Evaluation of Antibiotic Prophylaxis Prescriptions for Infectious Endocarditis Before Oral Procedures Between Cardiologists and Dentists

Abstract Background Infective endocarditis (IE) is a serious disease with a high mortality rate. Antibiotic prophylaxis for bacterial endocarditis before invasive procedures has been recommended in patients with predisposing cardiac conditions since 1960, but contemporary guidelines worldwide have proposed changes. Objective To evaluate the knowledge and pattern of prescription by cardiologists and dentists regarding antibiotic prophylaxis for bacterial endocarditis before risky oral procedures. Methods This is an observational and cross-sectional study. Data were obtained from an online questionnaire, sent to cardiologists and dentists linked to specialty societies, in the first semester of 2021. Data analysis was performed using descriptive statistics, and comparisons between variables were done in an exploratory approach. The significance level adopted was 5%. Results From 613 responders, 82.5% of cardiologists and 79.5% of dentists reported prescribing antibiotic prophylaxis for patients at high and moderate risk for IE. Of dental procedures capable of generating bacteremia, all were correctly identified by more than 50.0% of the sample. As for the habits of daily living, flossing and toothbrushing had almost 50.0% of correct answers, chewing had only 17.3%, and 40.9% reported that none of the actions presented a risk of bacteremia. When comparing variables, the correct prescription of amoxicillin (2 g, 30-60 minutes before the procedure) was more prevalent among cardiologists and in responders with less than 20 years of graduation (p<0.01). Conclusion In the present study, the prescription of antibiotic prophylaxis for IE were frequent for high- and moderate-risk patients, before oral/dental procedures. Partial knowledge was found about endocarditis, which highlights the need for continuous medical/dental education.

Antibiotic Prophylaxis Before Invasive Dental Procedures for Patients atHigh Risk of Infective Endocarditis - A Systematic Review

Background: Clinical use of antibiotics prophylaxis (AP) for preventing infective endocarditis (IE) after invasive dental procedures is controversial. Expert consensus guidelines are inconsistent, either restricting its use to high?risk individuals or advising its use again. Objectives: To determine whether there is a genuine need for AP to prevent IE in high?risk patients undergoing invasive dental procedures. Methods: Online search was performed on PubMed, Science Direct, British Dental Journal and Cochrane Register of Controlled Trials. The methodological quality of each study was assessed using the Cochrane Handbook for Systematic Reviews of Interventions. Results: Seventeen (17) clinical trials were included in the final analysis recruiting 2,410 patients (AP = 1,366; placebo = 1,044). Bacteraemia was detected in 302 AP patients (22.1%) and 362 placebo patients (34.7%). AP reduced the risk of bacteraemia by 49% (risk ratio: 0.51; 95% CI; 0.45 to 0.58; P = 0.0001). Conclusion: Although using AP for IE may be pragmatic and justified for high?risk patients undergoing invasive dental procedures, the evidence is inconclusive because post?procedural bacteraemia may not be a good surrogate marker for IE. Moreover, trials investigating the direct association between AP and IE are lacking due to low disease prevalence and high?cost challenges

Complicaciones de la endocarditis infecciosa al momento del diagnóstico y su relación con los gérmenes aislados en pacientes adultos

RESUMEN Introducción: la endocarditis infecciosa es una enfermedad de una variada presentación clínica. Es cada vez más frecuente debido a los cuidados relacionados con la salud. Objetivo: determinar las complicaciones de los pacientes con endocarditis infecciosa bacteriana al momento del diagnóstico y su relación con el agente causal y ofrecer una descripción general de las características demográficas y clínicas presentes en pacientes del Hospital Nacional, Itauguá, Paraguay, en el periodo 2017-2021. Material y métodos: estudio descriptivo, observacional, retrospectivo que incluyo 37 pacientes con el diagnóstico de endocarditis infecciosa con germen aislado. Resultados: la edad media fue 45 ±14 años, la mayoría provenía del área urbana y era del sexo masculino (65%). La comorbilidad más frecuente fue enfermedad renal crónica (50%). Los procedimientos invasivos (catéter venoso central simple) fueron el foco de bacteriemia más frecuente (65,22%). La válvula más comprometida fue la aórtica, la complicación más frecuente fue la insuficiencia cardiaca (70,27%), hubieron 49% de desenlaces fatales. El germen más frecuente y causante de la mayor morbimortalidad fue Staphylococcus aureus (43,24%). Conclusión: la enfermedad renal crónica fue el principal factor de riesgo. Ser portador de catéter venoso simple de hemodiálisis estuvo relacionado al aislamiento del Staphylococcus aureus como agente causal más frecuente. Este germen estuvo relacionado a la alta tasa de complicaciones al momento del ingreso y con el alto porcentaje de desenlaces fatales.

