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PubMed2001

Retroperitoneal suppurative lymphadenitis complicating Staphylococcus aureus acute bacterial endocarditis.

Acute bacterial endocarditis is commonly caused by Staphylococcus aureus. Acute bacterial endocarditis due to S. aureus is often complicated by metastatic infection to distant organs, i.e. the central nervous system, the heart, lungs, kidneys and joints. However, metastatic lymph node involvement has not been reported. This is a case report of S. aureus acute bacterial endocarditis complicated by metastatic suppurative lymphadenitis of retroperitoneal lymph nodes. We believe this is the first reported case of suppurative lymphadenitis of the mesenteric lymph nodes secondary to S. aureus acute bacterial endocarditis.

Acute Disease↗
PubMed2004

Isolated bacterial meningitis as the key syndrome of infective endocarditis.

BACKGROUND: Bacterial meningitis is an unusual first manifestation but a major complication of infective endocarditis. PATIENTS AND METHODS: We present three well documented cases of isolated bacterial meningitis in endocarditis. Against this background we review the literature. RESULTS: All patients presented with bacterial meningitis. Staphylococcus aureus was isolated in blood cultures of all patients, but was found only in the cerebrospinal fluid (CSF) of one patient. The underlying endocarditis was confirmed histologically in all three cases. Two patients recovered completely and one died. CONCLUSION: An extensive search for endocarditis is recommended in every case of an unusual isolate in bacterial meningitis whether it is isolated from blood or CSF.

Aged↗
PubMed1999

Duke criteria-negative endocarditis caused by Bartonella quintana.

Bartonella spp. were recently recognized as causative agents of culture-negative endocarditis. Molecular techniques, such as broad-range PCR, are now available to detect fastidious or slow-growing microorganisms, or those which cannot be cultured. Such microorganisms may be responsible for culture-negative endocarditis. Alcoholism and homelessness are known risk factors for Bartonella quintana endocarditis, even in patients without previous valvular disease. We report a case of B. quintana endocarditis diagnosed by PCR amplification on the excised heart valve, in a young non-alcoholic and immunocompetent patient with few clinical signs of infection who did not fulfill the Duke criteria.

Adult↗
PubMed1984

Gonococcal endocarditis: a case series demonstrating modern presentation of an old disease.

Gonococcal endocarditis appeared with striking frequency in the preantibiotic era compared with its surprising rarity today. We present a series of four episodes of gonococcal endocarditis, which presented to our institution in the last 2 years, after no cases in the previous decade. Three episodes involved the aortic valve and required emergency aortic valve replacement. One episode involved the tricuspid valve and was successfully cured with antibiotic infusion alone. Combining our four patients with the available 25 well-documented gonococcal endocarditis cases reported in the English medical literature during the antibiotic era, we demonstrated that the disease incidence may be increasing, that infections more often involve left-sided cardiac structures (particularly the aortic valve), and that the association with a quotidian fever curve, rash and arthritis, and overt gonococcal infection is less common than previously reported. These patients frequently present with fulminant and dramatic valvular insufficiency without immediately positive blood cultures and complete echocardiographic evaluation seems to provide a valuable aid in making a presumptive diagnosis of endocarditis and directing appropriate clinical management.

Adult↗
PubMed1986

Prognostic significance of vegetations detected by two-dimensional echocardiography in infective endocarditis.

Although 2DE is considered the most sensitive method for detecting vegetations in infective endocarditis, the independent clinical significance of these vegetations continues to be debated. To further examine this, we identified 74 patients who were diagnosed as having infective endocarditis over a 54-month period. The 50 patients who underwent 2DE examination form the basis of this report. Definite vegetations were present in 21 (42%) patients and measured 1.2 +/- 0.2 cm2. The vegetation was localized to the aortic valve in 10 patients, the mitral valve in eight, and the tricuspid valve in three. A major complication, defined as death, new-onset congestive heart failure, major arterial embolus, or valve surgery occurred in 86% of the vegetative endocarditis patients compared to 62% of those without vegetations. Among those patients with vegetations, death occurred in 24%, heart failure in 38%, arterial embolus in 48%, and surgery in 43%. This compared to 7%, 21%, 21%, and 24%, respectively, in those patients without vegetations. These data support the concept that 2DE detection of a vegetation defines a high-risk subgroup of patients with infective endocarditis in whom careful monitoring and aggressive management are warranted.

Adult↗
PubMed1983

Analysis of surgical versus medical therapy in active complicated native valve infective endocarditis.

