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PubMed1994

Bacterial endocarditis and septic arthritis presenting as polymyalgia rheumatica.

We describe a case of enterococcus endocarditis in a 74-year-old woman with hypercholesterolemia, porcine aortic valve, and osteoarthritis. She presented with the abrupt onset of severe back pain, proximal myalgia, and left knee synovitis, associated with an anemia and marked elevation of ESR. She was misdiagnosed as having polymyalgia rheumatica until both the synovial fluid and blood cultures grew enterococcus. Her musculoskeletal symptoms totally resolved with antibiotic treatment. Septic arthritis is a rare manifestation of bacterial endocarditis. However, one-third of all cases of bacterial endocarditis have musculoskeletal symptoms. These include backache, arthritis of the peripheral joints, and diffuse myalgia and arthralgia. Unexplained rheumatic complaints should alert us to the possibility of bacterial endocarditis.

Aged↗
PubMed1993

[Surgery of endocarditis in the drug dependent and HIV patient. A prospective comparison with conservative treatment].

The incidence of infective endocarditis in drug addicts is increasing with the spreading of intravenous drug abuse. The tricuspid valve is the most commonly involved valve followed by the mitral valve. We evaluated prospectively 22 patients with a mean age of 23 years, presenting with addiction-associated endocarditis endocarditis and referred to our institution during a three-year period. The tricuspid valve was involved in 13 instances, mitral valve in 4, mitral plus tricuspid valve in 5 patients and aortic valve in 1 case. Staphylococcus aureus was the most frequent infective organism (15x), followed by Streptococci (4x), Corynebacteria (2x) and one case with a mixed infection. Six patients were positive for an HIV-infection and 17 had evidence for a chronic viral hepatitis. Ten patients (3 of them HIV-seropositive) were treated surgically. Resection of the tricuspid valve with (1x) or without replacement (4x), resection of vegetations and valve repair (2x), mitral valve replacement (2x), aortic valve replacement (1x) were performed. In case of tricuspid endocarditis, the decision whether to proceed with resection, repair or replacement with a bioprosthesis was taken according to valve pathology and the psycho-social situation of the patient. When the vegetations involved only one leaflet and could be removed easily, vegetectomy with annuloplasty or with repair using autologous pericardium was performed. Valvulectomy without replacement was the chosen method for those where persistent or recurrent drug abuse could not be excluded. A bioprosthesis was inserted when the tricuspid valve was completely destroyed and there was a proven abstinence from drugs over a period of several weeks preoperatively.(ABSTRACT TRUNCATED AT 250 WORDS)

AIDS-Related Opportunistic Infections↗
PubMed1993

[Endocarditis caused by non-diphtheriae Corynebacterium. Presentation of 12 cases and review].

BACKGROUND: Corynebacterium is known as a pathogen for man, particularly C. diphtheriae, while other species may cause disease and particularly cardiac valve infection, mainly in immunosuppressed patients, intravenous drug addicts, valve prosthesis carriers, patients with previous valvular disease, with congenital heart diseases or those submitted to cardiothoracic surgery. METHODS: Seven episodes of endocarditis due to Corynebacterium no diphtheriae among six patients admitted to our hospital between 1989 and 1992 are analyzed. RESULTS: The mitral valve was often affected with a predominance of incidence in the native valve. Four cases were cured with antibiotic therapy and in three patients surgical valve replacement was required. Recurrence of endocarditis was observed in one of the patients. One case of mycotic cerebral aneurysm and one intracranial hemorrhage are complications of note. One of the patients had undergone kidney transplantation being the first case described with endocarditis by C. no diphtheriae in this subset of patients. Transesophageal echocardiography was the principal diagnostic measure. CONCLUSIONS: The increase in the number of immunosuppressed patients (organ transplantations and acquired immunodeficiency syndrome) and prosthesis carriers wake advisable that these microorganisms be taken into account as etiologic agents of infectious endocarditis.

Adult↗
PubMed1976

Antibiotic synergism in enterococcal endocarditis.