ABSTRACT Introduction: Infective endocarditis is a disease with a varied clinical presentation. It is becoming more frequent due to health-related care. Objective: To determine the complications of patients with bacterial infective endocarditis at the time of diagnosis and their relationship with the causal agent and offer a general description of the demographic and clinical characteristics present in patients of the Hospital Nacional of Itauguá, Paraguay, in the period 2017- 2021. Material and methods: Descriptive, observational, retrospective study that included 37 patients diagnosed with infective endocarditis with isolated germ. Results: The mean age was 45±14 years, the majority came from the urban area and was male (65%). The most frequent comorbidity was chronic kidney disease (50%). Invasive procedures (simple central venous catheter) were the most frequent source of bacteremia (65.22%). The most compromised valve was the aortic, the most frequent complication was heart failure (70.27%) and there was 49% of fatal outcomes. The most frequent germ and cause of the highest morbidity and mortality was Staphylococcus aureus (43.24%). Conclusion: Chronic kidney disease was the main risk factor. Being a carrier of a simple venous hemodialysis catheter was related to the isolation of Staphylococcus aureus as the most frequent causal agent. This germ was related to the high rate of complications at the time of admission and the high percentage of fatal outcomes.

Protocolo de profilaxis antibiótica para pacientes dentales en riesgo de infección / Antibiotic prophylaxis protocol for dental patients at risk of infection

La profilaxis antibiótica involucra el uso de fármacos en una etapa preoperatoria de atención odontológica, con la finalidad específica de contribuir a la prevención de infecciones sistémicas como la endocarditis infecciosa (EI) asociada a bacteriemias transitorias por procedimientos odontológicos que implican sangrado en pacientes con alto riesgo de complicación por su condición sistémica cardiaca o no cardiaca. Esta complicación potencial inflama el revestimiento interno de las válvulas cardiacas, por proliferación de microorganismos específicos, y aunque es infrecuente es responsable de una elevada tasa de morbilidad y mortalidad. En el año 2007, la Asociación Estadounidense del Corazón (AHA), publica la última actualización vigente en la literatura sobre las recomendaciones y directrices aplicadas para el uso de profilaxis antibiótica. El objetivo de esta revisión pretende desarrollar una síntesis de evidencia existente seguida de un balance honesto de los riesgos y beneficios de forma individual sobre el uso de este protocolo. Se realizó una búsqueda digital integral en idioma español e inglés sobre los protocolos de profilaxis antibiótica en pacientes con riesgo de infección. Se incluyeron bases de datos como: MEDLINE, PUBMED y SciELO, adicionalmente se tomaron como referentes de partida las recomendaciones de la AHA. Se concluye con gran énfasis y soporte de la literatura actual, que los beneficios del uso de profilaxis antibiótica en un momento preoperatorio superan los posibles riesgos de resistencia bacteriana y anafilaxia, por lo que son totalmente justificables y requeridos para los pacientes adultos y niños inmunológicamente comprometidos.

Antibiotic prophylaxis involves the use of drugs at a preoperative stage of dental care, with a specific aim of contributing to the prevention of systemic infections such as infectious endocarditis (IE) associated with transient bacteremia due to dental procedures that involve bleeding in patients at high risk of complication due to their non-cardiac or cardiac systemic condition. This potential complication inflames the inner lining of the heart valves, due to the proliferation of specific microorganisms, and although it is uncommon, it is responsible for a high rate of morbidity and mortality. In 2007, the American Heart Association (AHA) published the last current update in the literature on the recommendations and guidelines applied for the use of antibiotic prophylaxis. The aim of this review is to develop a synthesis of existing evidence followed by an honest assessment of the risks and benefits individually on the use of this protocol. A comprehensive digital search was conducted in both Spanish and English on antibiotic prophylaxis protocols in patients at risk of infection. Databases such as MEDLINE, PUBMED, and SciELO were included, in addition the AHA recommendations were taken as baseline references. It is concluded with great emphasis and support from the current literature, that the benefits of the use of antibiotic prophylaxis in a preoperative moment overcome the possible risks of bacterial resistance and anaphylaxis, so they are fully justifiable and required for immunologically compromised adult and children patients.

