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PubMed1989

Clostridial endocarditis. Report of a case caused by Clostridium bifermentans and review of the literature.

A case of Clostridium bifermentans endocarditis occurred in a 23-year-old man who was an intravenous drug user. There was no history of preexisting valvular heart disease. He was initially treated with high-dose penicillin G potassium but remained bacteremic for a ten-day period. The bacteremia resolved when the therapy was changed to metronidazole hydrochloride. A review of the 16 reported cases of clostridial endocarditis showed no predisposing host factor to the development of the disease. Penicillin is the treatment of choice for clostridial endocarditis, but metronidazole should be considered as an alternate therapy for treatment that fails.

Adult↗
PubMedDate not supplied

Wegener granulomatosis simulating bacterial endocarditis.

Cardiac involvement in Wegener granulomatosis is uncommon. We report a case of Wegener granulomatosis that presented as culture-negative endocarditis with aortic valvular vegetation. The clinical manifestations included gingival hyperplasia, gangrenous digital infarcts, mononeuritis multiplex, high fever, inflammatory arthritis, pansinusitis, splenic infarct, and aortic valvular vegetation, which underscore the difficulty of distinguishing systemic vasculitis from bacterial endocarditis. Contrary to the common notion that valvular vegetation is invariably associated with bacterial endocarditis, this case proves that such findings can occur in Wegener granulomatosis as well. Clinicians are guided toward early treatment with corticosteroids and cyclophosphamide to prevent fatal complications.

Aortic Valve↗
PubMed1976

Cerebral embolism, marantic endocarditis, and cancer.

Two subjects with cerebral embolism were found at autopsy to have marantic (nonbacterial thrombotic) endocarditis (NBTE) and an unsuspected carcinoma. A additional 16 subjects with marantic endocarditis and cancer were found on reviewing the autopsy records of 22 subjects with NBTE. Of these 18 subjects with NBTE and cancer, eight developed a stroke during their illness, in five as the initial manifestation of cancer. Although the association of cancer and marantic endocarditis is generally well recognized, cerebral embolism from this source should be more seriously considered as one of the "remote effects" of cancer on the nervous system.

Carcinoma↗
PubMed1977

Echocardiographic diagnosis of bacterial endocarditis of the mitral valve in a neonate.

A full-term normal neonate had acute staphylococcal endocarditis. Serial echocardiograms demonstrated abnormal echos in the region of the posterior mitral valve leaflet and aortic outflow tract that were subsequently proved to be a bacterial vegetation. This represents, we believe, the first case reported of the echocardiographic diagnosis of bacterial endocarditis in a neonate. There was progressive functional impairment of the mitral valve despite appropriate antibiotic therapy. At necropsy, a 1-cm vegetation was found attached to, and eroding through, the posterior mitral valve leaflet. The remainder of the heart, including the mitral valve apparatus, was normal. Endocarditis is a rare, but devastating, disease in a neonate, and the echocardiogram is a safe noninvasive method of making an accurate diagnosis and following the course of the disease.

Diagnosis, Differential↗
PubMed1983

Two-dimensional echocardiographic assessment of infective endocarditis in children.

We examined 11 children with infective endocarditis initially and serially by two-dimensional echocardiography. Nine (82%) of the 11 patients had echocardiographic findings at initial examination compatible with infective endocarditis. These results provided strong evidence in support of the diagnosis before bacteriologic confirmation was available. Congestive heart failure, major emboli, and/or the need for surgical intervention occurred in seven of the nine patients with positive two-dimensional echocardiograms. Echocardiographic evidence of vegetations persisted during antibiotic therapy and resolved slowly during many months. Serial echocardiograms were useful in cases in which obvious valve destruction or marked increase in vegetation size imaged echocardiographically could be combined with clinical evidence of progressive heart failure to support a decision for early surgical intervention. Two-dimensional echocardiography can make important contributions to the diagnosis and management of children with infective endocarditis.

Adolescent↗
PubMed1976

Surgical treatment of infective valvular endocarditis.

Infective valvular endocarditis, whether occurring on a native or prosthetic heart valve, continues to carry a serious prognosis. Death is usually due to congestive heart failure, arrhythmia, or embolic complications, rather than infection per se. While antimicrobial therapy and medications to control congestive heart failure continue to be the treatment of choice in most cases, early valve replacement is indicated in certain situations. During the past four years, 12 patients underwent valve replacement for infective endocarditis. Six patients underwent elective valve replacement after antibiotic or antifugal therapy. All survived the operation and were improved. Six other patients underwent emergency valve replacement. Two patients died intraoperatively and their operations, in retrospect, were delayed unnecessarily. Four patients survived and are improved. Prosthetic valve replacement during the course of infective valvular endocarditis should be considered based on indications such as congestive heart failure, rhythm disturbances, etc, rather than the status of the infection.

