Classic Peripheral Signs of Subacute Bacterial Endocarditis

A 50-year-old female patient with visual disturbances was referred for further evaluation of a heart murmur. Fundoscopy revealed a Roth spot in both eyes. A physical examination showed peripheral signs of infective endocarditis, including Osler nodes, Janeway lesions, and splinter hemorrhages. Our preoperative diagnosis was subacute bacterial endocarditis with severe aortic regurgitation. The patient underwent aortic valve replacement and was treated with intravenous antibiotics for 6 weeks postoperatively. The patient made a remarkable recovery and was discharged without complications. We report this case of subacute endocarditis with all 4 classic peripheral signs in a patient who presented with visual disturbance.

Endocardite infecciosa bacteriana originada a partir de procedimentos odontológicos / Infective bacterial endocarditis derived from dental procedures

Introdução: A endocardite infecciosa bacteriana (EIB) é uma infecção séria das válvulas cardíacas ou das superfícies endoteliais do coração. É causada por proliferação bacteriana nas superficies cardíacas alteradas. Na flora presente na cavidade bucal existem microorganismo que são usualmente agentes causais da EIB, como: estreptococos alfa-hemolíticos, enterococos (Streptococcus faecalis), pneumococos, estafilococos e estreptococos do grupo A. As manipulações dentárias constituem a causa principal de bacteriemia transitória, podendo desencadear EIB. Objetivo: O objetivo proposto no presente artigo foi o de realizar uma uma revisão bibliográfica, envolvendo artigos originais e de revisão sobre a repercussão provocada por procedimentos odontológicos no desencadeamento da EIB. Método: Foram utilizadas para consulta as bases de dados: Scopus, Lilacs, correspondente aos anos de 2005 a 2012, nos idiomas inglês e português. Foram encontrados 34 artigos, dos quais sete foram excluídos por não satifazerem aos critérios de inclusão adotados. Resultados: Em 75% dos artigos consultados, tornou-se clara a evidenciação do perigo eminente que há de, concomitantemente a uma intervenção dentária que conduza ao sangramento, propiciar-se o aparecimento de manisfestação sistêmica desfavorável, como bacterimia com posterior instalação de EIB. Conclusão: Conclui-se que é de extremada importância a conscientização por parte do cirurgião dentista de que ao intervir, mesmo na prática de um procedimento simples, poder propiciar, concomitantemente, o aparecimento de manisfestação sistêmica desfavorável à saúde geral dos seus pacientes e que o cirurgião dentista deve estar atualizado quanto aos protocolos e ter bom senso, evitando a banalização do uso de antibiótico, restrigindo o seu uso aos casos de estrita necessidade.

Introduction: Bacterial endocarditis (IBE) is a serious infection of the heart valves or heart endothelial surface. It is caused by bacterial growth on modified cardiac surfaces. In the flora present in the oral cavity, there are microorganisms which are usually causal agents of IBE, as alpha-hemolytic streptococci, enterococci (Streptococcus faecalis), pneumococci, staphylococcus and group A streptococcus. The dental manupulations are the main cause of transient bacterimia, potentially triggering IBE. Objective: The proposed objective of this article was to conduct a literature review, involving original and review articles on the impact caused by dental procedures in triggering the IBE. Method: We used to query the databases: PubMed, Scopus, Lilacs for the years 2005 to 2012 in English and Portuguese. It was found 34 articles, of which seven were excluded because they did not meet the inclusion criteria adopted. Results: In 75% of the articles found, it became clear, evidence of imminent danger that simultaneously a dental intervention that leads to bleeding, to provide the appearence of adverse systemic manifestations such as bacterimia with subsequent installation of IBE. Conclusion: It was concluded that it is of extreme importance the awareness of the dentist that to intervene, even in the practive of a practice of a simple procedure , he or she can foster the emergence of an unfavorable concomitant systemic manisfestation to the overall health of their patients and the dentist must be update regarding the protocols and have common sense, avoiding the trivialization of antibiotic use, restricting its use to cases of strict necessity.

