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PubMed1994

Osteomyelitis and infective endocarditis.

Osteomyelitis is thought to occur as a complication of infectious endocarditis in as many as 6% of cases of endocarditis. We describe this association in three patients. Osteomyelitis may be difficult to diagnose in patients with endocarditis because symptoms such as fever, bone pain and stiffness are common to both illnesses, therefore physicians need to have a high index of suspicion to avoid missing this important complication. We recommend that patients with endocarditis and persistent or localized musculoskeletal symptoms should be investigated to exclude osteomyelitis. Plain radiographs can be normal in 50% of cases of osteomyelitis in the early stages or show only minor abnormalities, but bone scans are highly sensitive. We suggest that a bone scan is performed if radiography is unhelpful, since a diagnosis of osteomyelitis can effectively be excluded if the bone scan is normal. We advocate close follow-up of these patients with prolonged antibiotic treatment consisting of at least 6 weeks of intravenous therapy, and 3 months or longer of oral therapy.

Administration, Oral↗
PubMed1999

Aetiology and outcome in 53 cases of native valve staphylococcal endocarditis.

Within the last 30 years the profile of infective endocarditis has altered considerably with regard to microbiological causation, clinical features, and natural history. A contributory factor has undoubtedly been the development of potent antibiotics and their sometimes indiscriminate use. The increase in intravenous drug abuse in urban centres, the use of immunosuppressive agents, and the use of prosthetic heart valves have also all contributed. Although cardiac surgery in the uninfected heart provides a perfect environment for infective endocarditis, the improved design of prosthetic valves and the enhanced long-term survival and decreased immediate operative risk, means that surgery is viewed as the best option in many cases. In a series of 53 cases of staphylococcal endocarditis from a national endocarditis survey, those risk factors which influenced outcome were analysed. Thirty out of 53 patients had predisposing heart disease. Mortality was 39.6%. Statistical analysis revealed that attributable mortality was significantly associated with skin infection, systemic embolisation, and inappropriate therapy. Interestingly, surgical treatment was associated with better outcome.

Anti-Bacterial Agents↗
PubMed1997

Infective endocarditis caused by HACEK microorganisms.

The HACEK group of fastidious gram-negative organisms is a recognized but unusual cause of infective endocarditis, responsible for approximately 3% of cases. We report our experience with 45 cases of endocarditis caused by HACEK organisms. In Olmsted County, Minnesota, the incidence of HACEK endocarditis was 0.14 per 100,000 person-years. In patients with native valves, 33 cases occurred, and in patients with prosthetic valves, 12 cases occurred. The most common presenting symptoms were fever, splenomegaly, new or changing murmur, and microvascular phenomena. Symptoms were present in the majority of patients anywhere from two weeks to six months prior to diagnosis. Blood cultures became positive in a mean 3.375 days, and therapy with a beta-lactam alone or as part of a combination was given for anywhere between three and six weeks. Within the first month of diagnosis, surgery was performed for 13 regurgitant valves in 11 patients (24%). Echocardiography was an insensitive predictor of subsequent major arterial embolization (odds ratio, 1.33; 95% confidence interval, 0.31-5.67). The overall survival in our cohort of patients was 87%. These results confirm previous reports that HACEK endocarditis portends a favorable prognosis.

Adult↗
PubMed1984

Aortic root abscess resulting from endocarditis: spectrum of angiographic findings.

Abscesses in the aortic root are a serious complication of infective endocarditis and require accurate diagnosis for antibiotic and surgical management. Nineteen cases of endocarditis of a native valve or prosthetic valve and adjacent abscess cavities were identified with angiography. Of 6 patients with endocarditis of a native valve, 5 had bicuspid aortic valves and all had severe aortic regurgitation. Of 13 patients with endocarditis of a prosthetic aortic valve, all had paravalvular regurgitation. Abscesses in the aortic root were saccular, ranged from 1 to 3 cm in diameter, and, depending on sinus of origin, extended beneath the main and right pulmonary arteries or into the interventricular septum or mitral anulus. Fistulas were detected into the mitral anulus in 8 patients, and into the right ventricle in 3 patients. No complications from the catheterization were recorded during the 48-hour follow-up.

Abscess↗
PubMed1999

Staphylococcus lugdunensis pulmonary valve endocarditis in a patient on chronic hemodialysis.

