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PubMed1992

Nonbacterial thrombotic endocarditis clinically mimicking veno-occlusive disease of the liver complicating autologous bone marrow transplantation.

Nonbacterial thrombotic endocarditis is an uncommon, but well-described, complication of bone marrow transplantation. We describe a case of nonbacterial thrombotic endocarditis following autologous bone marrow transplantation that was marked by weight gain, hepatomegaly, ascites, and extreme hyperbilirubinemia leading to a clinical diagnosis of hepatic veno-occlusive disease. Autopsy revealed nonbacterial thrombotic endocarditis of the tricuspid and pulmonic valves, and passive congestion of the liver, but there was no evidence of veno-occlusive disease. We discuss the pathophysiology and clinical features of nonbacterial thrombotic endocarditis and review its occurrence in association with bone marrow transplantation. Nonbacterial thrombotic endocarditis is often difficult to detect clinically and should be a diagnostic consideration in patients who develop systemic emboli or congestive heart failure after bone marrow transplantation.

Bone Marrow Transplantation↗
PubMedDate not supplied

Polymicrobial endocarditis involving Eikenella corrodens.

Two amphetamine abusers had polymicrobial endocarditis involving Eikenella corrodens as one of the infecting organisms. A 26-year-old woman with left-sided endocarditis due to S. aureus and Eikenella corrodens was treated successfully; however, severe mitral regurgitation resulted from the infection. In the second patient, a 29-year-old man with right-sided endocarditis, three organisms were isolated: a hemolytic Streptococcus, a non-hemolytic Streptococcus, and Eikenella corrodens. This is the first report of polymicrobial endocarditis involving Eikenella corrodens, and emphasizes the importance of this organism parenteral amphetamine abusers. Pitfalls in the diagnosis of polymicrobial endocarditis are discussed, with particular reference to the difficulties in the recognition and management of Eikenella valve infections.

Adult↗
PubMedDate not supplied

Case report: livedo reticularis in endocarditis.

The peripheral manifestations of bacterial endocarditis are manifold and provide diagnostic clues as to the onset, etiology and potential complications of the disease. Petechiae, splinter hemorrhages, and Osler's nodes are among the more common cutaneous signs of endocarditis thought to be secondary to an allergic vasculitis or, as in the case of Osler's nodes, peripheral emboli. An asymmetric livedo reticularis rash was the initial presentation in a patient we recently treated with peptostreptococcus intermedius endocarditis, a heretofore undescribed dermal sign of endocarditis. Immunofluorescence studies of skin biopsies suggest that a livedo reticular rash may be one of the immune complex vasculitic syndromes associated with endocarditis.

Adult↗
PubMed1986

Q fever endocarditis.

Q fever endocarditis, which is seen most often in Great Britain and Australia, has been rarely observed in the United States. A patient with an eight month febrile illness who had signs and symptoms of endocarditis and serologic studies diagnostic of Q fever endocarditis is reported. A history of extensive travel makes it unclear where he originally contracted the disease. Q fever endocarditis is probably underdiagnosed and should be looked for in any case of culture negative endocarditis or chronic fever of unknown origin.

Aged↗
PubMed1995

New developments in infective endocarditis.

Endocarditis as seen today differs significantly from that outlined by Sir William Osler in his famous Gulstonian lectures in 1885. The median age of the patients has increased; the spectrum of predisposing cardiac lesions has changed; more cases are due to unusual organisms, including gram-negative bacteria and fungi; and more cases present acutely and the classic findings of late endocarditis are seldom seen. Endocarditis was untreatable and uniformly fatal in 1885. Although continued advances in medical and surgical therapy have significantly increased survival, the recent appearance of multiresistant organisms in some cases is reminiscent of the Osler era. Recent advances in the diagnosis and management of endocarditis include the identification of a specific Staphylococcus aureus receptor protein on endothelial cells, better imaging of the cardiac structures using transesophageal echocardiography, improvement in clinical diagnostic criteria and surgical techniques, and the use of outpatient oral antibiotics for penicillin-sensitive streptococcal endocarditis.