Gustav Mahler: aspectos médicos y psicológicos que influenciaron la vida y obra del gran músico / Gustav Mahler: medical and psychological aspects

Gustav Mahler es considerado en la actualidad uno de los más importantes músicos que vivieron al final del siglo XIX. A pesar de tener en vida sólo un parcial reconocimiento como compositor, Mahler sufrió de complicaciones de una fiebre reumática, desarrollando un corea de Sydenham, manifestaciones obsesivas y compromiso valvular cardíaco. Gran importancia tuvieron en su vida y obra, aspectos psicológicos de su infancia revelados después de una estrevista terapéutica con Freud. Mahler lamentablemente falleció en el período más productivo y de madurez de su obra, debido a una endocarditis bacteriana subaguda.

Clinical outcomes of renal patients treated with therapeutic plasma exchange / 대한내과학회지

BACKGROUND: Therapeutic plasma exchange (TPE) is a procedure by which plasma is removed from whole blood and this can be used in the treatment of some renal diseases. METHODS: We reviewed the medical records for the chief complaints, underlying diseases, clinical courses and treatment outcomes of 23 patients who had been treated with TPE at the Renal Division of Chungnam National University Hospital from January 1995 to June 2005. RESULTS: Patients with thrombotic thrombocytopenic purpura (TTP), microcopic polyangitis, lupus nephritis, hyperacute humoral rejection after kidney trasnplantation and rapidly progressive glomerulonephritis (RPGN) secondary to subacute bacterial endocarditis were included in this study. Among the 11 patients with TTP, six patients improved and two patients progressed to end-stage renal disease (ESRD). Three patients with TTP died. Seven patients with microscopic polyangitis and two patients with lupus nephritis had pulmonary hemorrhage at the time of TPE. Eight of the 11 TTP patients showed improvement of their pulmonary hemorrhage after TPE. One of the two patients with hyperacute humoral rejection after kidney transplantation and one patient with secondary RPGN were improved after TPE. Hypotension (three cases) was the most common adverse effect of TPE, followed by two cases of itching sensation and one case of fever with chills. CONCLUSIONS: Therapeutic plasma exchange was an effective treatment for patients with TTP, microscopic polyangitis, lupus nephritis with pulmonary hemorrhage and hyperacute humoral rejection after kidney transplantation.

Long-term Result after Repair of Sinus Valsalva Aneurysm Rupture / 대한흉부외과학회지

BACKGROUND: Sinus valsalva aneurysm (SVA) is a rare disease, and it is frequently accompanied by ventricular septal defect and aortic valve regurgitaion. For treatment of SVA, several surgical mordalities were applied, but there was no report on the long-term result after surgical repair in Korea. We reviewed our 28 years of experiences and analyzed the long-term results after treatment of sinus valsalva aneurysm with or without rupture. MATERIAL AND METHOD: Between March 1974 and February 2002, 81 patients were operated under the impression of sinus valvsalva aneurysm or sinus valsalva aneurym rupture. Retrospectively we reviewed the patients' record. Mean age of patients was 29.2+/-11.5 and there were 49 males. Accompanyng diseases were as follows: VSD in 50, PDA in 2, Behcet's disease in 2, TOF in 1, RVOTO in 1, AAE in 1. Seventy-seven (95%) patients had sinus valsalva rupture and in 14 patients, subacute bacterial endocarditis was accompanied. Degree of aortic valve regurgitation was as follows: grade I: 8, II: 10, III: 9, IV: 4. Most common rupture site was right coronary sinus (66 patients, 81%) and most common communication site was right ventricle (53 patients). In repair of sinus valsalva rupture, patch was used in 37 patients, and direct suture was done in 38 patients. RESULT: There was one surgical death (1.2%). Follow up was done in 78 patients (97.5%), mean follow up period was 123.3+/-80.9 (3~330 months). During the follow up period, 3 patients died (3.8%). One patient died of heart failure, another patient died of arrhythmia and the other one died of unknown cause. In two patients, complete atrio-ventricular block was developed during follow up period, and there was no operation related event or complication. Kaplan-Meier survival analysis revealed 92.5+/-3.5% survival at 15 and 27 years and it seems to be satisfactory. CONCLUSION: Long-term surgical results and survival is satisfactory after repair of sinus valsalva aneurysm with or without rupture.

