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PubMed1992

Clinical relevance of vegetation localization by transoesophageal echocardiography in infective endocarditis.

Infective endocarditis is associated with significant morbidity and mortality, with valvular destruction and congestive heart failure being more common in patients with echocardiographically discernible vegetations. The transoesophageal approach affords consistently high quality images with excellent structural resolution. Two-hundred and eighty-one patients with clinically suspected infective endocarditis were studied, to evaluate the prognostic value of ascertaining the site of vegetations. Among them were 118 patients with vegetations attached to the aortic or mitral valve. These patients were followed for a mean period of 14 months. Mitral valve vegetations were associated with a significantly higher incidence of embolic events than vegetations on aortic valves (25% vs 9.7%). The incidence of abscess formation was higher in aortic than in mitral valve endocarditis (6% vs 0%), as were the need for surgical intervention (11% vs 5.5%) and mortality (1.6% vs 0%) respectively). Bivalvular endocarditis was associated with an increased rate of complications: embolism (50%), abscess formation (15%), surgery (35%) and mortality (10%). By multivariate analysis, echocardiographically accessible risk factors for subsequent embolism were a vegetation size of more than 10 mm and mitral valve involvement. Risk factors associated with in-hospital fatality were embolism, a vegetation size of more than 10 mm, and Staphylococcus aureus infection. Our data suggest that the site influences both the rate and the type of complications. Precise echocardiographic visualization of vegetations helps to stratify patients into a high-risk sub-group, perhaps warranting early prophylactic surgical intervention. Transoesophageal echocardiography may play an important role in assessing the clinical outcome for these patients.

Abscess↗
PubMed1995

Infective endocarditis due to Streptococcus bovis. A report of 53 cases.

Fifty-three patients (42 men; 11 women) with Streptococcus bovis infective endocarditis attended a tertiary cardiology hospital between 1980 and 1991, and constituted 11% of the total number of infective endocarditis cases hospitalized there during that period. The mean age was 59 +/- 15 years; 15 had previously suffered valvular disease (12) or had a valvular prosthesis (3); one patient had had a previous infective endocarditis. The infective episode involved the aortic valve in 26 patients, both the aortic and mitral valves in 18 patients, the mitral valve only in six and other valves in three. Echocardiographic examination showed one or more vegetations in 44 patients. Cardiac failure was diagnosed in 35 patients and embolic episodes in 22, of whom 11 were cerebrovascular accidents. The patients became afebrile 19 +/- 39 days after starting antibiotic treatment. Valve replacement was performed in 37 patients during their initial hospitalization, and in four during follow-up. After a mean follow-up of 4.6 +/- 3.1 years with a 100% follow-up, 15 patients died: 1 preoperatively, one in the first 30 days after operation, 13 later (8141 operated patients and 5/12 non-operated patients). Actuarial survival was 73% at 5 years. Gastrointestinal signs were present in 12 patients; 43 patients (81%) had a full colonic examination which showed polyps in 20 patients and adenocarcinomas in seven. Of 11 late deaths four were related to a malignant colonic tumour. This study confirms that Streptococcus bövis infective endocarditis is 'relatively benign', but it stresses the frequency and potential severity of the associated colonic lesions, requiring colonoscopy and making the treatment of high risk lesions mandatory.

Adenocarcinoma↗
PubMed1986

Fibrinolytic therapy in bacterial endocarditis: experimental studies in dogs.

An investigation was undertaken to assess the value of adding streptokinase therapy to standard penicillin treatment of artificially induced infective endocarditis due to Streptococcus sanguis. In pigs a low-grade infection could be induced which closely simulated streptococcal endocarditis in man, but for technical reasons this model proved unsatisfactory for further experimentation. In dogs the induction of S. sanguis endocarditis produced a more severe illness with a short natural history. Dogs were divided into two groups, one treated with penicillin alone, the other with penicillin and streptokinase. A five-day course, in which twice daily injections of an acylated streptokinase-plasminogen complex were given, caused a substantial reduction in the size of vegetations and possibly a higher proportion of cures and less damage to the valves. Infarction of the brain, almost certainly due to embolism, was significantly greater in the streptokinase treated group, but the same was not true of the kidneys. The possible value of such treatment for certain kinds of bacterial endocarditis in man, especially in the right side of the heart, is discussed.