Adolescent↗
PubMed1981

Bacterial endocarditis in the critically ill surgical patient.

The association of endocarditis with persistent intraperitoneal sepsis and right-sided heat catheterization (Swan-Ganz catheter and central venous catheter) was found in four (27%) of 15 patients with endocarditis identified at the University of Kentucky Medical Center, Lexington, during a 14-year period. These four patients had (1) intra-abdominal abscesses as a persistent source of sepsis, (2) documented septicemia, (3) long-term use of right sided heart catheters, and (4) prolonged hospitalization with a fatal outcome. In each case, endocarditis with persistent septicemia was considered a major factor contributing to a fatal outcome. Identification of a new cardiac murmur associated with septicemia was the most reliable means of diagnosis in these patients. The best form of treatment seems to be prevention by (1) eliminating septic foci, (2) using central catheters for specific indications for as short a period as possible, and (3) promptly discontinuing use of the catheter when septicemia is suspected.

Abscess↗
PubMed1981

Endocarditis complicating home hyperalimentation.

Catheter sepsis remains a persistent, though infrequent, complication of intravenous hyperalimentation (IVH). Those select patients requiring home hyperalimentation delivered through Silastic catheters are subject to this serious problem. Reported in this article is a case of Enterococcus endocarditis of the tricuspid valve in a patient receiving home IVH; the endocarditis was recognized early using two-dimensional echocardiography and was treated successfully with catheter removal and IV antibiotic administration. Ideal conditions exist for the formation of endocarditis in the setting of catheter sepsis with parenteral nutrition. Routine echocardiography is indicated when catheter sepsis is documented, since early diagnosis and treatment may reduce invasive cardiac tissue infection and permanent injury. The right atrial catheter generates reflections during echocardiography that require special attention for accurate interpretation.

Adult↗
PubMed2000

Physicians' recommendations to patients for use of antibiotic prophylaxis to prevent endocarditis.

CONTEXT: The American Heart Association recommendations for infectious endocarditis (IE) prophylaxis, published in June 1997, sought to improve patient and physician compliance by simplifying the dosing regimen and clarifying endocarditis risk. Adherence to these updated recommendations in patients with echocardiographic verification of their endocarditis risk profile is unknown. OBJECTIVE: To determine the recommended and actual use of IE prophylaxis as reported by patients undergoing echocardiography. DESIGN, SETTING, AND PARTICIPANTS: All patients who underwent outpatient transthoracic echocardiography at a university-based tertiary hospital in Boston, Mass, during December 1997 were contacted 6 to 9 months later to respond to a survey, completed by 218 (80%) eligible subjects. MAIN OUTCOME MEASURE: Patients' report of their physicians' instructions on actual use of IE prophylaxis in accordance with patient risk category, determined by echocardiographic data. RESULTS: One hundred eight patients (49.5%) had clinical or echocardiographic findings for which prophylaxis was indicated. Of these 108 patients, 71 (65.7%) reported that they were instructed to take IE prophylaxis. Sixteen high-risk patients (88. 9%) but only 55 moderate-risk patients (61.1%) reported that they were instructed to take prophylaxis. Among the 110 negligible-risk patients, 29 (26.4%) reported that they had been instructed to take IE prophylaxis. Overall, 100 patients (45.9%) reported that they received physician instructions to take IE prophylaxis. Of those who subsequently underwent a procedure for which IE prophylaxis was indicated (n=68), 9 (13.2%) elected not to follow their physician's advice to take prophylaxis. CONCLUSIONS: We found that although most patients reported receiving instructions for IE prophylaxis use consistent with American Heart Association guidelines, IE prophylaxis overuse among negligible-risk patients and underuse among moderate-risk patients was common. Continued physician and patient education may lead to improved adherence to the current American Heart Association recommendations. JAMA. 2000;284:68-71

Antibiotic Prophylaxis↗
PubMed2005

Staphylococcus aureus endocarditis: a consequence of medical progress.