From 1972 to 1980, 23 patients (Group A) with native valve infective endocarditis underwent surgical intervention, often for multiple indications, during the active stage of the infective process because of progressive class III and IV (New York Heart Association) heart failure (12 patients), persistent severe hypotension (3 patients), uncontrolled infection for over 21 days (11 patients), aortic root abscess (2 patients), and pericarditis (1 patient). Eighty-five patients (Group B) with active native valve endocarditis, matched for severity of illness, were treated medically. Two patients (9%) in Group A and 43 patients (51%) in Group B died during the hospital admission (p less than 0.001). Any difference in long-term cumulative survival rate between the 2 groups was largely due to the beneficial impact of surgical management on the hospital mortality. Of 23 patients in Group A, 11 (48%) had an entirely uncomplicated postoperative course. Long-term mortality rates in those with aortic valve endocarditis treated medically (79%) were significantly higher than in those with mitral valve involvement (47%) (p less than 0.05). Patients with aortic valve involvement treated surgically had a better hospital (p less than 0.005) and long-term (p less than 0.0005) survival rate than those treated medically. Two groups at risk for postoperative complications were identified; 3 of 11 patients (27%) with uncontrolled infection had an early postoperative recurrence, and 4 of 7 patients (57%) with an aortic root abscess had postoperative prosthetic paravalvular regurgitation. Surgery therefore effects a substantial reduction in hospital mortality in patients with complicated active infective endocarditis (9% versus 51%), but patients with preoperative prolonged periods of uncontrolled infection or with aortic root abscess are liable to postoperative complications.

Adolescent↗
PubMed1978

Vancomycin therapy of bacterial endocarditis.

Fifteen patients with bacterial endocarditis were treated with vancomycin between 1967 and 1976. The indications for vancomycin therapy were penicillin-cephalosporin allergy in six patients, antibiotic resistant bacteria in six, initial therapy in one and culture-negative endocarditis in two. The causative microorganisms were Staph. epidermidis (four patients), Staph. aureus (two patients), diphtheroids (four patients), viridans streptococci (two patients) and enterococci (one patient). Minimum inhibitory concentrations of vancomycin for these organisms ranged from 0.8 to 3.1 micrograms/ml. The patients received vancomycin for two to 10 weeks (mean five weeks). Cure was achieved in 13 patients, including six with prosthetic valve endocarditis (PVE). Two patients had a relapse of PVE and cultures of blood or heart valve were positive within two months of vancomycin therapy. Vancomycin serum levels did not exceed 50 micrograms/ml, and no serious drug toxicity was encountered in any patient. Three patients had minimal audiogram changes beyond the social hearing range. One patient had mild phlebitis and a rash, and one patient had a transient leukopenia. Vancomycin is an effective nontoxic antibiotic in patients with endocarditis when penicillin or cephalosporin therapy is not appropriate.

Adult↗
PubMed1982

Four-valve polymicrobial endocarditis caused by Pseudomonas aeruginosa and Serratia marcescens.

This report describes what is believed to be the first case of mixed Pseudomonas and Serratia endocarditis, of probable nosocomial etiology, with involvement of all four heart valves in a 56 year old nonaddicted patient. Although both organisms were recovered in culture, infection and tissue invasion were documented by light and electron microscopy. The clinical course in this patient differed from more typical patterns of Pseudomonas or Serratia endocarditis that have been observed as complications of narcotic addiction or compromised cardiac status. Our patient had the rare occurrence of endocarditis with two organisms and four-valve involvement. Clinically, however, this presented as a right-sided endocarditis and behaved as though only a single organism were present.

Endocarditis, Bacterial↗
PubMed1985

Efficacy of imipenem/cilastatin in endocarditis.

Imipenem, a potent new beta-lactam antibiotic, which is bactericidal against most pathogenic bacteria, and cilastatin, a dehydropeptidase inhibitor combined with imipenem to prevent the metabolism of imipenem in the kidney, were evaluated in the treatment of bacterial endocarditis. Seventeen patients, including 14 who used intravenous drugs, were treated with imipenem/cilastatin in a dose of 500 mg each infused over 30 minutes every six hours. The mean duration of treatment was 29 days with a range of 21 to 56 days. Causative bacteria were Staphylococcus aureus in 10 patients, S. aureus plus group B Streptococcus in one, viridans group Streptococcus in two, Neisseria subflava, Eikenella corrodens, and group G Streptococcus in one patient, and Staphylococcus epidermidis, Hemophilus aphrophilus, and Enterobacter aerogenes in one patient each. The minimal bactericidal concentration of imipenem against 16 of 18 isolates tested was 0.04 micrograms/ml, 1 microgram/ml against H. aphrophilus, and 0.4 micrograms/ml against E. aerogenes. The site of infection was the right side of the heart in 11 patients, the left side in five, and both sides in one. The mean number of days to defervescence was 9.7. All patients were cured, and none required cardiac surgery. Adverse effects were few and interrupted treatment occurred in only one patient who had acute dyspnea during an infusion on Day 26 of therapy. Imipenem/cilastatin appears to be a relatively safe and highly effective treatment of staphylococcal endocarditis in intravenous drug users; too few patients with endocarditis caused by other bacteria were treated to allow a firm statement about efficacy in non-staphylococcal endocarditis.