A Case of Non-Bacterial Thrombotic Endocarditis with Atypical Massive Vegitation / 日本心臓血管外科学会雑誌

The patient was a 68-year-old woman. She was diagnosed with uterine cancer after experiencing irregular genital bleeding. Contrast-enhanced computed tomography showed a 30 mm left ventricular mass and splenic infarction, and head MRI showed multiple cerebral infarctions. The patient was suffering from systemic embolism caused by the cardiac mass, and we decided to perform cardiac mass removal prior to uterine cancer treatment. A yellowish-white thrombus-like mass attached to the mitral valve, subvalvular tissue, and left ventricular endocardium was removed by a trans-septal approach under cardiopulmonary bypass. Pathological examination revealed that the mass was a fibrin-based thrombus with almost no inflammatory findings, we diagnosised non-bacterial thrombotic endocarditis (NBTE). Postoperatively, the patient developed Takotsubo cardiomyopathy, and treatment for uterine cancer, was delayed. Hypercoagulability was not controlled well, and she developed recurrence of left ventricle vegitation, acute arterial occlusion of the lower extremities and inferior vena cava thrombosis, making active intervention for uterine cancer difficult. The patient was treated palliatively and died on POD 36. NBTE tends to be characterized by multiple small growths, but giant vegetation may also occur as in this case. Unless the primary disease causing the hypercoagulability is treated, recurrence of NBTE is possible, and prompt treatment of the primary disease is required.

Endocarditis bacteriana por Escherichia coli / Bacterial endocarditis due to Escherichia coli

Introducción: La endocarditis bacteriana es una enfermedad poco frecuente, ocasionada en la mayor parte de casos por organismos gram positivos, como estafilococos y estreptococos, seguido por organismos del grupo HACEK y raramente por gram negativos no HACEK. Su incidencia es baja, pero se relaciona con una alta mortalidad; existen diversos factores de riesgo asociados: edad avanzada, sexo femenino, antecedente de cirugías cardiacas, válvulas protésicas, uso de catéteres venosos centrales o urinarios. Objetivo: Describir la evidencia disponible sobre endocarditis bacteriana por Escherichia coli. Desarrollo: Se describe el caso de un paciente adulto mayor, sin antecedentes quirúrgicos cardíacos, que presenta cuadro de desorientación, astenia, adinamia, elevación de la temperatura corporal, asociados a infección urinaria, que luego de recibir piperacilina-tazobactam por 7 días, persiste con alzas térmicas. Hemocultivos confirman bacteriemia por Escherichia coli y en ecocardiograma transesofágico se logra la visualización de una vegetación a nivel de válvula aórtica nativa. El paciente recibió tratamiento antibiótico con cefalosporina de tercera generación por 30 días, con mejoría clínica, eco transesofágico de control sin vegetaciones, ni necesidad inmediata de tratamiento quirúrgico. Conclusiones: La sospecha clínica de endocarditis es importante en el momento de solicitar exámenes diagnósticos e interpretar sus resultados(AU)

Introduction: Bacterial endocarditis is a rare disease, caused in most cases by gram-positive organisms, such as staphylococci and streptococci, followed by HACEK group organisms and rarely by non-HACEK gram-negative organisms. Its incidence is low, but it is related to high mortality; there are several associated risk factors: advanced age, female sex, history of heart surgery, prosthetic valves, use of central venous or urinary catheters. Objective: To describe the available evidence on bacterial endocarditis due to Escherichia coli. Case report: We describe the case of an elderly patient, without a history of cardiac surgery, who showed disorientation, asthenia, adynamia, elevation of body temperature, associated with urinary infection, persisting after taken piperacillin-tazobactam for 7 days with temperature rises. Blood cultures confirm Escherichia coli bacteremia and transesophageal echocardiography exhibited vegetation at the native aortic valve level. The patient received antibiotic treatment with third-generation cephalosporin for 30 days, with clinical improvement, echo transesophageal control with no vegetations, and no immediate need for surgical treatment. Conclusions: The clinical suspicion of endocarditis is vital when requesting diagnostic tests and interpreting their results(AU)

Endogenous endophthalmitis due to Kingella Kingae infectious endocarditis / Endoftalmite endógena por endocardite infecciosa devido a Kingella Kingae

Abstract This report presents a rare case of endogenous endophthalmitis due to Kingella kingae infectious endocarditis. Endogenous endophthalmitis is a rare condition that has a systemic underlying cause, with hematogenic dissemination of a pathogen that will eventually reach and infect the eye. In this article, we present a case of a 54-year-old woman with fever, chills and decreased visual acuity and pain in the right eye. The slit-lamp exam showed conjunctival injection, anterior chamber reaction with a great amount of fibrinous material obscuring her visual axis. Ultrasound echography revealed profuse exudates and scarce membranous formation in the posterior segment. Blood culture was positive for Kingella kingae, and the patient was treated with intravenous ceftriaxone, along with topic dexamethasone and mydriatic. After 15 days of intravenous antibiotic therapy, the patient exhibited best visual acuity of 20/60. Endogenous endophthalmitis is an ocular emergency that demands quick diagnosis and aggressive intervention in order to preserve vision. Therefore, it is important to recognize its signs and symptoms with no retard.