Adult↗
PubMed2002

Role of echocardiography in the diagnosis and management of infective endocarditis.

Infective endocarditis is a life-threatening disease with significant morbidity and mortality. Accurate and early diagnosis for initiation of effective treatment is essential in improving patient outcome. Echocardiography is currently the primary modality for the detection of vegetations and cardiac complications that result from endocarditis. Technological advances in echocardiography, particularly the development of transesophageal echocardiography (TEE), have revolutionized the diagnosis and management of infective endocarditis. With the enhanced resolution provided by TEE, vegetations and paravalvular complications can be reliably detected. Transthoracic and transesophageal echocardiography provides complementary information for patient management and follow-up, and is best used in conjunction with clinical data. By means of its high sensitivity and negative predictive value, TEE is essential in the evaluation of prosthetic valve endocarditis and the paravalvular complications of IE. All patients with suspected infective endocarditis should undergo transthoracic echocardiography, and most of these patients should also undergo TEE evaluation. The role of new technology such as harmonic and three-dimensional imaging is yet to be determined.

Abscess↗
PubMed1992

Duration of fever during treatment of infective endocarditis.

We reviewed the duration of fever among 123 patients treated for infective endocarditis at University Hospitals of Cleveland between 1972 and 1984. One half of these patients became afebrile within 3 days after initiation of antibiotic therapy and nearly three quarters were afebrile after 1 week of therapy. After 2 weeks of therapy, nearly 90% had defervesced. Endocarditis due to Staphylococcus aureus or gram-negative bacilli, and culture-negative endocarditis, were associated with prolonged fever. Microvascular phenomena, major vessel embolization, or vegetations seen on 2-D echocardiogram also were associated with prolonged fever. Multivariate analysis revealed that only microvascular phenomena or major vessel embolization were independently associated with longer duration of fever. Endocarditis-associated mortality among patients who remained febrile after 1 week of therapy was 18%, and this was greater than the 2% mortality among patients who defervesced (p less than 0.002). These data suggest that prolonged fever during treatment of infective endocarditis is often due to tissue infarction or vascular injury. Prolonged fever also identifies patients at higher risk of a fatal outcome.

Age Factors↗
PubMed1986

Coagulase-negative staphylococcal endocarditis: a view from the community hospital.

Review of our experience with infectious endocarditis at a single community hospital showed coagulase-negative staphylococci to be our leading cause of endocarditis. The pathogenesis of coagulase-negative staphylococcal endocarditis (CNSE) involved either hematogenous seeding of native or prosthetic valves, or direct implantation at surgery. Cases involving native valves demonstrated an acute onset and rapidly deteriorating course, while prosthetic valve endocarditis was more indolent; both types were associated with multiple complications. Although the number of our cases is small, mortality from native valve CNSE was higher than that of prosthetic valve endocarditis. Patients treated medically fared better than those receiving both medical and surgical treatment, though the medically treated group may not have been as ill as those having valve replacement. Vancomycin caused serious adverse effects in two of the five patients receiving it.

Adult↗
PubMed2003

HACEK endocarditis in infants and children: two cases and a literature review.

We report 2 cases of Haemophilus parainfluenzae endocarditis and review 34 cases of HACEK endocarditis from the literature. HACEK organisms are the most common cause of Gram-negative endocarditis in children. They have a propensity to form friable vegetations (especially H. parainfluenzae) that break off and cause symptomatic emboli. HACEK endocarditis (from a review of the 36 published cases) may involve previously normal hearts (33%), may be complicated by embolization (31%) and may require vegetectomy or other surgery (31%). Mortality with HACEK endocarditis was 14%. HACEK organisms may be resistant to penicillins but are susceptible to third generation cephalosporins.

Ceftriaxone↗
PubMed1986

Role of surgery in infective endocarditis.