Adult↗
PubMed1985

Pathogenesis and treatment of endocarditis.

The rabbit model has been invaluable for in vivo studies in the pathogenesis and treatment of bacterial endocarditis. Both of the features of the mature bacterial vegetations in this rabbit model, i.e., absence of phagocytosis and decreased metabolic activity, provide evidence to support the concept that a rapidly bactericidal antimicrobial agent provides the optimal approach to the successful treatment of endocarditis. Imipenem, a carbapenem with a very broad spectrum of in vitro activity, has been shown to be rapidly bactericidal in animals and highly effective in the treatment of experimental bacterial endocarditis. In addition, twenty-six patients with endocarditis, caused largely by Staphylococcus aureus, have been successfully treated with imipenem/cilastatin.

Animals↗
PubMed1985

Treatment of streptococcal infective endocarditis.

Patients with infective endocarditis caused by penicillin-sensitive streptococci (minimal inhibitory concentration for penicillin of 0.1 microgram/ml or less) may be treated successfully with one of the following regimens: aqueous penicillin G administered intravenously for four weeks, intravenous aqueous penicillin G for four weeks combined with streptomycin for the first two weeks of therapy, or parenterally administered penicillin plus streptomycin for two weeks. A cure rate of at least 98 percent may be anticipated with each of these regimens. During a 12-year period among 142 patients treated for two weeks with penicillin and streptomycin, one (0.7 percent) had relapse and four (3 percent) had vestibular toxicity. The major advantage of the two-week regimen is that it is more cost-effective than the four-week regimens. The major disadvantage of the use of streptomycin is the relatively low risk of vestibular toxicity. Patients with enterococcal endocarditis were treated initially for four weeks with aqueous penicillin G together with either streptomycin (streptomycin-susceptible enterococci, 36 patients) or gentamicin (streptomycin-resistant enterococci, 20 patients). Compared with patients who had symptoms for less than three months, patients with symptoms for longer than three months had a higher relapse rate (0 percent versus 44 percent; p less than 0.001) and mortality (2.5 percent versus 25 percent; p less than 0.001). Patients with mitral valve endocarditis had a significantly higher relapse rate (25 percent) than patients with aortic valve infection (0 percent; p less than 0.01]. Gentamicin-associated nephrotoxicity was more frequent (p less than 0.001) among patients treated with more than 3 mg/kg per day of gentamicin than among those treated with 3 mg/kg per day or less (100 percent versus 20 percent). Relapse and mortality rates did not differ significantly between patients treated with low-dose or high-dose gentamicin regimens. Patients who have had symptoms of enterococcal endocarditis for longer than three months or perhaps patients with mitral valve infection should receive at least six weeks of penicillin therapy together with an aminoglycoside; patients without either high-risk factor may be treated successfully for four weeks.

Anti-Bacterial Agents↗
PubMed1988

Rupture of a pulmonary artery mycotic aneurysm associated with candidal endocarditis.

Candidal endocarditis can develop if candidemia occurs during Swan-Ganz catheterization. Candida endocarditis may persist for many months and is fatal unless the infected valve is resected. Herein is reported the first case of rupture of a mycotic pulmonary artery aneurysm caused by chronic candidal endocarditis. The endocarditis followed Swan-Ganz catheterization and aneurysm progressed despite appropriate medical and surgical therapy.

Amphotericin B↗
PubMed1989

Occult polymicrobial endocarditis with Haemophilus parainfluenzae in intravenous drug abusers.