We describe a case of Staphylococcus lugdunensis pulmonary valve endocarditis in a 65-year-old woman on chronic hemodialysis and provide a review of previously reported cases. The patient presented with fever and altered mental status, but had no other localizing symptoms or signs; coagulase-negative staphylococcus (subsequently identified as S. lugdunensis) was isolated from two sets of blood cultures. Transthoracic and transesophageal echocardiograms showed a large (2.3 x 3.1 cm) vegetation on the pulmonary valve with moderate valvular insufficiency. The patient was treated with 6 weeks of antibiotic therapy and is stable 4 months following the completion of therapy; no surgical intervention was performed. Of the 28 previously reported cases of S. lugdunensis endocarditis, only 1 had previously survived with medical therapy alone. This is the 3rd case report of S. lugdunensis endocarditis in a patient on hemodialysis; the presumed portal of entry in this and previously reported cases was the vascular access device. Endocarditis due to this organism is characterized by a high mortality, rapid tissue destruction, and a predilection for native valves. Because the clinical outcome is much more favorable with valvular replacement, speciation of the organism assumes great importance in defining the therapeutic approach.

Aged↗
PubMed2005

Long-term results of mitral valve repair in active endocarditis.

BACKGROUND: Several investigators have reported the feasibility of mitral valve repair in active endocarditis, but the long-term results are still unknown. METHODS AND RESULTS: We reviewed 37 consecutive patients who underwent mitral valve repair with the Carpentier technique for active endocarditis in our center between 1989 and 1994. This repair involved prosthetic annuloplasty in 31 patients (84%), valve resection in 31 (84%), chordal shortening or transposition in 19 (51%), pericardial patch in 16 (43%), and direct suture of leaflet perforation in 4 (11%). Associated procedures were primarily aortic valve repair or replacement in 11 (30%) and tricuspid repair in 2 (6%). Early complications included 1 operative death (3%; 95% CI, 0 to 15.5) and 1 reoperation for pericardial patch dehiscence. Recurrence of endocarditis was observed in 1 patient (3%; 95% CI, 0 to 16). The 10-year survival rate and freedom from mitral valve reoperation were 80% (95% CI, 66 to 94) and 91% (95% CI, 81 to 100), respectively. At 10 years, most patients (96%) were in good functional status (NYHA class I to II) with no or trivial mitral regurgitation (92%) on echocardiography. CONCLUSIONS: Mitral valve repair using Carpentier's techniques in patients with active endocarditis offers very good long-term results with a low rate of recurrence or reoperation.

Adolescent↗
PubMed1978

Technetium-99m stannous pyrophosphate imaging of experimental infective endocarditis.

Technetium-99m stannous pyrophosphate (99mTc-PYP) cardiac scintigraphy was performed in 15 rabbits with experimental Streptococcus sanguis aortic valve infective endocarditis. The animals were imaged five to seven days after the administration of bacteria, and in each case abnormal accumulation of the tracer was visualized in the region of the aortic valve. Three types of cardiac scintigraphic patterns were demonstrated: focal, multifocal and extensive, each correlating well with the anatomical extent of the lesion as defined by gross pathology. Tissue distribution studies demonstrated a 30 +/- 5.3 (mean +/- SEM) fold excess of radionuclide uptake in the infective endocarditis lesion compared with that of normal myocardium. Imaging of excised hearts from four animals showed an excellent correlation with in vivo imaging as well as gross pathology. Five animals with nonbacterial thrombotic aortic valve endocarditis demonstrated similar scintigraphic and tissue distribution results. In contrast, four normal animals failed to demonstrate abnormal 99mTc-PYP cardiac scintigrams or tissue uptake. This study demonstrates that 99mTc-PYP cardiac scintigraphy is a sensitive technique to detect experimental aortic valve endocarditis.

Animals↗
PubMed1985

Uptake of hematoporphyrin derivative by valvular vegetations in experimental infective endocarditis.