The recognition of enterococci highly resistant to streptomycin (S) raises questions concerning the choice of aminoglycoside in treatment of enterococcal endocarditis. Left-sided endocarditis was induced in rabbits with an S-sensitive enterococcus, strain 1 (inhibited by 125 mug per milliliter S), and an S-resistant enterococcus, strain 2 (resistant to 7,500 mug per milliliter S). Treatment was initiated 6 hours, 24 hours, or 3 days after infection with procaine penicillin (P) alone, P plus S, P plus gentamicin (G), or P plus sisomicin (Si). In rabbits infected with strain 1 for 6 hours before treatment, most vegetations were sterile after 3 days therapy with each combination but not with P alone which had mean log10 colony forming units per gram of vegetation (log CFU) of 2.5. With strain 2 the log CFU were lower (1.9 to 2.6) with each combination than with P (4.0). In rabbits infected with strain 1 for 24 hours and then given 9 days of therapy, the log CFU were decreased with each combination (2.0 to 2.3) as compared with P alone (4.9). With strain 2 the log CFU were lower with P plus G or Si (1.5 and 2.5) than with P alone or P plus S (4.5 AND 4.1). In rabbits infected with strain 1 for 3 days and then given 7 days of therapy, the log CFU were 4.1 to 5.5 with each combination and 6.7 with P. With strain 2 the log CFU was 4.0 with P plus G or Si as compared with 6.4 and 6.7 for P or P + S. These studies showed little difference between the 3 antibiotic combinations with the S-sensitive enterococcus or in early (6-hour) endocarditis caused by the S-resistant enterococcus. There was a large advantage of P plus G and P plus Si over P + S in more established (24 hour or 3 day) endocarditis caused by the S-resistant enterococcus.

Animals↗
PubMed1994

Bacterial endocarditis in patients with chronic liver disease.

OBJECTIVE: Although patients with cirrhosis have an increased susceptibility for bacterial infections, endocarditis complicating cirrhosis has been reported only infrequently. In this study, our objective was to determine whether, bacterial endocarditis is, in fact, a complicating factor in cirrhosis. METHODS: We retrospectively studied all cases of bacterial endocarditis that occurred over the last 15 yr in patients with known cirrhosis. RESULTS: Ten patients (three males, seven females) were identified, whose mean age was 55 yr (range 29-65 yr). Bacterial organisms included Staphylococcus aureus, coagulase-positive (eight patients), Peptostreptococcus (one patient), and Enterococcus (one patient). Underlying liver disease consisted of alcoholism (five patients), autoimmune chronic active hepatitis (two), cryptogenic cirrhosis (two), and primary biliary cirrhosis (one). Distribution of heart valves affected were mitral valve (six), aorta (two), and there were two involving both mitral and aortic valves. Echocardiograms revealed vegetation in 50% of the patients. Laboratory studies were markedly abnormal, with mean values of albumin 2.4 mg/dl, creatinine 2.5 mg/dl, BUN 76.5 mg/dl, and total bilirubin 8.2 mg/dl. Potential associated sources of infection were upper gastrointestinal bleeding (four), pneumonia (two), and one each of spontaneous bacterial peritonitis, hip replacement, heart catheterization, and abdominal abscess. The outcome was poor, with death in eight of 10 patients. CONCLUSIONS: Bacterial endocarditis may complicate cirrhosis, may be more frequent in females, typically involves the mitral valve, and probably is due to Staphylococcus aureus.

Adult↗
PubMed1994

Surgical treatment of active infective endocarditis with paravalvular involvement.

Aortic root infection remains a challenging problem in the surgical treatment of both native and prosthetic valve endocarditis. Between 1980 and 1991, 73 patients with active aortic valve endocarditis and paravalvular infection underwent operation. Indications for operation included congestive heart failure and uncontrolled sepsis. Aortic root abscesses were located in the noncoronary anulus or in the aorticomitral junction in 45% of cases, followed by the subannular interventricular septum in 23%. Two patients had an aorticoatrial fistula, seven an interventricular septal defect. Total or partial left ventricular-aortic dehiscence was observed in 27 patients. All patients underwent aortic valve replacement, nine with simultaneous mitral valve operations. Two of the latter required patch reconstruction of the destroyed aorticomitral septum with double valve replacement. Reconstruction of the aortic base was possible in 16 patients, whereas in 12 total replacement of the aortic root was necessary. In one patient, supracoronary aortic valve replacement was used. Recently, topical application of antibiotics in fibrin sealant was used in 25 patients. The operative mortality rate was 21% and correlated to preoperative uncontrolled sepsis and the presence of extensive root destruction. Operation for active endocarditis of the aortic root requires radical, individualized techniques and results in an acceptable operative and long-term risk. The use of an antibiotic fibrin compound appears to be a useful prophylactic tool to prevent postoperative residual endocarditis.

Abscess↗
PubMed1993

Review of patients with infective endocarditis of native valves over a five-year period.