Animals↗
PubMed1996

Native-valve endocarditis caused by Staphylococcus lugdunensis.

Coagulase-negative staphylococci cause about 5% of native-valve endocarditis. Staphylococcus lugdunensis, a recently-described species of coagulase-negative staphylococci, has been reported to cause destructive native-valve endocarditis with a high mortality. We report four consecutive cases of definite Staphylococcus lugdunensis native-valve endocarditis by the Duke criteria over a 4-year period. All patients required urgent aortic valve replacement 1-5 days after admission, and recovered. An intriguing, aspect in the presentation of these patients was a history of vasectomy and inguinal skin breaks in the immediate period preceding the occurrence of endocarditis.

Adult↗
PubMedDate not supplied

Endocarditis due to enteric bacilli other than Salmonellae: case reports and literature review.

The clinical and pathological findings in two recent patients with non-salmonella enterobacterial endocarditis are described, and those of 42 patients in the literature are summarized. Most of the patients acquired their endocarditis secondary to urinary tract infection and had an acute clinical course characterized by high fever and chills. Thirty-two of these patients died, and all except one had a postmortem examination. The most frequent pathological finding was the occurrence of very large vegetations which caused relatively little destruction of the underlying valve. Prompt diagnosis and antibiotic therapy chosen on the basis of bactericidal as well as bacteriostatic activity against the individual bacterium may improve the prognosis in this disease. Results of tricuspid and pulmonic valvulectomies for bacteriologic failure in pseudomonas and in a few cases of enterobacterial endocarditis appear to warrant a surgical approach in patients with right-sided enterobacterial endocarditis who fail to respond to vigorous medical therapy.

Aged↗
PubMedDate not supplied

Beta hemolytic streptococcal endocarditis: predominance of non-group A organisms.

Identification of beta hemolytic streptococci (BHS) as group A or non-group A on the basis of bacitracin sensitivity rather than Lancefield serogrouping may lead to misidentification of the pathogen. In four recent cases of endocarditis due to BHS, the pathogens initially were identified as group A; Lancefield serogrouping showed all four to be group G. All four patients presented with a syndrome characteristic of acute bacterial endocarditis. Review of all cases of endocarditis at our institution for the past five years showed none due to group A BHS. In 166 previously reported cases of endocarditis due to BHS, 68 pathogens were serogrouped: 53 belonged to groups B, C, G, or H; only five were group A. Our four cases and review of the literature demonstrate the need for Lancefield serogrouping in serious beta hemolytic streptococcal infections, rather than reliance on bacitracin sensitivity.

Acute Disease↗
PubMedDate not supplied

Subacute bacterial endocarditis due to Actinobacillus actinomycetemcomitans.

Sixteen documented cases of Actinobacillus actinomycetemcomitans endocarditis have been reported in the past 15 years. The characteristic granular growth and the fastidious nature and slow-growing character of this organism decrease the yield of positive blood cultures. Two recently observed cases of subacute endocarditis due to Actinobacillus are reported, one in a patient who required surgical intervention for complications of his disease and the other case associated with an aortic prosthetic valve. The first patient had late embolic complications which are commonly seen with Actinobacillus endocarditis. A review of the literature; including a synoptic table with clinical failures, treatment, and outcome is presented. Unless special care is taken to isolate these slow growing organisms, these cases will be misclassified as culture negative endocarditis.

Actinobacillus↗
PubMedDate not supplied

Heart block during bacterial endocarditis: a review of the literature and guidelines for surgical intervention.

The management of patients with bacterial endocarditis complicated by atrioventricular block is based on uncontrolled data, mostly from retrospective surgical and autopsy series. It is difficult to advance broad recommendations on the basis of such a biased population. Nevertheless, it is the firm opinion of many experienced clinicians that heart block developing as the result of aortic endocarditis signals myocardial abscess formation, and thereby is an indication for early surgery. I present a patient with aortic and mitral endocarditis in whom first degree heart block developed and then disappeared over five days; she was successfully managed with medical therapy alone. This case illustrates that some patients with endocarditis and heart block will not require surgery. In this setting, I propose the following guidelines in selecting patients for operation: 1) the observed appearance or progression of heart block; 2) the presence of aortic valve involvement; 3) the persistence of heart block, despite at least one week of optimal antibiotics; and 4) the elimination of other potential causes of conduction abnormalities.