Drugs that localize in valvular vegetations may be useful in the diagnosis and treatment of infective endocarditis. We therefore tested the hypothesis that parenterally injected hematoporphyrin derivative (HPD), which is concentrated in tumors and atherosclerotic plaques, localizes in the vegetations of experimental infective endocarditis. In 14 rabbits, various bacteria were given intra-arterially immediately after injury to the aortic valve. In 12 additional rabbits, sterile vegetations on the aortic valve were produced by the trauma caused by an indwelling catheter that had been in place over a long period. HPD, 2.5 mg/kg, was injected intravenously 1 to 2 days before the animals were killed in six rabbits with sterile vegetations and in seven rabbits with infected vegetations. In all rabbits, multiple vegetations on the aortic valve leaflets were identified. On exposure to ultraviolet light, strong porphyrin fluorescence of all vegetations, whether sterile or infected, was observed only in rabbits given HPD. In two rabbits given HPD 10 weeks after catheter implantation across the aortic valve, however, only mild fluorescence could be detected in healing endocardial vegetations. In frozen sections of HPD-laden lesions, a patchy distribution of fluorescence was observed that was similar to the pattern of HPD localization in atheromatous plaques. Since vegetations in experimental infective endocarditis selectively concentrate HPD, porphyrins could be useful in the diagnosis and treatment of infective endocarditis.

Animals↗
PubMed1997

Systemic infection related to endocarditis on pacemaker leads: clinical presentation and management.

BACKGROUND: Endocarditis related to pacemaker (PM)-lead infection is a rare but serious complication of permanent transvenous pacing. To determine in which situations the diagnosis should be evoked and to determine optimal management, we reviewed our experience with endocarditis related to PM-lead infection. METHODS AND RESULTS: Fifty-two patients were admitted for endocarditis related to PM-lead infection. The presentation was acute in 14 patients, with onset of symptoms in the first 6 weeks after the last procedure on the implant site, and chronic in 38 patients. Fever occurred in 86.5%. Clinical and/or radiological evidences of pulmonary involvement were observed in 38.4%. Pulmonary scintigraphy disclosed pulmonary infarcts in 31.2%. Local complications were found in 51.9%. Elevated C-reactive protein was found in 96.2%. A germ was isolated in 88.4% of patients and was a Staphylococcus in 93.5%. Transthoracic echocardiography demonstrated vegetations in only 23% of patients, whereas transesophageal echocardiography disclosed abnormal appearances on the PM lead in 94%. We systematically tried to ablate all the material. Two techniques were used: percutaneous ablation or surgical removal during extracorporeal circulation. All patients were treated with antibiotics after removal of the infected material. Two patients died before lead removal and 2 after surgical removal; the predischarge mortality was 7.6%, and the overall mortality was 26.9% after a follow-up of 20.1+/-13 months. CONCLUSIONS: The diagnosis of endocarditis related to PM-lead infection should be suspected in the presence of fever, complications, or pulmonary lesions after PM insertion. Transesophageal echocardiography should be performed to look for vegetations. Staphylococci are involved in the majority of these infections. The endocardial system must be entirely removed and appropriate antibiotic therapy pursued for 6 weeks.

Aged↗
PubMedDate not supplied

Mycotic aneurysm, subarachnoid hemorrhage, and indications for cerebral angiography in infective endocarditis.

We compared the clinical course of 68 patients with infective endocarditis and mycotic aneurysm and 147 patients with infective endocarditis but no mycotic aneurysm. Among the patients with mycotic aneurysm, 57% had subarachnoid hemorrhage without warning. Forty-three percent had a neurologic prodrome 2 days to 18 months (median 17 days) prior to discovery of the mycotic aneurysm. A focal deficit consistent with embolism was the most common prodrome (23%). However, there was no significant difference in the frequency of neurologic symptoms between patients with and without mycotic aneurysm. During an average follow-up of 40 months, there were no instances of subarachnoid hemorrhage/mycotic aneurysm among 121 patients discharged after a full course of antibiotic therapy. Therefore, the risk of rupture of an unsuspected mycotic aneurysm following a full course of antibiotics is low. When a prodrome does precede a mycotic aneurysm, it most often is a focal deficit consistent with embolism. We favor angiography in all patients with infective endocarditis who experience a focal deficit with good recovery. The timing and other indications for angiography in infective endocarditis are discussed.

Adult↗
PubMed1992

Is cerebral angiography indicated in infective endocarditis?

BACKGROUND AND PURPOSE: Patients with infective endocarditis may develop intracranial mycotic aneurysms. Whether these patients should undergo cerebral angiography followed by prophylactic surgery if an aneurysm is detected is an unresolved question. METHODS: We estimated the probability of survival 12 weeks after the diagnosis of infective endocarditis on the basis of data available in the literature. RESULTS: For a 40-year-old female patient with right-sided hemiplegia, the 12-week survival is estimated to be 83.75% without angiography and 83.65% with angiography; the specific mortality of intracranial mycotic aneurysms is relatively small but increases by 40% (from 0.25% to 0.35%) if angiography is performed. The risk of aneurysm rupture in infective endocarditis and the mortality from rupture appear to be the most important factors that affect the analysis. CONCLUSIONS: Cerebral angiography should not be performed routinely in patients with infective endocarditis. Specific subgroups in whom such a policy might be beneficial have not yet been identified.