The clinical characteristics, echocardiographic features, bacteriologic data, morbidity and mortality of patients who were admitted to our hospital with infective endocarditis of their native valves over a five-year period were reviewed. There were 32 patients with a mean age of 38.2 +/- 16.2 years (range: 17 to 71 years) in our study population; 24 patients had underlying valvular abnormalities, six patients had congenital heart disease and two patients had no structural cardiac abnormality. Echocardiography was performed for all patients. Vegetations were absent in three (9.4%) patients, single in 19 (59.4%) patients and multiple in ten (31.3%) patients. Of the 24 (75%) patients who had left-sided endocarditis, mitral valve disease was the commonest valvular abnormality (16 patients). Ventricular septal defect was the commonest underlying abnormality in patients with right-sided endocarditis. Blood cultures were positive in 26 (81.3%) patients; the commonest organism was streptococcal (16 or 50% patients). Complications were present in 13 (40.6%) patients, of which eight patients had evidence of embolism, four patients had cardiac failure and one patient had a paravalvular abscess. Four (12.5%) patients died, two as a result of refractory heart failure and two as a consequence of septic embolism. Advances in medicine have resulted in a better outcome for patients with infective endocarditis, however, it remains an important disease with significant morbidity and mortality.

Adolescent↗
PubMed1993

[Infectious endocarditis due to Q fever. A report of 4 new cases].

Q fever (Coxiella burnetii) is an uncommon cause of culture-negative infective endocarditis. Four cases of Q fever endocarditis diagnosed at our hospital in the last 7 years are reported (8% of all infective endocarditis). Infection involved a prosthetic heart valve in 3 cases (15% of all prosthetic valve endocarditis), and one patient with single ventricle and pulmonary stenosis in the remaining case. Important complications developed in all cases, and 3 patients underwent cardiac surgery. Mortality was 50%. Some diagnostic and therapeutical aspects of this disease are discussed.

Adult↗
PubMed1993

[Endocarditis due to penicillin-sensitive and -resistant pneumococci: the current perspectives on the disease].

BACKGROUND: To evaluate the clinic characteristics and therapeutic aspects of endocarditis by Streptococcus pneumoniae sensitive and resistant to penicillin. METHODS: Twelve cases of pneumococcal endocarditis evaluated in 4 Spanish hospitals over the last 10 years were studied, analyzing their clinical characteristics and the existence of resistance to penicillin. The features were compared with a series of 98 cases found in a review of the literature. RESULTS: All the patients were males, most being alcoholics. The course of the disease was acute (2 weeks) in all the cases and evolved with great aggressivity: cardiac failure (9 patients), myocardial abscess (7 patients), multiple arterial embolisms (5 patients), septic arthritis (4 patients). Three patients had simultaneous pneumococcal meningitis but only one had pneumonia. The valve most affected was the aortic (9 cases). Three cases were due to strains of Streptococcus pneumoniae with moderate resistance to penicillin (CMI 0.5-1 micrograms/ml). Global mortality was 42%. All the patients receiving inadequate antibiotic treatment died. Vancomycin and cefotaxime appear to be effective in the treatment of cases produced by strains of pneumococcus with intermediate sensitivity to penicillin. There were no apparent differences in mortality between the cases of endocarditis by pneumococcus sensitive or moderately resistant to penicillin. CONCLUSIONS: Pneumococcal endocarditis continues to condition a high mortality similar to that produced in previously made series. The classic relation with meningitis and pneumonia is infrequent today. The appearance of strains resistant to penicillin may increase the incidence of this infection and further worsen prognosis.

Adult↗
PubMed1993

Staphylococcus aureus bacteremia and endocarditis. New diagnostic and therapeutic concepts.

Staphylococcus aureus is an important and prevalent cause of both uncomplicated bacteremia, as well as endocarditis. This article addresses the following controversial strategies: diagnosis of endocarditis in staphylococcemic populations; optimal treatment strategies for right-sided and left-sided S. aureus endocarditis; use of echocardiography in S. aureus endocarditis; and therapy options for catheter-associated staphylococcemias.

Bacteremia↗
PubMed1993

Ceftriaxone and outpatient treatment of infective endocarditis.

