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Haemophilus influenzae endocarditis on a prosthetic valve has previously been reported only once. Routine physical and laboratory evaluation does not distinguish endocarditis from this organism from other causes of endocarditis. Our patient with prosthetic mitral valve endocarditis was successfully treated with antibiotics, but surgery was subsequently required for congestive heart failure from valve dehiscence.
Osler's nodes are classic lesions strongly associated with infective endocarditis. Osler's original description placed them as a frequent finding (70%) in cases of endocarditis. Recent literature, however, has infrequently described these lesions, which in general are no longer found to be useful. We review the clinical syndromes of infective endocarditis and their association with these lesions. We also review the pathogenesis of the lesion that currently supports the embolic nature of Osler's nodes. Osler's nodes are helpful clues if they appear in patients with infective endocarditis, and biopsy and culture of the lesion may provide an etiologic diagnosis.
Enterococcal endocarditis occurred in a young man with tetralogy of Fallot who had just completed therapy for staphylococcal endocarditis. The patient had a transient reversal of flow through the ventricular septal defect during staphylococcal endocarditis with lung abscesses and had persistently elevated teichoic acid antibody titers during the second episode caused by enterococcus. Our review of the literature on recurrent infective endocarditis indicates that our case represents one of the shortest intervals of recurrence with a second organism.
Endocarditis in IV drug abusers involves the right side of the heart with much higher incidence than in the general population, being limited to the left in 30% to 40% of cases. The infecting organism is Staphylococcus aureus approximately 50% of the time, followed by Streptococcus (all groups), which accounts for 15% of all cases. In a retrospective study of infective endocarditis in IV drug abusers treated at Charity Hospital over a 5-year period, 67 patients had vegetations documented by two-dimensional echocardiogram. Left-sided involvement was present in 38 (57%) of these patients, a higher prevalence than reported in the literature in such populations. Right-sided involvement was limited to only 27 (40%). A total of 55 patients had positive blood cultures, most of which yielded Staphylococcus aureus (32 [58%]), with the next largest group being Streptococcus species (14 [25%]). This distribution of isolates was consistent with that found in the literature. From these data we conclude that the prevalence of left ventricular endocarditis in our population is higher than expected. With the known increase in morbidity and mortality of left-sided endocarditis as compared to right, it is imperative that careful consideration be given this entity often encountered in IV drug abusers.
Polymicrobial infective endocarditis is uncommon, particularly vancomycin-resistant endocarditis and fugal endocarditis. The incidence of these infections is likely to. increase with advances in mediCAl technology and widespread use of central venous catheters. We report a case of bivalve endocarditis in which four organisms were identified, including vancomycin-resistant Enteroocausfaecium and Torulopsis glabrata.
BACKGROUND: Recent medical and surgical advances have increased the potential risk of endocarditis. Epidemiology, pathogens, morbidity and/or mortality may have evolved in the past decade in pediatric patients diagnosed with endocarditis. METHODS: Retrospective reviews of medical records from Arkansas Children's Hospital were done to identify patients with infective endocarditis from January 1990 through December 2002. Basic demographic and clinical data were gathered and reviewed. RESULTS: Of 76 patients identified, 57 were included based on diagnostic criteria. Congenital heart disease with (56%) and without (25%) correction were the most common risk factors. Echocardiograms revealed vegetations in 67%. Echocardiograms remain relatively deficient in patients with complex cyanotic heart disease (50% positive) vs. those with normal anatomy (83% positive). Streptococci (30%) and Staphylococcus aureus (21%) were the most common organisms identified overall; however, we observed a predominance of enterococci in infants <2 years of age (41%). Our study revealed a reduced rate of complications, especially of the central nervous system (7% vs. 25 and 33% in prior studies); however, our rate of S. aureus was lower (21% vs. 32 and 39%), and this pathogen continues to be associated with a higher incidence of complications. CONCLUSIONS: Infective endocarditis continues to present a difficult challenge in pediatrics; its associated pathogens and outcomes have changed little in the past decade.