Resumo O presente relato apresenta um raro caso de endoftalmite endógena por endocardite devido à Kingella kingae. Endoftalmite endógena é uma doença pouco comum com uma causa sistêmica subjacente. A disseminação hematogênica de um microrganismo infeccioso leva à infecção ocular. Nesse artigo, apresentamos o caso de uma mulher com 54 anos, febre, calafrios, baixa da acuidade visual e dor em olho direito. Ao exame na lâmpada de fenda apresentava injeção conjuntival, reação de câmara anterior e acúmulo de fibrina no eixo visual. Ultrassonografia revelou exsudatos profusos e escassa formação membranosa em segmento posterior.A hemocultura foi positiva para Kingella kingae e a paciente foi tratada com ceftriaxone venoso conjuntamente com dexametasona e midriático tópicos. Após 15 dias de terapia antibiótica endovenosa, a paciente apresentou acuidade visual corrigida de 20/60. Endoftalmite endógena é uma emergência ocular que demanda rápido diagnóstico e intervenção agressiva para preservar a visão. Portanto, é importante o reconhecimento precoce dos sinais e sintomas.

Endocarditis bacteriana a propósito de un caso / Bacterial endocarditis case report

OBJETIVO: informar acerca de un caso de endocarditis bacteriana. Paciente varón de 34 años de edad, con único antecedente de rinitis alérgica con tratamiento irregular. Él es procedente de Valparaiso Chile, se encuentra en sus vacaciones en la ciudad de La Paz, acude al servicio de medicina interna ­ emergencias, con clínica compatible con edema agudo de pulmón de la altura y edema cerebral de la altura, asociado a sepsis de foco pulmonar, que progresa a choque séptico, durante su internación intercurre con alzas térmicas continuas, asociado a hallazgo ecocardiográfico de vegetación en ventrículo derecho con hemocultivo positivo, por lo que se llega al diagnóstico de endocarditis bacteriana, se realizó el tratamiento correspondiente, y resolución del cuadro.

OBJECTIVE: to report a case of bacterial endocarditis A 34-year-old male patient with a unique history of allergic rhinitis with irregular treatment. He comes from Valparaiso Chile, is on vacation in the city of La Paz, goes to the service of internal medicine - emergencies with compatible clinical with acute pulmonary edema of height and cerebral edema of height, associated with sepsis of focus pulmonary disease, which progresses to septic shock, during internment with continuous hyperthermia, associated vegetation in right ventricle for echocardiography, also positive blood culture, so that a diagnosis of bacterial endocarditis is reached, Corresponding treatment was carried out, and resolution of pathology..

Molecular Docking Analysis of Lipoprotein Receptor Antigen I –Causing Endocarditis Interaction with Antibiotics and Immunoglobulins

Bacterial endocarditis is a life-threatening infectious disease. In recent years, significant changes have occurred in risk factors, prophylaxis, common causative microorganisms, antibiotic resistance patterns of these organisms, diagnostic criteria, and antibiotic treatment of bacterial endocarditis. The viridans group of streptococci the most common cause of endocarditis, and its lipoprotein receptor antigen proteins (LraI) function as adhesins in several streptococci, as a virulence factor for endocarditis. The increasing trend of antibiotic resistance towards endocarditis, there is an immediate need to identify the mechanisms of molecular interactions of these virulence factors with common antibiotics and immunoglobulins. Thus, in this study, a group of five Streptococcal enzymes of LraI family (SsaB from Streptococcus sanguinis, ScaA from S. gordonii, PsaA from S. pneumoniae, FimA from S. parasanguinis, and ScbA from S. cristatus) were selected and considered as reactive sites. Three dimensional structure of the target receptor LraI family enzymes were docked with the antibiotic molecules using Hex 8.0.0 molecular docking method. The study found no potential affinity between the enzymes (receptors) and the antibiotics (ligands) during the molecular docking. However, a strong binding affinity towards IgM was observed with all the LraI family of five enzymes; hence, IgM was the most efficient antibody that could be used against bacterial endocarditis.