Comparing transesophageal echocardiography and transthoracic echocardiography for diagnosis of infectious endocarditis

Infectious endocarditis [IE] is caused by a variety of microbial agents and poses severe complications such as embolic and septic events. This condition is aggravated among elderly patients and is associated with a high morbidity rate. Recent advances in diagnostic modalities, especially transesophageal echocardiography [TEE] have revolutionalized early diagnosis, prediction of emboli, treatment and evaluating the outcomes of interventions. In this article, we explain our experience with 4 cases of infectious endocarditis. Having had the clinical suspicions to IE, patient underwent routine diagnostic procedures including transthoracic echocadiography [TTE] and blood culture. Surprisingly, TTE was negative for all patients; however, the clinical symptoms and the presence of complications were favoring IE, therefore, all were subjected for TEE. TEE confirmed the diagnosis of IE in all 4 cases. There were mitral valve vegetations measured 0.5-3cm in three cases, whereas the other one presented with aortic valve vegetation measured 1cm. Three patients had blood culture positive for staphylococcus aureus and one patient with aortic valve vegetations had enterococcus positive blood culture. All patients had developed various complications and one had splinter hemorrhage. Two patients underwent surgical valvuloplasty, however, one of them was re-operated for splenectomy due to splenic abscess. All patients received an appropriate antibiotic regimen including vancomycine and cefteriaxon and were discharged in satisfactory state. Patients were routinely admitted for follow up TEE, while none developed symptoms or complications compatible with IE. Our results revealed that TEE is significantly superior to TTE for diagnosis and follow up of IE

Operative Treatment of Mitral Valve Regurgitation Due to Chordal Rupture and/or Papillary Muscle Rupture / 대한흉부외과학회지

BACKGROUND: As the rupture of chordae and/or papillary muscle became the main cause of mitral valve regurgitation, mitral reconstructive surgery has a very important role. In this regard, we analyzed the clinical result and postoperative early result of operative treatment performed in our hospital. MATERIAL ANDMETHOD: For this analysis, forty nine patients (male 26, female 23, mean age 49.0+/-16.5) who underwent mitral valve operation caused by the rupture of chordae and/or papillary muscle from August 1991 to April 2002 were reviewed. Among forty nine patients, twenty two (44.9%) received mital valve reconstruction and twenty seven (59.2%) received mitral valve replacement. RESULT: As to the pathological etiology of rupture of mitral and papillary muscle, twenty five cases (51.0%) were nonspecific degeneration, eleven cases (22.4%) were myxomatous degeneration, seven cases (14.3%) were subacute bacterial endocarditis. Three patients suffered mortality after operation (6.1%) and valve replacement was performed again on one patient because of remnant mitral insufficiency after valve reconstruction. The 5-year survival rate after operation for the entire mitral valve regurgitation patients was 81.4%. We have also compared and analyzed the operation results of a group of patients who underwent valve reconstruction and the other group of patients who underwent valve replacement from thirty six patients who had suffered from mitral valve regurgitation caused by degenerative disease. The mortalities were 0% and 14.3%, respectively and the 5-year survival rates were 90.2% and 64.3%, respectively, but there were no statistical significance. CONCLUSION: The most common pathological etiology of mitral valve regurgitation caused by rupture of chordae and/or papillary muscle was nonspecific degeneration. In case of degenerative disease is the cause of mitral valve regurgitation, valve reconstruction showed better long-term effects in many respects and better operation results compared to valve replacement.