PURPOSE AND PATIENTS AND METHODS: Fewer than 8 percent of intravenous drug abusers are found to have polymicrobial endocarditis. We report on cases of occult polymicrobial infective endocarditis with Haemophilus parainfluenzae in 10 intravenous drug abusers. Clinical and laboratory data on all 10 patients were obtained from hospital charts, and information on illicit drug use methods was given by five patients. Blood cultures were performed, as well as susceptibility testing to antibiotics. Subsequent molecular epidemiologic studies were performed on selected Staphylococcus aureus and H. parainfluenzae strains. Phage typing of S. aureus and biotyping of H. parainfluenzae strains were also done. RESULTS: Results of the initial blood cultures were positive on the second to fifth days (mean, 2.6 days), demonstrating a gram-positive pathogen in nine patients and Bacteroides asaccharolyticus in one. Significantly, in each case, H. parainfluenzae alone was subsequently identified from additional blood cultures, with a mean delay of 20.4 days (range, five to 57 days) to the isolation of this organism. Epidemiologic data indicated that our cases did not represent a point-source outbreak. Antibiotic therapy uniformly failed until an agent active against H. parainfluenzae was added. The constellation of clinical, microbiologic, and epidemiologic findings was similar, and permitted prospective diagnosis and therapy in three patients. Despite the absence of S. aureus bacteremia in four, all 10 patients had right-sided endocarditis with septic pulmonary emboli. Five patients had initial blood cultures that were positive for two facultative gram-positive cocci (S. aureus and commensal oral streptococcal species). CONCLUSION: Our findings suggest that polymicrobial endocarditis with H. parainfluenzae in intravenous drug abusers is a distinct clinical syndrome, and should be considered in all patients if the response to appropriate antibiotics is atypical or if pulmonary emboli continue with therapy.

Adult↗
PubMed1992

Subacute bacterial endocarditis secondary to Streptococcus pneumoniae.

Pneumococcal endocarditis characteristically presents as an acute illness, often accompanied by purulent meningitis, rapid destruction of the heart valves, congestive heart failure, and high mortality. We describe two patients with subacute pneumococcal endocarditis without a known primary source of pneumococcal bacteremia, fever, meningitis, or congestive heart failure. Both patients were cured with medical therapy. Pneumococcal endocarditis can present as an indolent illness resembling viridans streptococcal endocarditis.

Aged↗
PubMed1990

Valve repair in acute endocarditis.

Forty patients were operated on in the early phase of active endocarditis between 1980 and 1988. Indications for operation were heart failure (30 patients), severe valvular regurgitation (4), uncontrolled sepsis (2), septic emboli (3), and other (1 patient). Time between onset of endocarditis symptoms and operation ranged from 12 to 45 days (mean, 30 days). The aortic valve was involved in 3 patients; the mitral valve, in 28; both valves, in 7; and the tricuspid valve, in 2. There was no previous underlying valve pathology in 40%. Lesions found were cusp perforation (17 patients), annular abscess (4), vegetation (13), and chordal rupture (22). Positive blood cultures were found in 30 patients (75%). Bacterial findings were Streptococcus in 12 patients (30%), Staphylococcus in 15 (37.5%), gram-negative in 3 (7.5%), and unknown in 10 (25%). Criteria to perform valve repair were adequate antibiotic therapy for at least 1 week and large excision of all macroscopically involved tissues. In all cases, Carpentier's reconstructive techniques were used. Perioperative mortality was 2.5% (1 patient). Reoperation was necessary in 1 patient. Late mortality was 2.5% (1 patient). Repair was assessed either by angiography or by Doppler echocardiography before hospital discharge: 32 patients showed no regurgitation, whereas 7 had mild regurgitation (3 aortic, 4 mitral). Mean follow-up of 30 months was achieved in all survivors. There was no recurrence of endocarditis and no reoperation for valvular insufficiency. We conclude that valve repair in acute endocarditis is possible and effective in most instances.

Acute Disease↗
PubMed1990

Results of homograft aortic valve replacement for active endocarditis.

Since July 1985, cryopreserved homograft prostheses have been used for aortic valve replacement in 10 patients, aged 2 to 77 years, with active endocarditis. Five patients had positive bacterial cultures from excised valves, and all had clinical findings of uncontrolled infection while receiving appropriate antibiotics. Homograft valves (four) or valved conduits (six) were implanted for treatment of sepsis (6 patients), congestive heart failure (3) or recurrent emboli (1 patient), and complicating native (5 patients) or prosthetic valve (5) endocarditis. Staphylococci (6 patients), streptococci (3), and Candida (1) were infecting organisms. Preoperatively, Doppler echocardiography showed aortic regurgitation in all patients. At operation, 9 patients had gross vegetations, 9 had single or multiple abscess cavities, and 5 had pericarditis. Complex reconstruction of the aortic valve and annulus with homograft conduits was necessary in 6 patients (3 with previous aortoventriculoplasty). Two early deaths (ventricular failure, perioperative stroke) occurred. Mean follow-up of all operative survivors was 2.1 years (range, 0.6 to 3.6 years), and one late death resulted from arrhythmia. Homograft valve regurgitation increased in 1 patient, and 7 late survivors are asymptomatic. No patient has had recurrence of endocarditis. We conclude that cryopreserved homograft aortic valve/root replacement is an effective method for management of active endocarditis complicated by annular destruction.