Adult↗
PubMed1985

Infectious endocarditis caused by Actinobacillus actinomycetemcomitans.

Actinobacillus actinomycetemcomitans is a very uncommon cause of infectious endocarditis. The organism was first described in 1912. Thjotta and Sydnes reported its isolation in pure culture from a long standing abscess which had developed after tooth extraction. Subsequently this organism was found to be part of the normal flora, and the organism was defined as a slow growing, fastidious gram negative bacillus. Carbon dioxide is essential for the growth of A. actinomycetemcomitans. Approximately 50 cases of endocarditis due to A. actinomycetemcomitans have been reported since the first case reported in 1964. The purpose of this report is to document a case of endocarditis due to A. actinomycetemcomitans and to stress the value of the echocardiogram in the assessment of patients with endocarditis.

Actinobacillus↗
PubMed2000

Prosthetic biologic valve endocarditis caused by a vancomycin-resistant (vanA) Enterococcus faecalis: case report.

We recently observed (February 1999) a 68-year old patient with endocarditis on a prosthetic biologic valve caused by a vancomycin-resistant Enterococcus faecalis. Broth dilution tests showed susceptibility to ampicillin (MIC=0.5 microg/ml), no high resistance to aminoglycosides (MIC for gentamicin <500 microg/ml) and resistance to vancomycin (MIC >256 microg/ml) and teicoplanin (MIC >16 microg/ml). A PCR assay detected vanA gene in this strain. A transthoracic echocardiogram did not show valvular vegetations. A possible endocarditis was diagnosed and the patient received ampicillin for 8 weeks and gentamicin for 6 weeks. The patient remained afebrile after a 4-month follow-up when he underwent surgical replacement of the dysfunctional bioprosthetic valve. Mitral valve was sterile on culture, but histology confirmed the diagnosis of previous endocarditis. This is the third case of endocarditis caused by vancomycin-resistant E. faecalis reported to date.

Aged↗
PubMed2006

Successful treatment of Candida parapsilosis mural endocarditis with combined caspofungin and voriconazole.

BACKGROUND: Fungal mural endocarditis is a rare entity in which the antemortem diagnosis is seldom made. Seven cases of mural endocarditis caused by Candida spp. have been collected from literature and six of these patients died after treatment with amphotericin B. CASE PRESENTATION: We report a case of mural endocarditis diagnosed by transesophageal echocardiogram and positive blood cultures to Candida parapsilosis. Because blood cultures continued to yield C. parapsilosis despite caspofungin monotherapy, treatment with voriconazole was added. CONCLUSION: This is the first description of successful treatment of C. parapsilosis mural endocarditis with caspofungin and voriconazole.

Antifungal Agents↗
PubMed2002

Complicated infective endocarditis necessitating ICU admission: clinical course and prognosis.

AIM: To study incidence, clinical course and prognostic factors in patients admitted to medical intensive care units (ICUs) because of a complicated course of infective endocarditis. METHOD: This was a retrospective multicenter observational study of 4106 patients admitted to four medical ICUs in one tertiary hospital and one university hospital between 1994 and 1999. RESULTS: Infective endocarditis was identified in 33 (0.8%) patients. Of these, 26 were male, mean age was 59 +/- 12 and APACHE-III score was 75 +/- 31. Reasons for transfer to the ICU were congestive heart failure in 64%, septic shock in 21%, neurological deterioration in 15% and cardiopulmonary resuscitation in 9%. Inotropes or vasoconstrictors were required in 73% and multiorgan failure developed in 64% of the patients. Prosthetic valve endocarditis was present in 21%. Gram-positive cocci were found in 96% of all positive cultures; cultures were negative in 27% of the patients. Transthoracic echocardiograms were diagnostic in only 33% and transesophageal studies were required in 91% to confirm diagnosis or fully to delineate the extent of disease. Surgical intervention was performed in 60% of the patients, and the remaining 40% were only treated medically. The APACHE-III score on admission did not differ statistically between the two groups (69 +/- 30 versus 84 +/- 34, P = 0.17). In-patient mortality was 84% in patients treated medically, and 35% in surgically treated patients. Using multivariate analysis, acute renal failure on admission was identified as the independent single predictor for in-patient death (OR 5, 95% CI 1.04-24.03, P = 0.04). CONCLUSION: The prognosis for patients with infective endocarditis requiring admission to a medical ICU is serious. Nevertheless, the data suggest that surgical intervention may be successfully performed in a substantial number of patients despite the presence of severe shock and occurrence of multiorgan failure.