We present a case report of a patient who was previously treated for spontaneous epistaxis with a petroleum jelly gauze (0.5 in x 72 in) anterior nasal packing filled with an antibiotic ointment, along with prophylactic oral clindamycin. The patient presented with fever and hypotension 3 days after the nasal packing. Her blood cultures grew methicillin-resistant Staphylococcus aureus and the transesophageal echocardiography showed vegetation on the atrial surface of the posterior mitral valve leaflet, confirming the diagnosis of bacterial endocarditis attributable to nasal packing. Several case reports discuss toxic shock syndrome after nasal packing, but none describe endocarditis of the native heart valves subsequent to anterior nasal packing. Current guidelines on endocarditis prophylaxis produced by the American Heart Association, European Cardiac Society, and British Cardiac Society together with published evidence do not recommend endocarditis prophylaxis for patients with native heart valves undergoing anterior nasal packing.
Capnocytophaga canimorsus is a fastidious, Gram-negative rod that forms part of the normal oral flora of dogs and cats. Known for its ability to cause fulminant sepsis following dog bites, particularly in asplenic patients or alcoholics, this bacterium is also an uncommon cause of endocarditis. This article reviews 12 cases of endocarditis caused by C. canimorsus. Mean age of patients was 53 years, with 78% of cases occurring in males. Overall, a history of dog-bite was documented in four cases (33%) and a further four (33%) reported contact with dogs. Four (33%) of the endocarditis cases had underlying cardiological risk factors and two abused alcohol, but none had had a previous splenectomy. Subacute presentation, often involving more than one hospital admission, was common, as were initially negative blood cultures. A variety of antibiotics was used, but penicillins were the most common therapy. Three (25%) of the 12 endocarditis patients died.
Fifty-six strains of lactobacilli were examined for the production of glycosidases and proteases (arylamidases) that could be associated with the ability to grow in vivo and/or be a factor in the pathogenesis of endocarditis. The strains were from seven species, with an emphasis on Lactobacillus rhamnosus and Lact. paracasei subsp. paracasei, both of which have been associated with endocarditis and provided 12 of the 13 strains isolated from cases of the disease. Other species were Lact. acidophilus, Lact. plantarum, Lact. salivarius, Lact. fermentum and Lact. oris. Commonly expressed glycosidase activities were alpha-D-galactosidase and beta-N-acetyl-D-glucosaminidase followed by beta-D-glucosidase and alpha-L-fucosidase. The combined production of beta-N-acetyl-D-glucosaminidase and alpha-D-galactosidase was a feature of the endocarditis isolates. In contrast, beta-D-galactosidase was produced by very few of the strains within species implicated in endocarditis but most of the strains of Lact. salivarius, Lact. fermentum and Lact. oris. The most commonly produced arylamidases active against substrates employed for testing human blood clotting cascade were activated protein C(Ca)-like, activated factor X(Xa)-like and Hageman factor-like followed by kallikrein-like and chymotrypsin-like enzymes.(ABSTRACT TRUNCATED AT 250 WORDS)
Fungal valvular endocarditis is an unusual cause of endocarditis, yet very important because of its historically poor prognosis. We report two fatal cases of fungal valvular endocarditis following cardiovascular surgery, presenting as femoral artery embolism. Aspergillus terreus and A. flavus were the causative agents of endocarditis in the two patients. Diagnosis was established very early by culture of the emboli and was confirmed later by isolation of the same Aspergillus species from the resected valve tissue.