One-hundred-and-thirteen patients with endocarditis and valvular insufficiency were studied retrospectively with special regard to indications for operation and the optimum time for cardiac valve surgery. Thirty patients (group I) had acute, 63 (group II) subacute and 20 (group III) prosthetic valve endocarditis. Group I: Eleven patients underwent surgery in the acute stage, 8 while bacteremic; 5 of the latter died perioperatively. Of the 19 patients treated medically, 16 died. Group II: All patients underwent operation in a bacteria-free state. The mortality was 5%. Group III: Eight patients had early (less than 60 days postoperatively) and 12 late endocarditis. Total mortality was 40% (71% early and 25% late mortality). Ten patients underwent reoperation, with a mortality of 20%, compared with 60% in the medically treated group. The results support the indication for early operation in acute endocarditis with progressive cardiac failure and renal failure and prosthetic valve endocarditis, even during bacteremia.

Acute Disease↗
PubMed2006

Candida endocarditis in neonates: report of five cases and review of the literature.

Candidal endocarditis is an uncommon and serious complication of invasive Candida infection in neonates. The aim of this study was to further characterise candidal endocarditis in neonates. Between 1995 and 2000, 56 patients were diagnosed with Candida bloodstream infections (CBSI) in the Neonatal Intensive Care Unit of Schneider Children's Medical Center of Israel. Five of them (9%) developed mycetoma of the right atrium. None of the patients had congenital heart disease or a central venous catheter in the right heart at the time of diagnosis. All were treated with amphotericin B alone or in combination with other antifungals, without surgical intervention. One patient died of the disease and one died later of polymicrobial sepsis and necrotizing enterocolitis. A review of the literature since 1980 yielded an additional 25 cases of candidal endocarditis. For the whole sample (n = 30) survival rate was 73.1%. Six of the 10 patients treated with antifungal agents and surgery survived (60%), compared with 13 of the 20 patients treated only medically (65%) (P = 1.0). Candida endocarditis in neonates differs from fungal endocarditis in adults in risk factors, clinical presentation and outcome. As the outcome of surgical and medical treatment are comparable, antifungal therapy alone may be a valid therapeutic option in high-risk cases.

Amphotericin B↗
PubMed1995

Has transesophageal echocardiography changed the approach to patients with suspected or known infective endocarditis?

Infective endocarditis is still a great clinical challenge. Its diagnosis is difficult to establish, and mortality has remained around 30%. Early diagnosis and optimal treatment are crucial fo prognosis improvement. Echocardiography plays an indispensable role in the management of this disease, especially with the recently introduced approach, transesophageal echocardiography (TEE). TEE can overcome the limitations of transthoracic echocardiography (TTE) and is superior to TTE in almost every way in providing earlier and more information for the diagnosis and treatment of infective endocarditis. TEE detects valve vegetations with much higher sensitivity and specificity than TTE. It can demonstrate smaller vegetations in the early stage of the disease and vegetations on atypical locations (e.g., mitral valve annulus), and provides detailed characterization of vegetations (e.g., location, size, mobility, and changes during treatment). Such information is of great prognostic value and may help in selecting proper treatment. TEE is more sensitive for detecting complications, such as mitral valve perforation, abscess, and subaortic complications, which respond poorly to medicine and for which timely surgery may be the best treatment. For those with prosthetic valve endocarditis, TEE is especially useful because TTE is greatly limited by the acoustic shadow of prostheses. Both positive and negative results of TEE examination are valuable for confirming or excluding infective endocarditis. TEE also plays a unique role in intraoperative monitoring and can assess surgical results before the chest is closed. TEE has become an invaluable tool for the diagnosis and management of patients with suspected or known infective endocarditis.

Diagnosis, Differential↗
PubMed1995

Criteria for the diagnosis of endocarditis and the role of echocardiography.

When infective endocarditis is a diagnostic possibility, echocardiography permits noninvasive imaging of cardiac structures. As involvement of the endocardium is a sine qua non of endocarditis, echocardiography may assist in its diagnosis by demonstrating such involvement. The ability of echocardiography to detect the intracardiac manifestations of infective endocarditis has continued to improve, especially with the introduction of transesophageal imaging. This article will discuss some of the echocardiographic findings in endocarditis and elucidate the incorporation of these findings in the new Duke criteria for the diagnosis of endocarditis.