Endocarditis bacteriana por Kocuria kristinae en un paciente inmunocompetente. Reporte de caso / Bacterial endocarditis by Kocuria kristinae in an immunocompetent patient. Case report

Los miembros del género Kocuria corresponden a cocos Gram positivos ubicuos, generalmente inocuos y que hacen parte de la flora saprófita de un porcentaje importante de la población; ocasionalmente han sido descritos como los agentes responsables de patologías infecciosas, principalmente dentro del contexto de pacientes que concomitantemente cursan con enfermedades crónicas y estados de inmunosupresión. Son escasos los casos reportados como causa de endocarditis en pacientes inmunocompetentes a nivel global por especies de este género. Se expone el caso de una mujer inmunocompetente de 44 años, sin antecedentes de importancia, en quien solo el diagnóstico microbiológico permitió confirmar la presencia de Kocuria kristinae como agente causal de su endocarditis infecciosa; la literatura señala la dificultad existente al momento de diferenciar la endocarditis producida por Staphylococcus spp. versus Kocuria kristinae por su evolución clínica similar, indicando la importancia de la microbiología al momento de identificar y diagnosticar apropiadamente.

Members of the genus Kocuria correspond to ubiquitous, generally harmless, Gram-positive cocci that are part of the saprophytic flora of a significant percentage of the population; occasionally they have been described as the agents responsible for infectious pathologies, mainly in the context of patients who concomitantly have chronic diseases and are under an immunosuppression state. There are few cases reported as a cause of endocarditis in immunocompetent patients globally by species of this genus. We present the case of a 44-year-old immunocompetent woman, with no relevant history, in whom only the microbiological diagnosis confirmed the presence of Kocuria kristinae as the causative agent of her infectious endocarditis; Literature points out the difficulty existing when differentiating endocarditis produced by Staphylococcus spp. versus Kocuria kristinae because of their similar clinical evolution, indicating the importance of microbiology when identifying and diagnosing accurately.

Endocarditis infecciosa por Staphylococcus aureus meticilino sensible en pediatría. Presentación de un caso y revisión de la literatura / Methicillin-sensitive Staphylococcus aureus infective endocarditis in pediatrics. A case report and literature review

Resumen: La endocarditis infecciosa es una enfermedad poco frecuente en pediatría pero con importante morbimortalidad. Si bien existen grupos de riesgo bien definidos puede presentarse en niños sin cardiopatía subyacente e inmunocompetentes, en quienes la etiología estafilocócica es la más frecuente y el diagnóstico continúa siendo un desafío. Presentamos el caso de un niño de 2 años, previamente sano, con una endocarditis a Staphylococcus aureus meticilino sensible de presentación no usual.

Summary: Infective endocarditis is rather an unusual condition in pediatrics, although it is associated with significant morbility and mortality. In spite of there being well defined risk groups the disease may present in children with no underlying heart disease who are immunocompetent, Staphylococcus aureus being the most frequent etiology. In those cases, diagnosis still constitutes a challenge. The study presents the case of a 2 year-old patient, with a healthy history, who presented methicillin-sensitive Staphylococcus aureus infective endocarditis, with rather an unusual presentation.

Endocarditis infecciosa secundaria a Streptococcus gordonii, complicada con aneurisma y fístula en válvula mitral: Reporte de caso / Infective endocarditis due to Streptococcus gordonii complicated with an aneurism and mitral valve fistula.: Case report

Entre las bacterias poco comunes que causan Endocarditis infecciosa (EI), se encuentran el Streptococcus gordonii, conocido por su habilidad de colonizar y dañar las válvulas cardiacas. Asimismo, se conoce que el hallazgo de aneurisma complicado con fístula intracardiaca es infrecuente en EI, sólo se presenta en el 1,6% de pacientes. Se reporta el caso de un varón de 58 años con EI por Streptococcus gordonii complicada con aneurisma y fístula en la válvula mitral. (AU)

Streptococcus gordonii is a rare cause of infective endocarditis (IE) known for its ability to colonize and damage cardiac valves. Moreover, it is known that complicated aneurism with intracardiac fistula is an infrequent finding in IE, reported in1.6% of patients. We report the case of a 58 year old male patient with IE infected with Streptococcus gordonii and complicated with an aneurism and mitral valve fistula. (AU)

Endocarditis infecciosa por Haemophilus parainfluenzae / Haemophilus parainfluenzae infectious endocarditis

