for 1 month to 130 months (mean follow-up, 43 months). Only 1 patient required reoperation for persistent infection. There were ten late deaths. Most survivors (96%) are currently in New York Heart Association class I or II. The 5-year actuarial survival was 79% +/- 7%. These data demonstrate excellent results in patients with native valve endocarditis, and support the premise that patients with prosthetic valve endocarditis should have early surgical intervention.

Adult↗
PubMed1994

Prosthetic valve endocarditis: superiority of surgical valve replacement versus medical therapy only.

The objective of our study was to assess the long-term outcome of patients with prosthetic valve endocarditis. We used a multicenter, prospective, observational study design. Six university teaching hospitals with high volume cardiothoracic surgery participated. Seventy-four patients with prosthetic valve endocarditis as defined by explicit, objective criteria were selected for participation. All patients were followed up prospectively for 1 year. Thirty-one percent and 69% had development of endocarditis within 60 days of valve insertion ("early") and after 60 days ("late"), respectively. The most common causes were Staphylococcus epidermidis (40%), Staphylococcus aureus (20%), streptococcal species (18%), and aerobic gram-negative bacilli (11%). Physical signs of endocarditis (new or changing murmur, stigmata, emboli) were seen in 58%. At 6 months and 12 months, mortality was 46% and 47%, respectively. Surgical replacement of the infected valve led to significantly lower mortality (23%) as compared with medical therapy alone (56%), as assessed by both univariate and multivariate analyses (p < 0.05). Improved outcome was seen for the surgical group even when controlling for severity of illness at time of diagnosis. From these findings we conclude that accurate assessment of outcome in prosthetic valve endocarditis requires long-term follow-up of at least 6 months following diagnosis. Surgical therapy warrants greater scrutiny; evaluation in controlled clinical trials is appropriate.

Adult↗
PubMed1995

Surgical and long-term antifungal therapy for fungal prosthetic valve endocarditis.

BACKGROUND: Fungal prosthetic valve endocarditis is an uncommon but serious disease. We have developed a strategy of treatment that includes perioperative amphotericin B, radical debridement of infected tissue, reconstruction using biologic tissue when possible, and prolonged oral suppressive antifungal therapy. METHODS: We retrospectively reviewed the charts of 12 patients reoperated on for fungal prosthetic valve endocarditis involving the aortic valve (10 patients: six porcine valves, two mechanical valves, two homografts) and the mitral valve (2 patients, both porcine valves). Prosthetic valve endocarditis developed in 7 within 12 months after the first valve procedure. The organisms included Candida species (9 patients), Scopulariopsis brevicaulis (1), Saccharomyces cervisiae (1), and histoplasmosis (1). RESULTS: At operation, all patients had prosthetic vegetations, 8 had abscesses, and 4 had sinus tracts. Seven received aortic homografts, 4 received porcine valves (two mitral), and 1 received a mechanical prosthesis. Two patients died in the hospital after prolonged illnesses (83% hospital survival). Four patients had recurrence an average of 25 months later and 3 underwent further surgical intervention. One patient had recurrence and died 17 months postoperatively. One other late death occurred 96 months after operation, and there was no evidence of recurrence. Eight patients (67%) are alive and well 51.5 +/- 61.0 months (range, 1 to 189 months) after the first redo procedure for fungal prosthetic valve endocarditis. CONCLUSIONS: We conclude that preoperative treatment with amphotericin B, radical resection of all infected tissue, cardiac reconstruction using biologic tissue when possible, and life-long oral antifungal therapy is effective for fungal prosthetic valve endocarditis.

Abscess↗
PubMed1989

Diagnosing endocarditis with the cloned 112 kDa antigen of Enterococcus faecalis.

A new indirect ELISA is presented for the diagnosis of enterococcal endocarditis. It is based on the cloning of Enterococcus faecalis DNA into lambda gt11. The library was screened by antisera from three cases of E. faecalis endocarditis. Three positive clones were found, all of which cross-reacted with the 112 kDa antigen of E. faecalis. One of these was taken and lysogenised into E. coli Y1089 to produce a fusion protein of 125 kDa. This IPTG dependent protein was purified by affinity chromatography and used in an indirect ELISA. The test differentiated between five cases of enterococcal endocarditis (IgG ELISA optical density greater than 0.8) and patients with endocarditis due to staphylococci (IgG ELISA optical density less than 0.243) and other streptococci (IgG ELISA optical density less than 0.656). Patients with a simple E. faecalis septicaemia had a maximum IgG ELISA optical density of 0.636. The only major cross-reaction occurred in patients with Streptococcus bovis endocarditis.

Antibodies, Bacterial↗