Diagnosis, Differential↗
PubMed1989

Surgical treatment of prosthetic valve endocarditis with homograft aortic valve replacement.

This article presents the University of Alabama experience with homograft aortic valve replacement for prosthetic valve endocarditis. Of 117 patients who have undergone homograft aortic valve replacement since 1981, there has been a total of 22 patients who underwent operation for endocarditis. Sixteen were isolated valve replacements, three combined with other procedures, and three were aortic root replacements. When placed in a setting of active endocarditis, there have been no reoperations for endocarditis of the homograft valve. Surgical techniques are presented for the freehand sewn homograft as well as aortic root replacement. Prosthetic valve endocarditis is a highly lethal event and when aortic valve replacement is advised in this setting, we believe a homograft aortic valve should be implanted whenever possible.

Aortic Valve↗
PubMed1975

Mechanism of anaemia in experimental bacterial endocarditis.

Rabits with Streptococcus viridans aortic valve endocarditis develop anaemia and reticulocytosis which increase with the duration of infection. Mean red cell counts decreased from 6.05 +/- 0.29 X 10(6) per mul before infection to 4.10 +/- 0.18 X 10(6) per mul after 11 to 20 days of endocarditis and reticulocytes increased from 1.16 +/- 0.14 X 10(5) per mul to 4.91 +/- 0.83 X 10(5) per mul after more than 20 days of endocarditis. The anaemia could not be explained by intravascular haemolysis. Anti-erythrocyte antibodies were not detected. Splenomegaly was a consistent finding and also increased with the duration of infection. Red cell half life (T1/2) was shortened to 4.7 +/- 0.3 days in rabbits with endocarditis compared with normal T1/2 of 11.1 +/- 0.5 days. The T1/2 of red cells from infected animals was prolonged when measured in noninfected rabbits and splenectomized animals had a mean red cell T1/2 of 9.25 days after three weeks of infection. These studies suggest that splenic enlargement associated with infection results in red cell sequestration, a mechanism not well recognized as contributing to the anaemia of endocarditis.

Anemia↗
PubMed1989

Evaluation of teicoplanin for treatment of endocarditis caused by gram-positive cocci in 20 patients.

Teicoplanin, a new glycopeptide antibiotic similar to vancomycin, was evaluated for the treatment of bacterial endocarditis in an open multicenter study from May 1985 to August 1987. A total of 20 patients with positive blood culture endocarditis received teicoplanin once daily as a mean intravenous injection of 7.3 mg/kg of body weight (range, 4.8 to 10.6 mg/kg); in 17 patients, teicoplanin was combined with another antibiotic, usually an aminoglycoside. The mean duration of therapy was 28 days (range, 7 to 66 days). The diagnosis of endocarditis was confirmed by echocardiography or anatomical findings in 15 patients and established on the basis of clinical manifestations plus positive blood cultures in 5 patients. The tricuspid valve was involved in 11 of the 20 patients. Isolates from blood were 12 Staphylococcus aureus, 1 Staphylococcus hominis, 1 Micrococcus sedentarius, 1 Enterococcus faecalis, 3 Streptococcus bovis, and 2 nongroupable Streptococcus sp. At the end of therapy, bacterial eradication was achieved in 17 of 20 patients (85%), and a favorable clinical outcome had occurred in 14 of 17 evaluable patients (82%). Of these 14 patients, one relapsed 4 months after the end of treatment. Thus, teicoplanin was effective in 13 of 17 patients (76%). Mean peak levels of teicoplanin in serum were lower, 23.1 +/- 2.9 micrograms/ml, in patients who failed than in those who were cured (45.8 +/- 8.4 micrograms/ml). Side effects occurred in 7 of 20 patients (35%), and required premature discontinuation of teicoplanin in 3 patients. These side effects were fever in three patients, rash in three patients, hearing loss in two patients, and increased serum transaminase levels in two patients. This study demonstrates the efficacy of teicoplanin in the treatment of endocarditis and the need for achieving peak levels in serum close to 40 micrograms/ml. Teicoplanin should now be further evaluated in endocarditis caused by gram-positive cocci means of controlled comparative study with standard therapy.