Resumen Introducción: la endocarditis infecciosa (EI) es una enfermedad poco frecuente pero con elevada morbimortalidad. A pesar del incremento en la incidencia de S. aureus, el grupo HACEK constituye una etiología frecuente. Se comunica un adolescente con cardiopatía congénita que presentó EI a H. parainfluenzae. Caso clínico: 13 años, varón, comunicación interventricular (CIV). Caries. Ingresa 20/6/12 por adelgazamiento, astenia y adinamia de 2 semanas de evolución. Agrega dolor tipo puntada de lado a izquierda, disnea y fiebre. Al examen: regular estado general, frecuencia cardíaca 105 cpm, soplo sistólico 5/6, presión arterial 107/70. Polipnea 28 rpm. Abolición del murmullo alvéolovesicular y matidez en base de hemitórax izquierdo. Leucocitosis 17.700/mL, hemoglobina 8,7 g/dL, Proteína C reactiva 226 mg/dL. Radiografía de tórax: derrame paraneumónico izquierdo. Persiste febril, aumenta dolor torácico, peoría del estado general. Hemocultivo desarrolla H. parainfluenzae. Ecocardiograma transtorácico (ET): CIV sin repercusión hemodinámica, sin vegetaciones. Se reitera ET y se constata vegetación de 12 mm adherida al borde de CIV. En la evolución episodios de probables embolias pulmonares sépticas. A los 12 días cirugía cardíaca con evolución favorable. Discusión: el aislamiento de H. parainfluenzae fue decisivo en la búsqueda de EI. Es importante mantener alto índice de sospecha cuando existen factores de riesgo (CIV, caries). El riesgo embólico aumenta cuando la vegetación es mayor a 10 mm. Es una enfermedad médico-quirúrgica. La indicación y oportunidad de la cirugía es decisiva. Este caso se pudo haber evitado mediante prevención y tratamiento de las caries.

Summary Introduction: infective endocarditis (IE) is a rare disease with high morbidity and mortality rates. The incidence of S. aureus has increased but the agents of the HACEK group are frequent cause of EI. The case reported is an adolescent with congenital heart disease with an IE caused by H. parainfluenzae. Clinical report: 13 years old, male, ventricular septal defect (VSD). Tooth decay. The patient evidenced weight loss and asthenia since June 20, 2012 and in 2 weeks developed adinamia. Later on he presented pleuritic pain, dyspnea and fever. Physical findings: fair general condition; 105 bpm heart rate, 5/6 systolic murmur, blood pressure 107/70 mmHg. Polypnea 28 rpm. Abolition of vesicular murmur and dullness of the left hemithorax. Leukocytosis 17.700 /mL, hemoglobin 8.7 g / dL, C reactive protein (CRP) 226 mg/dL. RxTx: left parapneumonic effusion. Persistent fever, chest pain increases and general condition worsens. H. parainfluenzae was isolated from a single sample of blood culture. Transthoracic echocardiography (TE): VSD without hemodynamic repercussion, no vegetations. TE is reiterated and vegetation of 12 mm attached to the edge of VSD is found. In the evolution the patient develops episodes of probable septic pulmonary emboli. After 12 days of hospitalization, cardiac surgery was performed. After surgery the patient improved. Discussion: the isolation of H parainfluenzae led to IE diagnosis. It is important to maintain a high index of suspicion when there are risk factors (VSD, tooth decay). The embolic risk increases when vegetation is greater than 10 mm. It is a medical-surgical disease. The indication and timing of surgery is crucial. This case could have been avoided through prevention and treatment of tooth decay.

Ruptura de músculo papilar antero lateral por endocarditis local: Presentación inusual de la endocarditis de válvula nativa / Rupture of the anterolateral papillary muscle due to focal infective endocarditis: An unusual presentation of native valve endocarditis

Se presenta en caso de un varón de 55 años con diagnóstico de insuficiencia mitral severa por ruptura de músculo papilar; los hallazgos operatorios mostraron vegetaciones múltiples en la cabeza del musculo papilar anterolateral con ruptura total del mismo y velos valvulares normales. La histopatología mostró infiltrado inflamatorio polimorfonuclear en el tejido endocárdico y miocárdico, además vegetaciones fibrinosas en la superficie del musculo papilar, el cultivo del tejido resultó positivo a K. pneumoniae, concluyéndose como endocarditis aislada por infección directa del músculo papilar. El paciente recibió tratamiento antibiótico por seis semanas y fue dado de alta a los 45 días del ingreso con grado funcional. (AU)

We report the case of a 55-year old male patient diagnosed of severe mitral valve insufficiency due to rupture of the papilar muscle. Surgical findings included multiple vegetations on the head of the antero-lateral papilar muscle with complete rupture of it and abnormal valve veils. Histoptahology revealed polymorphonuclear infiltrate on the endocardic and myocardic tissues, and fibrinous vegetations on the surface of the papilar muscle. Klebsiella pneumoniae was isolated from the papilar muscle. The patient received 6-weeks of treatment and was discharged after 45 days of being admitted with functional class. (AU)

Tricuspid and pulmonary valve endocarditis associated with double-chambered right ventricle / 고신대학교의과대학학술지

We report a rare case of tricuspid valve and pulmonary valve endocarditis associated with a double-chambered right ventricle in an adult female with pulmonary artery aneurysm and septic pulmonary embolism by Streptococcus mitis. She was treated with aggressive antibiotic therapy followed by debridement of the infective lesion of tricuspid valve, pulmonary valve replacement using xenograft and resection of obstructing muscular bundles in right ventricle.