There are a total of 8000 cases of infective endocarditis yearly in the United States. Central nervous system metastatic infections are not uncommon in infective endocarditis. Because ceftriaxone is highly bound to serum proteins, there is concern that the drug is highly bound to serum proteins, there is concern that the drug might not penetrate well in the core of an infected vegetation. To date, there are two published studies on the treatment of nonenterococcal streptococcal endocarditis by ceftriaxone in humans. Ceftriaxone appears to be an attractive alternative antibiotic therapy to conventional regimens in the treatment of streptococcal endocarditis.

Ambulatory Care↗
PubMed1993

[Prosthetic valve endocarditis after double valve replacement].

This is a report of a patient who underwent re-AVR due to prosthetic valve endocarditis after double valve replacement (MVR, AVR). A 54-year-old female was admitted to other hospital on April 14, 1990, because of high fever, progressive anemia, and cardiomegaly. The patient was hospitalized to our department urgently with the diagnosis of prosthetic valve endocarditis. Arterial blood culture grew methicillin-resistant Staphylococcus epidermidis. Echocardiography showed a vegetation at the disc of the mechanical valve in the mitral position, but we could not find any vegetation or thrombus there at the reoperation, and the aortic mechanical valve seemed to be intact. Signs of inflammation continued to be positive after reoperation. On the 33rd hospital day, a diastolic murmur was heard, and emergency cardiac catheterization was done. Detachment of the prosthetic aortic valve and rupture of the sinus of Valsalva due to mycotic aneurysm, and the dissection of the aorta had occurred. We performed re-AVR and replacement of the ascending aorta. The patient died of multiple organ failure following drug-induced hepatic failure. It is suggestive that we missed the prosthetic aortic valve endocarditis during the reoperation. Our thoughts and introspections on the echocardiographic diagnosis of the prosthetic valve endocarditis after double valve replacement were discussed.

Aneurysm, Infected↗
PubMed1993

The unsuspected complications of bacterial endocarditis imaged by gallium-67 scanning.

In this case report, we present a patient with bacterial endocarditis who was evaluated by 67Ga imaging for persistent fever despite treatment with multiple intravenous antibiotics. Although evidence of bacterial endocarditis was absent with 67Ga imaging, the study demonstrated findings that represent complications of bacterial endocarditis. The procedure demonstrated moderate pericardial uptake of isotope and thus provided the first evidence of pericarditis which was later confirmed at surgery. The study also demonstrated mildly increased activity in the vicinity of the aortic root and right atrium. A sinus of valsalva abscess, complicating the underlying diagnosis of bacterial endocarditis, was found and treated with surgery and antibiotics. At autopsy 4 wk later, a persistence sinus of valsalva abscess was found which extended into the right atrium.

Abscess↗
PubMed1996

[Infective endocarditis in 100 patients subjected to heart transplantation].

PURPOSE: An analysis of occurence, etiology, clinical aspects and death rate of infectious endocarditis cases involving patients who underwent heart transplantation. METHODS: 100 consecutive heart transplant patients were analysed; follow-up varied from three to 90 (medium of 25.38, SD +/- 27.97) months. Diagnostic criteria for endocarditis were those of the epidemiology and quality control service, Heart Institute, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, that agree with those of the Center for Disease Control. Diagnosis was established mostly by blood cultures, echocardiograms, either transthoracic or esophageal and autopsy. RESULTS: Six cases of endocarditis were recognized, with four deaths; in three of those we found severe systemic compromise. All cases had fever as an important symptom. CONCLUSION: Death risk seems high of infectious endocarditis after heart transplantation. The cause of this high risk appears to be linked to the bacteria themselves, to association with other clinical situations and to the use of immunosuppresive agents. We recommend a high index of suspition when risk factors are present in order to make a rapid diagnosis soon enough in the natural history of the disease; treatment has to be started as soon as possible.

Adolescent↗
PubMed1996

[Pulmonary valve replacement for endocarditis. Apropos of 2 cases].

The authors report two cases of pulmonary valve endocarditis which required emergency surgical treatment. A 74 year old patient with trivalvular endocarditis (pulmonary, aortic, mitral), due to Sptreptococcus D bovis, developed cardiogenic shock with acute pulmonary oedema and underwent double aortic and pulmonary valve replacement with Carpentier-Edwards prostheses and simple resection of a mitral valve vegetation. Another 36 year old drug addict developed isolated pulmonary valve endocarditis due to Staphylococcus aureus infection complicated by pulmonary regurgitation with right ventricular failure and by septic pulmonary embolism with persistent sepsis: he underwent pulmonary valve replacement with a Bravo 300 bioprosthesis. The postoperative course was uncomplicated in both cases, with interruption of the infection and normalisation of the haemodynamic status. The insidious and severe nature of pulmonary valve endocarditis is demonstrated by these two cases, confirming previous reports which have underlined the poor prognosis of this condition. Surgery has been shown to be effective and well tolerated and should be integrated early in the therapeutic strategy, the results being all the better when an aggressive attitude is taken.