Adolescent↗
PubMed1991

Comparison of fluconazole and amphotericin B for prevention and treatment of experimental Candida endocarditis.

Fluconazole and amphotericin B were compared in the prophylaxis and treatment of Candida albicans aortic endocarditis in a rabbit model. In the prophylaxis study, catheterized rabbits received, prior to intravenous (i.v.) challenge with C. albicans (2 x 10(7) blastospores), either no therapy, single-dose i.v. amphotericin B (1 mg/kg of body weight), single-dose fluconazole (50 mg/kg or 100 mg/kg i.v. or intraperitoneally [i.p.]), or fluconazole (50 mg/kg or 100 mg/kg i.v. or i.p.) with a second dose 24 h after inoculation. A single dose of amphotericin B was significantly more effective than either the one- or two-dose regimens of fluconazole at both 50 mg/kg (P less than 0.001 and P less than 0.03, respectively) and 100 mg/kg (P less than 0.01 and P less than 0.001, respectively) in the prevention of C. albicans endocarditis. In parallel treatment studies of established C. albicans endocarditis, i.v. amphotericin B (1 mg/kg) or i.p. fluconazole (50 mg/kg) was begun 24 or 60 h postinfection and continued daily for 9 or 12 days. At these dose regimens, amphotericin B was consistently more effective than fluconazole in reducing fungal vegetation densities, regardless of the timing of initiation of therapy. We also examined the efficacy of fluconazole at a daily dose of 100 mg/kg i.p. administered for 21 days in the treatment of established C. albicans endocarditis. When therapy was continued for 2 weeks or longer, fluconazole was more effective than no drug and approximately twice as effective as 12 days of amphotericin B in reducing intravegetation fungal densities. Our results suggest that amphotericin B is superior to fluconazole in both the prophylaxis and treatment of C. albicans endocarditis in the rabbit model. These findings may relate to the predominantly fungistatic activity of fluconazole against C. albicans in vitro.

Amphotericin B↗
PubMed1991

Beta-Lactam-beta-lactamase-inhibitor combinations are active in experimental endocarditis caused by beta-lactamase-producing oxacillin-resistant staphylococci.

Optimal therapeutic strategies for serious infections caused by borderline and heterotypic oxacillin-resistant Staphylococcus aureus (BORSA and ORSA) strains have not been fully characterized. Recent evidence suggests that the dominant penicillin-binding protein of ORSA strains (PBP 2a) shows good affinity for ampicillin and that these strains commonly produce beta-lactamase. Therefore, we compared the in vivo efficacy of the combination of ampicillin plus sulbactam with that of vancomycin against ORSA strains. Also, the moderate resistance of BORSA strains appears to be attributable mainly to the hyperproduction of beta-lactamase. Therefore, we also studied the in vivo efficacy of ampicillin plus sulbactam against such organisms. Experimental aortic endocarditis was induced in rabbits by the following three strains: beta-lactamase-producing BORSA strain VP-986, beta-lactamase-producing ORSA strain 67-0, and its beta-lactamase-negative clone. In animals with BORSA endocarditis, ampicillin plus sulbactam and oxacillin were highly effective in reducing mean intravegetation bacterial densities, with each being significantly better than either ampicillin alone or no therapy. In animals with endocarditis caused by the beta-lactamase-producing ORSA strain, ampicillin plus sulbactam was significantly better at reducing mean vegetation bacterial densities than the other regimens. For endocarditis caused by the beta-lactamase-negative ORSA clone, ampicillin was better than vancomycin in reducing mean intravegetation bacterial densities. These data show that infections caused by beta-lactamase-producing BORSA strains respond therapeutically in a manner similar to that of infections caused by oxacillin-susceptible strains, with both oxacillin and ampicillin plus sulbactam being highly efficacious. Moreover, high-dose ampicillin treatment strategies were effective in the therapy of ORSA endocarditis; this efficacy is presumably related to the relatively high affinity profile of this compound (compare with that of oxacillin) for the functionally dominant ORSA PBP 2a.

Animals↗