APACHE↗
PubMed2006

Mitral valve repair in patients with infective endocarditis.

BACKGROUND: The goal of the present study was to investigate the feasibility of mitral valvle repair in patients with infective endocarditis (IE). METHODS AND RESULTS: Twenty-one patients who had undergone mitral valve surgery for IE were reviewed. Valve repair was performed in 8 patients with active and in 6 patients with healed endocarditis: 6 of these 14 patients were New York Heart Association (NYHA) functional class III or IV preoperatively. Valve replacement was performed in 5 patients with active endocarditis and in 2 with healed endocarditis: 6 of these 7 patients were NYHA functional class III or IV preoperatively. Repair techniques included annuloplasty (n=13), resection-suture (n=13), chordal transfer (n=2), and closure of the perforation (n=3). In the valve replacement group, 6 patients required concomitant aortic valve replacement. In the valve repair group, 1 patient died and 1 patient required reoperation for recurrent mitral regurgitation. Postoperative echocardiography demonstrated no (n=8) or mild (n=4) mitral regurgitation at the last follow-up examination. In the valve replacement group, 1 patient died and 1 patient required reoperation because of a paravalvular leak. No cases of recurrent infection occurred in either group. CONCLUSIONS: Mitral valve repair in patients with IE is feasible and has low morbidity.

Adolescent↗
PubMed1997

Timing of surgical treatment for active native value endocarditis.

The aim of the study was to assess the optimum timing of surgical treatment for the active phase of native valve endocarditis. A retrospective study was conducted of the records of patients who had undergone aortic and/or mitral valve replacement for active native valve endocarditis during 1979-94 at Kinki University Hospital. Thirty-three patients with active infective endocarditis of the native valves were treated surgically. Their mean age was 45.4 years (range 11-71). The infective organism was streptococcus in 9 cases, Staphylococcus aureus in 8, and enterococcus in 4 cases. Blood cultures were negative in 9 cases. Of the patients infected with Staphylococcus aureus, 3 died soon after the operation and 1 died later during hospitalization. These 4 patients had been treated medically more than 2 weeks before operation. Another patient who was also treated medically more than 2 weeks before surgery survived. In contrast, all 3 patients infected with Staphylococcus aureus who were operated on within 2 weeks after the onset survived. No early or in-hospital deaths were documented among patients infected with organisms other than Staphylococcus aureus. Among patients who had suffered preoperative embolic episodes, the time from the initial pyrexia to the embolic event was clearly shorter in those infected with Staphylococcus aureus than in those infected with other organisms. Among the former group, 5 out of 6 patients suffered an embolism within 2 weeks of the onset of pyrexia and the remaining 1 within 3 weeks. Thus, in patients presenting with active native valve endocarditis caused by Staphylococcus aureus, surgical treatment should be performed as soon as possible after the onset of pyrexia, preferably within 2 weeks or as soon as the infective organism is identified as Staphylococcus aureus.

Adolescent↗
PubMed2003

Left ventricular outflow tract-right atrial communication (Gerbode type defect) associated with bacterial endocarditis in a dog.

Left ventricular (LV) outflow tract-right atrial (RA) communication associated with bacterial endocarditis is described in a 6-year-old intact male Great Pyrenees dog with a 4- to 5-day history of fever, lethargy, weight loss, severe regenerative anemia, and asplenia. Typical vegetative mural endocardial lesions were observed grossly. Histologic evaluation revealed small gram-negative coccobacilli that were consistent with Bordetella avium-like organisms. These bacteria were associated with severe endocardial inflammation characterized by neutrophilic infiltration, extensive necrosis of endocardium, and fibrin deposition. LV-RA shunt (Gerbode defect) is a rare cardiac defect in humans that can be either congenital or, more rarely, secondary to septic endocarditis, valve replacement procedures, or thoracic trauma. B. avium-like organisms causing septicemia and endocarditis in immunocompromised and asplenic human patients have been described. To our knowledge, no previous descriptions of Gerbode defect associated with bacterial endocarditis in domestic animals have been reported in veterinary literature.

Animals↗