Adolescent↗
PubMed1996

Valve replacement in patients with endocarditis and acute neurologic deficit.

BACKGROUND: Acute neurologic deficits occur in up to 40% of patients with left heart endocarditis. Appropriate evaluation and management of patients with acute neurologic dysfunction who require valve operations for endocarditis remain controversial. This retrospective review was undertaken to develop recommendations for the evaluation and treatment of these challenging patients. METHODS: From 1983 to 1995, 247 patients underwent operations for left heart native valve endocarditis at the Johns Hopkins Hospital. From a review of medical and pathology records, 34 patients (14%) with preoperative neurologic deficits were identified. Data on these 34 patients were recorded and analyzed. RESULTS: Causes of neurologic dysfunction included embolic cerebrovascular accident (n = 23, 68%), embolic cerebrovascular accident with hemorrhage (n = 4, 12%), ruptured mycotic aneurysm (n = 3, 9%), transient ischemic attack (n = 2, 6%), and meningitis (n = 2, 6%). Preoperative diagnostic studies included computed tomography (32 patients), magnetic resonance imaging (11 patients), cerebral angiogram (14 patients), and lumbar puncture (2 patients). Computed tomography demonstrated structural lesions in 29 of 32 patients; in only 1 patient did magnetic resonance imaging reveal a lesion not already seen on computed tomography. Of 14 patients having cerebral angiograms, 7 had a mycotic aneurysm. Three mycotic aneurysms had ruptured, and these were clipped before cardiac operations. The mean interval from onset of neurologic deficit to cardiac operation was 22.2 +/- 2.8 days for all patients and 22.1 +/- 3.0 days for those with embolic cerebrovascular accident. The hospital mortality rate was 6%. New or worse neurologic deficits occurred in 2 patients (6%). CONCLUSIONS: Neurologic deficits are common in patients with endocarditis referred for cardiac operations. Despite substantial preoperative morbidity, most of these patients do well if the operation can be delayed for 2 to 3 weeks. Computed tomography scan is the preoperative imaging technique of choice, as routine magnetic resonance imaging and cerebral angiogram are unrewarding. Cerebral angiogram is indicated only if computed tomography reveals hemorrhage.

Acute Disease↗
PubMed1985

Gentamycin for prophylaxis of bacterial endocarditis: a review for the dentist.

New guidelines have recommended that gentamicin in combination with ampicillin be used for prophylaxis of bacterial endocarditis in patients with prosthetic heart valves. This article reviews some of the important and practical considerations for its use by the dentist. Gentamicin is an aminoglycoside antibiotic most exclusively reserved for treatment of serious infections caused by gram-negative bacteria in which less toxic antibacterials are ineffective. It has also been shown to be impressive in combination with penicillin in treating high-risk endocarditis patients. All strains of enterococci that are resistant to penicillin plus streptomycin are almost always sensitive to penicillin plus gentamicin. There is minimal absorption into the bloodstream from the gastrointestinal tract after oral administration but rapid absorption after intramuscular injection. Peak serum concentrations appear 30 to 90 minutes after intramuscular injection. The T1/2 is 2 hours, and in normal kidneys 85% to 95% of the drug is excreted within 24 hours by glomerular filtration. Ototoxicity and nephrotoxicity are the most serious toxic effects resulting from gentamicin therapy. The incidence of ototoxicity is about 2%, with affected patients experiencing vestibular effects rather than hearing loss. Nephrotoxicity is usually not seen before the patient has had 5 to 7 days of frequent dosing for treatment of systemic infections; the incidence is 2% to 4%. There are no data to suggest that ototoxicity or nephrotoxicity will occur in the patient given a single intramuscular injection of gentamicin for the prophylaxis of bacterial endocarditis. A single intramuscular or intravenous injection each of ampicillin and gentamicin should provide adequate blood levels for protection in the endocarditis patient for at least 4 to 5 hours.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