Adult↗
PubMed1996

Infective endocarditis of the tricuspid valve in an orthotopic heart transplant recipient.

A 43-year-old orthotopic heart transplant recipient had coagulase-negative staphylococcus endocarditis 26 weeks after the operation. A diagnosis of endocarditis was confirmed and followed up by serial transoesophageal echocardiography. Treatment with intravenous gentamycin and vancomycin cured her endocarditis, and a 2.5 cm vegetation regressed significantly. She has been well since and, at 14 months after transplantation, was back to her normal activities. Although repeated blood culture yielded only intermittent light growths of coagulase-negative staphylococci, there were several positive samples. In a setting of infective features, light growths of coagulase-negative staphylococcus should be taken seriously if repeatedly positive in heart transplant recipients or other immunocompromised patients. Transesophageal echocardiography offers significant advantages over the transthoracic modality in suspected endocarditis.

Adult↗
PubMed1996

Mitral valve reconstruction for active and healed endocarditis.

BACKGROUND: Mitral valve reconstruction rather than replacement for mitral insufficiency offers a number of well-accepted benefits. However, the feasibility and results of reconstruction for endocarditis remain largely unknown. METHODS AND RESULTS: We reviewed 22 consecutive patients referred to the Thoracic Surgical Service at the University of Michigan from January 1, 1991, through October 1, 1995, who underwent mitral valve reconstruction for mitral insufficiency caused by isolated mitral valve endocarditis. Mean age, preoperative ejection fraction, and New York Heart Association (NYHA) functional class were 53 +/- 15 years, 54 +/- 12%, and 3.2 +/- 0.8, respectively. Seven patients had early operation because of septic embolization, persistent infection, or refractory heart failure. Fifteen were cured of infection and were operated on for progressive symptomatic heart failure and left ventricular dilation. Preoperative transesophageal echocardiograms demonstrated severe mitral insufficiency in 20 patients. Valvular pathology noted at operation included annular (6 patients) or leaflet calcification (2), chordal rupture (13), leaflet vegetations (11), annular abscess (3), annular dilation (18), flail leaflet (12), leaflet prolapse (17), chordal shortening (1), and mitral stenosis (1). Mitral valve reconstruction included debridement of infected tissue and implantation of an annuloplasty ring (20 of 22 patients), as well as other complex techniques. Postrepair transesophageal echocardiograms demonstrated mild mitral insufficiency in 6 patients and none in 16 patients. There were no operative or in hospital deaths. Mean follow-up was 20 +/- 14 months. One late death occurred at 30 months. At follow-up, 90% of surviving patients were in NYHA functional class I or II. CONCLUSIONS: Mitral valve reconstruction for active or healed endocarditis can be performed with low operative morbidity and mortality and yields excellent functional results. Although longer-term follow-up is mandatory, these data support strong consideration of mitral valve reconstruction rather than mitral valve replacement for mitral insufficiency secondary to endocarditis.

Adult↗
PubMed1996

[Endocarditis in patients with endocardial catheters; role of transesophageal echocardiography for its detection (report of 4 clinical cases)].

UNLABELLED: To evaluate the usefulness of transesophageal echocardiography in the diagnosis of patients with non-prosthetic intracardiac material and clinical suspicion of endocarditis. A brief review of the literature was also made. PATIENTS: All the clinical cases of patients with febril syndrome, clinical suspicion of endocarditis and non-prosthetic intracardiac material who were referred to our Department of Echocardiography for an echocardiographic examination - transthoracic and transesophageal approach. RESULTS: Four patients were found from our revision, three of them had a permanent endocavitary pacing catheter and one had a central venous catheter. Transthoracic echocardiography confirmed the diagnosis in three patients, but did not provide accurate information in two cases due to deficient acoustic window. Transesophageal echocardiography confirmed the clinical suspicion of endocarditis in all four patients and gave more information about the size and site of vegetations, involvement of cardiac valves and existence or absence of abcesses. CONCLUSIONS: Transesophageal echocardiography improves the diagnosis of right heart endocarditis in patients with non-prosthetic intracardiac material providing more accurate information, sometimes with prognostic and therapeutic importance.

Adult↗