A Case of Acute Infective Endocarditis Initially Presenting as Acute Pyelonephritis

Infective endocarditis carries high risk of morbidity and mortality. Rapid diagnosis and effective treatment are essential to good patient outcome. However, nonspecific symptoms and various clinical manifestations make early diagnosis difficult. Here we report on an unusual case of infective endocarditis initially presenting as acute pyelonephritis (APN). A 44-year-old female with a history of heart surgery was admitted for fever and both flank pain. The patient had undergone dental extraction 3 weeks prior to admission. Her lab work and physical examination revealed pyuria, positive bacterial culture of both blood and urine, costovertebral knocking tenderness, and CT findings consistent with APN, leading to her initial diagnosis as APN. Despite treatment with antibiotics, her symptoms did not improve while further physical examination revealed newly developed Osler's nodes and Janeway lesions. Echocardiography showed vegetation of the aortic valve with severe aortic regurgitation. She was diagnosed as a case of infective endocarditis and was treated successfully.

Afasia post acv de acm unilateral por embolia infecciosa en endocarditis bacteriana / Aphasia post unilateral cerebral media stroke associated to infectious embolism in acute bacterial endocarditis

Se reporta el caso de un paciente con endocarditis infecciosa que sufre un accidente cerebro vascular (ACV) isquémico a nivel parieto-occipital e ínsula posterior izquierda, con manifestaciones afásicas de rasgos mixtos, donde prima la fluidez y los problemas de repetición, agresividad, agrafia y dificultades de lectura. Es un caso llamativo por la singularidad de los hallazgos y la mejoría funcional posterior al evento. Son escasos reportes en la literatura que muestren una complicación afásica por una endocarditis infecciosa con vegetaciones aórticas por Streptococo mitis versus S. oralis. El origen de la endocarditis infecciosa fue atribuido a procedimiento de endodoncia, y justificado en hallazgos de RMN, punción lumbar y ECO-TE. En la actualidad, el paciente posee un lenguaje funcional, con ciertas dificultades a nivel del lenguaje expresivo y de la comprensión.

We present a clinical report of a patient with infective endocarditis who suffered an ischemic stroke at the parietal occipital and posterior insula, with aphasic demonstrations including mixed features, primordially exhibiting fluency and repetition problems, aggression, dysgraphia, and reading difficulties. It is a striking case because of the uniqueness of the findings and the functional improvement after the event. There are few previous reports describing an association between these bacteria and this injury and the patient's improvement. The cause of the endocarditis was attributed to an endodontic procedure because other paraclinical tests made during medical care showed no other apparent cause. Currently the patient only has difficulty with expressive language and understanding certain commands.

Congenital heart disease combined with infective endocarditis: A clinical analysis of 58 cases / 第二军医大学学报

Objective To assess disease spectrum and clinico-pathological characteristics of infective endocarditis(IE) in patients with congenital heart disease(CHD). Methods Clinical characteristics of IE patients with CHD were investigated,who were receiving surgical treatment and pathological diagnosis during 2010.01-2013.12 in Changhai hospital. The clinical datas，disease species and clinico-pathological characteristics were retrospectively analyzed. Results During these 4 years, there were 58 IE cases associated with CHD whose mean age is (28.3±7.3)years accounting for 33.7(58/172) of all patients with IE receiving surgical treatment. The top three types of congenital heart disease were included bicuspid aortic valve accounted for 34.5% (20/58), ventricular septal defect(VSD) accounted for 20.7% (12/58) and patent ductus arteriosus(PDA) accounted for 15.5% (9/58). Other congenital heart diseases (including aortic stenosis, subaortic stenosis, aortic sinus aneurysm right ventricular fistula, mitral stenosis, mitral incompetence and pulmonary stenosis) accounted for 13.8% (8/58),while complex CHD (containing two or more abnormalities) accounted for 15.5% (9/58). Mean age of bicuspid aortic valve patient was higher than other CHD patients with infective endocarditis [(38.7 ± 11.7) years vs (26.6 ± 12.4) years, P <0.05]. Positive rate of blood culture were 42.1% (25/58),in which viridans accounted for 48.0%(12/25). Echocardiography was performed in all patients and the positive rate was 96.6%(56/58) It was common that excrescence attached multiple sites, For patients with bicuspid aortic valve, excrescence often attached aortic valve, for VSD patients, excrescence often attached tricuspid septal leaflet and VSD right ventricular surface,while for PDA patients,was aortic valve,opening of PDA or the left pulmonary artery wall eroded by shunt. Conclusion CHD is common underlying disease for IE , in which bicuspid aortic valve ranks first, VSD and PDA also occupy a high proportion. Blood culture positive rate is low, while transthoracic echocardiography(TTE) is recommended as a reliable inspection techniques. Different diseases have different parts of the vegetation involving, more common is that multiple sites are involved.