Adult↗
PubMed2000

Citrobacter diversus endocarditis.

Citrobacter species are motile Gram-negative bacilli that cause disease in humans, such as urinary tract infection, pneumonia, superficial and deep wound infections, gastroenteritis, meningitis, bacteremia, and rarely endocarditis. In those cases of endocarditis, intravenous drug use has been associated with Citrobacter species. Gram-negative organisms are present in less than 10% of cases of endocarditis in intravenous drug users. We present a case of tricuspid valve endocarditis in an intravenous drug user caused by Citrobacter diversus alone.

Citrobacter↗
PubMed1982

Immediate and long-term outlook for valve replacement in acute bacterial endocarditis.

The clinical course of 22 patients with acute endocarditis treated surgically less than six weeks after the onset of antibiotic therapy was reviewed. The aortic valve was infected in 13 patients, the mitral in six, the tricuspid in two, and one patient had both aortic and mitral valve involvement. The indications for surgical intervention before the completion of adequate antibacterial therapy included uncontrollable congestive heart failure, persistent sepsis, systemic embolization, and multiple septic pulmonary embolizations. The annulus was involved by the infectious process in five of the 13 patients with aortic valve endocarditis, in one of the two patients with tricuspid valve infection, and in none of the patients with mitral valve endocarditis. There were two surgical deaths, for a mortality of 9.1%. During the follow-up period, four patients died three months, seven months, four years, and seven years after surgery. The remaining patients have been followed up for a period of five months to 10 years. One patient has a hemodynamically insignificant paravalvular leak, and another developed paravalvular regurgitation and a false aneurysm of the left sinus of Valsalva two weeks after the initial operation. She subsequently underwent successful valve replacement and repair of the aneurysm. This study confirms that valvular replacement should be done for acute endocarditis as soon as indicated, and that the incidence of reinfection and/or the development of valvular or paravalvular problems is small even in the patients with incomplete antimicrobial therapy, whether or not the annulus is involved by the infectious process.

Acute Disease↗
PubMed1991

Infectious endocarditis after fiberoptic sigmoidoscopy. With a literature review.

Infectious endocarditis is a feared complication of procedures causing bacteremia. Gastrointestinal procedures cause bacteremia, but are seldom followed by infectious endocarditis. Of nine cases found in the English literature, only five have convincing evidence that endocarditis resulted from the gastrointestinal procedure. I present a new case of endocarditis due to Streptococcus sanguis type II after fiberoptic sigmoidoscopy.

Endocarditis, Bacterial↗
PubMed1978

Endocarditis with the indwelling balloon-tipped pulmonary artery catheter in burn patients.

The postmortem finding of acute right-sided bacterial endocarditis in a burn patient monitored with an indwelling pulmonary artery (Swan-Ganz) catheter for 14 days prompted a review of burn autopsies in which the catheter had been used. Autopsies of six consecutive burn patients monitored with a pulmonary artery catheter and who then died showed septic or aseptic endocarditis. In two of the six patients, right-sided staphylococcal endocarditis was the anatomic cause of death. In the remaining four, the lesions were aseptic thrombotic vegetations involving primarily the right atrium, tricuspid valve, right ventricle, and pulmonic valve. Several factors in the severely burned patient would favor endocarditis where a foreign object impacts on the heart valves. These include intermittent bacteremia, hypercoagulability, hyperdynamic cardiovascular function, and the use of antibiotics resulting in resistant strains. While an indwelling pulmonary artery catheter can provide useful monitoring information, it is sometimes responsible for serious complications in burned or septic patients.

Adult↗
PubMed1979

Infective endocarditis caused by slow-growing, fastidious, Gram-negative bacteria.

In a review of endocarditis caused by fastidious, slow-growing gram-negative rods, similarities in the spectrum of disease overshadow differences among cases grouped by specific organisms. Cardiobacterium hominis, Actinobacillus actinomycetemcomitans and Haemophilus species usually seed previously damaged cardiac valves presumably during bacteremia from an upper respiratory site. The clinical presentation resembles that of Streptococcus viridans endocarditis and is usually subacute or chronic. Despite bacteriologic cure, severe CHF and/or systemic embolization frequently develops during or following the course of antibiotics, resulting in significant morbidity and a high mortality rate. This report of nine cases diagnosed at five hospitals in a 7-year period suggests that endocarditis due to these organisms is more common than previously appreciated and frequently goes unrecognized. This is probably due to a lack of attention to the requirements for culture of this group of bacteria with propensity for granular growth in broth. We have proposed specific cultural techniques appropriate to the search for these organisms in patients with apparent culture-negative endocarditis.