OBJECTIVES: To determine the clinical features at presentation of children with infective endocarditis to a tertiary centre and review the role of the emergency department in these cases. The subsequent course and outcomes are briefly discussed. METHODS: Retrospective audit of children with endocarditis presenting to a tertiary children's hospital over a 16-year period. RESULTS: Twenty-three cases of infective endocarditis were identified. Initial presentation via the paediatric emergency department occurred in 78% of cases and was associated with the least delay to commencement of appropriate treatment. The average duration of illness at the time of presentation was 6 days. Prior medical care had been sought in 65% of the cases, with antibiotics prescribed for an alternate diagnosis in 73%. Children with and without cardiac anomalies were equally represented. Of the group with normal cardiac anatomy, 45% presented without a murmur. Staphylococcus aureus was the most frequent causative organism (43%) and accounted for 64% of cases in children with no pre-existing cardiac abnormalities. Permanent sequelae were more likely to occur with S. aureus. The overall mortality rate was 9%. CONCLUSIONS: Infective endocarditis is a rare illness in children and represents a diagnostic challenge. The majority of cases will present via the paediatric emergency department with a non-specific febrile illness, having frequently commenced antibiotics for an alternate diagnosis. Specific expertise in paediatric emergency care can assist in early diagnosis and management. Morbidity remains significant, particularly in cases caused by S. aureus.
The epidemiology, and clinical and microbiological spectrum, of infective endocarditis (IE) in Greece was analysed in a prospective 4-year study in a tertiary hospital and a heart surgery centre in Athens. In total, 101 cases of IE (71 men, 30 women, aged 54.4 +/- 17.1 years) were studied, with a follow-up period of 3 months. Seventy-seven cases were definite and 24 possible; 59 involved native valves (native valve endocarditis; NVE), 31 prosthetic valves (prosthetic valve endocarditis; PVE), of which nine were early and 22 late, and 11 permanent pacemakers (pacemaker endocarditis; PME). There was a predominant involvement of aortic (48/101) and mitral (40/101) valves. Seven patients had rheumatic valvular disease, two had mitral valve prolapse, and eight had a previous history of IE. Thirteen and six patients had undergone dental and endoscopic procedures, respectively. In 13 patients, intravenous catheters were used within the 3 months before diagnosis of IE. There were three intravenous drug users among the patients. Staphylococcus aureus was the most important pathogen, isolated in 22% of cases, followed by viridans streptococci (19%) and coagulase-negative staphylococci (16%). Enterococcus spp. were responsible for 3%, HACEK group for 2%, and fungi for 6% of cases. Viridans streptococci were the leading cause of NVE (29%), Staphylococcus epidermidis of PVE (16%), and S. aureus of PME (54.5%). Six of 22 S. aureus and ten of 16 S. epidermidis isolates were methicillin-resistant. Surgical intervention, including total pacemaker removal, was performed in 51.5% of patients. Overall mortality was 16%, but was 29% with PVE, and was significantly higher with medical than with combined surgical and medical therapy (24.5% vs. 8%). Compared with previous studies, there were changing trends in the epidemiology, microbiology, treatment and prognosis of IE in Greece.
Investigations performed over the last few years support the invaluable usefulness of transesophageal echocardiography in the diagnosis of left-sided endocarditis. Whether this can be applied to right-sided endocarditis remains speculative. Patients at risk of having right-sided endocarditis can be classified into three different and well-defined groups: (1) intravenous drug abusers; (2) patients with pacemakers; and (3) patients with congenital heart diseases. In this article, we review the different value of transesophageal echocardiography in right-sided endocarditis depending on the subset of patients considered.
The jet lesions of valvular regurgitation or intracardiac shunts have been hypothesized to play an important role in the pathogenesis of endocarditis for many years. We describe a case of mitral valve endocarditis that involved the left atrium along the path of a jet lesion. This resulted in atrial endocarditis and pericarditis, both of which complicated her presentation and hospital course. Using transesophageal echocardiography, we were able to directly visualize the path and full extent of infection prior to surgery. Special attention should be focused upon the path of eccentric jets in order to fully define the extent of endocarditis.