CONTEXT: The global significance of infective endocarditis (IE) caused by Staphylococcus aureus is unknown. OBJECTIVES: To document the international emergence of health care-associated S aureus IE and methicillin-resistant S aureus (MRSA) IE and to evaluate regional variation in patients with S aureus IE. DESIGN, SETTING, AND PARTICIPANTS: Prospective observational cohort study set in 39 medical centers in 16 countries. Participants were a population of 1779 patients with definite IE as defined by Duke criteria who were enrolled in the International Collaboration on Endocarditis-Prospective Cohort Study from June 2000 to December 2003. MAIN OUTCOME MEASURE: In-hospital mortality. RESULTS: S aureus was the most common pathogen among the 1779 cases of definite IE in the International Collaboration on Endocarditis Prospective-Cohort Study (558 patients, 31.4%). Health care-associated infection was the most common form of S aureus IE (218 patients, 39.1%), accounting for 25.9% (Australia/New Zealand) to 54.2% (Brazil) of cases. Most patients with health care-associated S aureus IE (131 patients, 60.1%) acquired the infection outside of the hospital. MRSA IE was more common in the United States (37.2%) and Brazil (37.5%) than in Europe/Middle East (23.7%) and Australia/New Zealand (15.5%, P<.001). Persistent bacteremia was independently associated with MRSA IE (odds ratio, 6.2; 95% confidence interval, 2.9-13.2). Patients in the United States were most likely to be hemodialysis dependent, to have diabetes, to have a presumed intravascular device source, to receive vancomycin, to be infected with MRSA, and to have persistent bacteremia (P<.001 for all comparisons). CONCLUSIONS: S aureus is the leading cause of IE in many regions of the world. Characteristics of patients with S aureus IE vary significantly by region. Further studies are required to determine the causes of regional variation.

Cross Infection↗
PubMed1999

Aortic valve endocarditis caused by Salmonella species.

We report a case of aortic valve endocarditis caused by an uncommon pathogen, Salmonella species. Transthoracic echocardiography proved to be inadequate to show the valvular destruction. Transesophageal echocardiography was instrumental in establishing the diagnosis of endocarditis by documenting aortic vegetations with attendant tissue damage extending beyond the valve leaflets (i.e., subvalvular and perivalvular damage). The findings were anatomically confirmed at surgery, which also revealed an aortic root-right ventricular fistula and several aortic ring abscesses. Early implementation of transesophageal echocardiography is strongly recommended in patients with suspected endocarditis.

Aged↗
PubMed1982

Mid-diastolic aortic valve opening in bacterial endocarditis of aortic valve.

Echocardiographic features of acute aortic regurgitation resulting from bacterial endocarditis have been well documented (Nathan et al., 1980; Weaver et al., 1977; Wray, 1975a), and include thick shaggy echoes from aortic valve in diastole, fine diastolic flutter of aortic valves suggestive of rupture of cusps, and premature closure of mitral valves. Echocardiography being a sensitive noninvasive technique for detecting aortic valve vegetations is heavily relied on for earlier diagnosis and prompt therapy of these patients. Prognosis of echocardiographically positive endocarditis is known to be worse than for echo-negative patients. The following case is being presented because of an unusual echocardiographic manifestation with mid-diastolic aortic valve opening secondary to flail aortic valve from staphylococcal endocarditis of the aortic valve.

Adult↗
PubMed1992

Propionibacterium acnes prosthetic valve endocarditis: a case of severe aortic insufficiency.

Propionibacterium acnes rarely causes systemic disease. Few cases of P. acnes endocarditis have been reported. This report describes a 63-year-old man who presented with severe congestive heart failure. He had prosthetic valve endocarditis which resulted in severe acute aortic insufficiency. During surgery he was found to have complete disruption of the aorta and left ventricle with a false aneurysm encompassing the circumference of the aortic annulus. Cultures of the valve grew P. acnes. Thus, although P. acnes is a rare cause of endocarditis, it may pursue a very aggressive course, especially in the setting of a prosthetic valve.

Aortic Valve↗
PubMed1993

Infective endocarditis due to Fusobacterium nucleatum: case report and review of the literature.

Endocarditis caused by Fusobacterium nucleatum is exceedingly rare. We report a case of F. nucleatum right-sided endocarditis in a patient with no known intravenous drug abuse. A detailed computer and manual search of the literature using Med-Line and Index Medicus, respectively, revealed a total of five cases of endocarditis due to this species. The clinical characteristics and the patient's hospital course are summarized and reviewed.

Dental Caries↗
PubMed1994

A case of Trichosporon beigelii endocarditis 8 years after aortic valve replacement.

We report a case of Trichosporon beigelii endocarditis in a 77-year-old diabetic man who presented with an embolic stroke 8 years ago after a porcine aortic valve replacement. He was treated successfully with amphotericin, rifampin, and replacement of the original porcine valve; however, he died suddenly 8 months later from unknown causes. Blood cultures 2 months prior to death were negative. The first manifestation of the endocarditis was a left hemiparesis followed some days later by a splenic infarction. Transthoracic echocardiography failed to demonstrate the aortic vegetation, which was clearly visualized subsequently by transesophageal echocardiography. The literature on Trichosporon beigelii endocarditis is reviewed.