Actinobacillus Infections↗
PubMed1986

Left-sided endocarditis due to Pseudomonas aeruginosa. A report of 10 cases and review of the literature.

Ten confirmed cases of left-sided endocarditis due to Pseudomonas aeruginosa were reported in detail and the English literature was reviewed. In recent years, venous access (usually illicit) has been the major predisposing factor to this infection and abuse of pentazocine and tripelennamine has been particularly associated with endocarditis due to this organism. This infection involves previously damaged as well as normal valves. The development of congestive heart failure did not adversely affect the prognosis of this infection. However, the development of azotemia was associated with a greater likelihood of a fatal outcome. In the current series, deaths were due to uncontrolled infection. This often occurred despite inhibitory and bactericidal activity in serum generally considered adequate for treatment of endocarditis. Medical treatment alone rarely produced cure of infection. Our experience with a high frequency of major vessel embolization (4/10) and the improved survival after medical/surgical treatment suggests that prompt valve replacement combined with high doses of an aminoglycoside plus carbenicillin or ticarcillin provide the best opportunity for successful outcome in patients with left-sided endocarditis due to P. aeruginosa.

Adult↗
PubMed1994

The prevention and diagnosis of infective endocarditis. The primary care provider's role.

Infective endocarditis, a microbial infection of the endocardium, is a complex multifaceted disease that may affect any organ system. Despite advances in diagnostic technology and treatment, overall mortality rates from infective endocarditis remain between 15-45%, and as high as 40-70% among the elderly. Explanations for the persistence of high mortality rates have focused on delays or errors in diagnosis. The classic diagnostic triad of fever, cardiac murmur, and positive blood cultures are not always present. Elderly patients often have more non-specific symptoms than do younger patients. Infective endocarditis should be considered in conditions dominated by the insidious onset of congestive heart failure, acute mental status or neurological changes, or the acute onset of arthralgias or myalgias. This article reviews the pathogenesis, epidemiology and etiology, risk factors, and clinical presentations of infective endocarditis, as well as current recommendations for antibiotic prophylaxis.

Aftercare↗
PubMed1976

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.

Adolescent↗
PubMed1978

Blood chemistry abnormalities in bacterial endocarditis of narcotic addicts.

We recently treated two narcotic addicts with bacterial endocarditis who developed the syndrome of inappropriate antidiuretic hormone secretion (SIADH). This prompted a retrospective review of blood chemistry studies in all narcotic addicts admitted to our hospital over a 30-month period because of a clinical suspicion of bacterial endocarditis. Patients with culture-positive endocarditis (group 1) had significantly lower plasma osmolality, sodium, calcium and albumin values (P less than .02, .001, .005, and .005 respectively) than addicts without endocarditis (group 2). More than 90% of those in group 1 had hyponatremia, and 48% had plasma hypoosmolality. These findings may be of value in the initial evaluation of ill narcotic addicts for hospitalization.

Adult↗
PubMed1979

Comparison of staphylococcal and nonstaphylococcal endocarditis in narcotic addicts.

In a 54-month retrospective review, we compared the clinical features of 26 narcotic addicts with staphylococcal endocarditis (group 1) and ten other addicts with nonstaphylococcal endocarditis (group 2). The admission temperature and the respiratory rate of patients in group 1 were significantly higher (P less thn .05 and less than .02 respectively) than those of patients in group 2. Group 1 also differed from group 2 in the following variables: (1) bilateral multiple pulmonary infiltrates in 46% vs none in group 2; (2) greater incidence of symptoms referable to the central nervous system (50% vs none in group 2); and (3) gastrointestinal symptoms of vomiting, diarrhea, or constipation in 62% vs 10% in group 2. Serious cardiovascular, renal, and other complications were more frequent in staphylococcal endocarditis. Tricuspid regurgitation occurred with equal frequency in both groups and was of no value in differentiating staphylococcal from nonstaphylococcal endocarditis.

Adult↗