Surgical treatment for infective endocarditis and hospital mortality in a Brazilian single-center / Tratamento cirúrgico para endocardite infecciosa e mortalidade hospitalar em centro único brasileiro

OBJECTIVE: We evaluated patients underwent cardiac valve surgery in the presence of infective endocarditis in an attempt to identify independent predictors of 30-day mortality. METHODS: We evaluated 837 consecutive patients underwent cardiac valve surgery from January 2003 to May 2010 in a tertiary hospital in São José do Rio Preto, São Paulo (SP), Brazil. The study group comprised patients who underwent intervention in the presence of infective endocarditis and was compared to the control group (without infective endocarditis), evaluating perioperative clinical outcomes and 30-day all cause mortality. RESULTS: In our series, 64 patients (8%) underwent cardiac valve surgery in the presence of infective endocarditis, and 37.5% of them had surgical intervention in multiple valves. The study group had prolonged ICU length of stay (16%), greater need for dialysis (9%) and higher 30-day mortality (17%) compared to the control group (7%, P=0.020; 2%, P=0.002 and 9%, P=0.038; respectively). In a Cox regression analysis, age (P = 0.007), acute kidney injury (P = 0.004), dialysis (P = 0.026), redo surgery (P = 0.026), re-exploration for bleeding (P = 0.013), tracheal reintubation (P <0.001) and type I neurological injury (P <0.001) were identified as independent predictors for death. Although the manifestation of infective endocarditis influenced on mortality in univariate analysis, multivariate Cox regression analysis did not confirm such variable as an independent predictor of death. CONCLUSION: Age and perioperative complications stand out as predictors of hospital mortality in Brazilian population. Cardiac valve surgery in the presence of active infective endocarditis was not confirmed itself as an independent predictor of 30-day mortality.

OBJETIVO: Avaliamos pacientes submetidos à cirurgia valvar em vigência de endocardite infecciosa na tentativa de identificar preditores independentes de mortalidade intrahospitalar em 30 dias. MÉTODOS: Foram avaliados 837 pacientes consecutivamente submetidos à cirurgia valvar, no período de janeiro de 2003 a maio de 2010, em um hospital terciário de São José do Rio Preto, SP, Brasil. O Grupo de Estudo compreendeu indivíduos submetidos à intervenção em vigência de endocardite infecciosa e foi comparado ao Grupo Controle, considerando complicações clínicas perioperatórias e óbito por todas as causas em 30 dias. RESULTADOS: Em nossa casuística, 64 (8%) pacientes foram submetidos à cirurgia valvar em vigência de endocardite infecciosa, sendo 37,5% deles com indicação de intervenção cirúrgica em múltiplas valvas. O Grupo de Estudo apresentou maior permanência em Unidade de Terapia Intensiva (16%), necessidade de diálise (9%) e maior mortalidade em 30 dias (17%) comparado ao Grupo Controle (7%, P=0,020; 2%, P=0,002 e 9%, P=0,038; respectivamente). A análise de regressão de Cox confirmou idade (P=0,007), lesão renal aguda (P=0,004), diálise (P=0,026), reoperação (P=0,026), reintervenção por sangramento (P=0,013), reintubação orotraqueal (P<0,001) e lesão neurológica tipo I (P<0,001) como preditores independentes para óbito. Embora a manifestação de endocardite infecciosa influencie na mortalidade na análise univariada, a regressão de Cox não confirmou tal variável como preditor independente de óbito em nossa casuística. CONCLUSÃO: Idade e complicações perioperatórias destacam-se como preditores de mortalidade hospitalar em população brasileira. Cirurgia valvar em vigência de infecção ativa não se confirma como preditor independente de óbito nesta casuística.

Culture-negative Endocarditis Caused by <i>Bartonella henselae</i> / 日本心臓血管外科学会雑誌

There is <i>Bartonella henselae</i> (<i>B. henselae</i>) leads to cat-scratch disease and causes infective endocarditis, but shows as negative in blood cultures. We performed aortic valve replacement in a patient with aortic valve infective endocarditis which was regative on blood cultures. The patient had a contact history with a cat prior to admission. Thus, we suspected <i>B. henselae </i>and made a definitive diagnosis by PCR method and Warthin-Starry (WS) stain. A correct diagnosis was possible by detailed history taking and the use of appropriate antibiotics.