Aged↗
PubMed1997

Effect of antibiotic treatment on vegetation size and complication rate in infective endocarditis.

BACKGROUND: Infective endocarditis is associated with significant morbidity and mortality, with valvular destruction, and with congestive heart failure. Embolic events are more common in patients with echocardiographically discernible vegetations, especially when vegetations are > 10 mm in diameter. HYPOTHESIS: The objective of the study was to follow vegetation morphology during native valve endocarditis, to compare it with the clinical course and antibiotic treatment chosen, and to evaluate whether the impact on vegetation size and complication rate of antibiotic regimens differed in patients with positive and negative blood cultures. METHODS: The effect of different antibiotic regimes on vegetation size monitored by using transesophageal echocardiography was evaluated in 183 patients with echocardiographic evidence of infective endocarditis. A total of 223 vegetations attached to the aortic or mitral valves were detected using the transesophageal approach. The patients were followed for a mean of 76 weeks and underwent a minimum of two consecutive transesophageal echocardiographic examinations. RESULTS: Treatment with different kinds of antibiotics corresponded with significant differences in vegetation size; vancomycin-associated treatment was related to a 45% reduction, ampicillin to a 19% reduction, penicillin to a 5% reduction, penicillase-resistant drugs to a 15% increase, and cephalosporin to a 40% increase in vegetation size. Multivariate analysis showed that penicillin, cephalosporin, and penicillase-resistant drug treatments were associated with an increased embolic risk, vancomycin treatment with abscess formation, and cephalosporin medication with increased mortality. Plotting changes in vegetation size against the incidence of embolism and mortality, linear regression analysis suggested a 40-50% reduction in vegetation size, thereby greatly reducing the risk of embolism and mortality. CONCLUSION: Our study shows that different antibiotics have different effects on vegetation size. The highest complication rate was observed when vegetations significantly increased in size during antibiotic treatment. Especially in culture-negative patients, monitoring vegetation size by means of transesophageal echocardiography may prove to be useful for estimating the efficacy of antibiotic treatment.

Anti-Bacterial Agents↗
PubMed1998

A novel source of enterococcal endocarditis.

An important element of the evaluation of patients with infective endocarditis is the determination of an infectious source. In approximately 20-45% of cases, no source is identified. Often the specific organism involved implicates the source, as is classically described by the association of S. bovis with colonic neoplasia. Other gut organisms have been reported to infect heart valves when colorectal pathology is present, but at far less frequency than S. bovis. This report deals with the case of a 75-year-old man with Enterococcus faecalis endocarditis of an unusual source--a cecal carcinoma that was causing intermittent appendiceal obstruction and infection. This case adds to previous case reports which suggest that the occurrence of enterococcal endocarditis in the absence of a classic infectious source should lead to a search for occult colorectal pathology.

Adenocarcinoma↗
PubMed1991

Relapsing native-valve enterococcal endocarditis: a unique cure with oral ciprofloxacin combination drug therapy.

Enterococcal endocarditis is the third most common presentation in native valves, and it is the most refractory. Unique among the streptococci, enterococci are relatively resistant to beta-lactam antibiotics requiring a combination aminoglycoside regimen for cure. Relapse is common even after apparently adequate therapy and may be seen in up to 25% of cases that involve streptomycin-resistant strains. This problem is magnified by the recent appearance of beta-lactamase-producing strains of S. faecalis resistant to both ampicillin and gentamicin. Ciprofloxacin is being investigated with a number of antimicrobials in the attempt to identify superior protocols against troublesome pathogens. However, little published data is available concerning the clinical efficacy of this drug in enterococcal endocarditis. In vitro studies and preliminary trials with animal models have generally been disappointing with broth macrodilution time-kill or agar dilution proving the most reliable in vitro methods for predicting in vivo outcomes. The urgent need to identify new combination drug regimens is underscored not only by the development of new resistance patterns, but by the well-documented toxicities of conventional therapies. The authors present a case of relapsing enterococcal endocarditis caused by a non-beta-lactamase-producing strain of S. faecalis, which demonstrated high-level resistance to streptomycin but not to gentamicin. Relapses occurred despite favorable laboratory data and aggressive beta-lactam-gentamicin therapies. Cure was achieved using oral ciprofloxacin in a combination drug regimen, which is reported here for the first time.

Adult↗