Bacterial endocarditis of the mitral valve appears to be much less common than bacterial endocarditis of the aortic valve. One of the main etiologic factors is the presence of degenerative lesions of the mitral apparatus, ballooning or mitral floppy valve. The surgical anatomy of the lesions is described: vegetations, perforations, rupture of chordae tendinae, abscess of the mitral ring observed in the isolated mitral endocarditis, mitral-aortic dislocation, abscesses and aneurysms of the mitral-aortic fibrosa and jet lesions on the anterior mitral leaflet. In the isolated primitive mitral infective lesions, all the technical skills are directed toward the prevention of the perivalvular leakage of the prostheses. Special procedures are described for the management of the abscesses of the mitral ring. In patients with mitral-aortic lesions, the main problem is treatment of the dislocation of the annuli or aneurysms of the mitral-aortic fibrosa. Despite technical advances, the surgical prognosis of the mitral endocarditis remains severe. In a personal series, the authors recorded a mortality of 12% in isolated mitral cases and 42% in the combined mitral-aortic patients. Early surgical treatment remains the most significant factor in decreasing the fatality of such lesions.
Bacterial endocarditis (BE) is a rare and life-threatening heart infection that can be caused by oral microorganisms. Patients with specific cardiac valvular abnormalities as well as those with a history of recurrent episodes of endocarditis are considered to be at high-risk for developing BE. Antibiotic prophylaxis is recommended for high-risk individuals when bleeding is anticipated during dental procedures. Penicillins are the antibiotics of choice in preventing endocarditis, while other medications are indicated for patients with penicillin allergies. This case presentation outlines antibiotic prophylaxis prior to restorative care for a 44-year-old man who had a prosthetic heart valve, history of recurrent infective endocarditis and penicillin allergy. Intravenously administered vancomycin and gentamicin were prescribed due to the patients' level of risk and bleeding propensity. This article was written to raise the awareness of dental practitioners to the antibiotic prophylaxis options available for the treatment of patients with cardiac and associated systemic conditions.
A 42-year-old male was admitted to our hospital because of high grade fever on October 6, 1992. He had no history of cardiac and underlying disease. For the past 10 days, he had complained of high grade fever and noticed arthralgia on his left shoulder. Physical examination on admission revealed that there was a body temperature of 39.0 degrees C and tenderness in the left shoulder. There were no abnormal findings for the chest or abdomen. On the second hospital day, he developed a diastolic murmur which had not been present on admission. And blood culture was positive for Streptococcus agalactiae. Ultrasonic-cardiogram indicated the presence of vegetation. He was diagnosed as infective endocarditis and treated with PCG 20 million units/day, IPM/CS 2 g/day and ISP 400 mg/day. But he was not responding to the chemotherapy. Aortic valve replacement was done on 22nd, October. Valve surgery succeeded and he became well after that time. Endocarditis caused by S. agalactiae is extremely rare, and is an important condition which carries a high mortality. Only seven cases of S. agalactiae endocarditis have been reported in Japan. It is difficult to treat these cases with antibiotic therapy alone. Therefore, we suggest that early surgery should be considered in infective endocarditis caused by S. agalactiae.
We report four cases of infective endocarditis due to nutritionally variant streptococci (NVS) that occurred between 1981 and 1991. Three female and one male patients had underlying heart diseases. Causative organisms showed satellitism to staphylococci. Two strains were identified as S. adjacens and the other two were identified as S. defectivus by DNA-DNA hybridization. All strains had tolerance and one strain had resistance to benzylpenicillin (MIC 4 micrograms/ml). This penicillin-resistant strain also had tolerance to gentamicin. There was no synergism of benzylpenicillin and gentamicin against this strain by a killing curve in vitro. A 11-year-old female patient with infective endocarditis due to this strain, who had a transposition of great arteries, had large vegetations in external conduits by the Rastelli's operation. Some intensive antimicrobial chemotherapies were unsuccessful and a surgical replacement of the conduits must be done in this case. Since infective endocarditis due to NVS is not rare in Japan, NVS should be considered for the causative organisms in culture negative endocarditis.