Subacute Bacterial Endocarditis Associated with Upper Endoscopy

Transient bacteremia associated with various endoscopic procedures is a well-documented phenomenon. Clinically important bacteremias are very rarely seen, however, this malady has significant morbidity in susceptible patients with valvular heart disease, liver cirrhosis, malignancy and immune deficiency. This bacteremia is a complication that is generally observed secondary to upper endoscopy and other associated invasive procedures in at risk patients, and the more serious manifestations include spontaneous bacterial peritonitis, septic arthritis, meningitis, brain abscess and infective endocarditis. Infective endocarditis is an extremely rare complication of gastrointestinal endoscopy, and it has been convincingly documented in only seven cases. We report a case of native valve endocarditis due to Streptococcus intermedius in a patient with valvular heart disease as a consequence of routine upper endoscopy.

A Case of Infective Endocarditis in Renal Transplant Recipient Successfully Treated by Valve Annuloplasty / 대한이식학회지

Infectious complications are the leading causes of morbidity and mortality among kidney transplant recipients. Infective endocarditis has been reported as a rare complication in kidney transplant recipients and substantially impacts kidney transplant recipient survival. The early diagnosis of endocarditis is essential in order to initiate appropriate antibiotic treatment. In selected cases, surgery can be undertaken to prevent significant subsequent morbidity and mortality. We report a case of subacute bacterial endocarditis due to beta- hemolytic streptococcus in a 25-year-old kidney transplant recipient, which was successfully treated with antibiotics and valve annuloplasty.

A Case of Prosthetic Valve Endocarditis Caused by Listeria monocytogenes / 감염

Listerial endocarditis is rare disease with about 60 reported cases in the literatures. Although the clinical and laboratory features of listerial endocarditis are similar to those of subacute bacterial endocarditis caused by other pathogens, the incidence of complications and mortality rates are high. Early diagnosis, adequate treatment, and timely surgery are important for the better outcome. We report a case of a 62 year-old male with prosthetic valve endocarditis caused by Listeria monocytogenes, who was successfully treated with antibiotics and surgery (aortic valve and mitral valve re-replacement).

A Case of Polycythemia Vera with Splinter Hemorrhages

Once splinter hemorrhage can be considered as a pathognomonic sign of subacute bacterial endocarditis. But it can also be associated with a variety of systemic disorders that increase capillary fragility or primary nail bed involvement in dermatologic disorders. The cause of splinter hemorrhage can usually be established by careful history and physical examination. We report a case of 33-year-old man with splinter hemorrhages, who had polycythemia vera.

Endocardite pneumocócica de evoluçäo subaguda / Pneumococcal endocarditis of subacute evolution

With the development of penicillin, Streptococcus pneumoniae has become an uncommon cause of bacterial endocarditis in adults. Subacute manifestation of pneumococcal endocarditis has been reported a few times in the literature, but most reports define the disease as acute, severe, and having a high mortality rate. We report the case of a 58-year-old male with subacute bacterial endocarditis due to Streptococcus pneumoniae. We stress the low frequency of this agent as a cause of endocarditis and the atypical evolution of this case. The pathophysiology, clinical manifestations and evolution, and the therapeutical options for this type of infection are also discussed.

Manifestaciones cutáneas de meningococcemia aguda: a propósito de un caso / Cutaneous manifestations of acute meningococcemia: case report

La Neisseria meningitidis es un coco gram negativo, capaz de producir vasculitis por daño directo, invadiendo la pared vascular, o por depósito de inmunocomplejos. Presentamos un paciente con vasculitis meningocóccica y comentamos la clínica, patología, diagnóstico y tratamiento de dicha enfermedad

Subacute Bacterial Endocarditis and Cerebral mycotic Aneurysm

A 30-year-old man was transferred to Yonsei Cardiovascular Hospital after 20 days of hospitalization under the diagnosis of bacterial endocarditis with mitral regurgitation and septic splenic infarct. He had suffered from intermittent high fever and general weakness for 3 months. Echocardiogram showed moderate mitral regurgitation and multiple large vegetations in both leaflets. Streptococcus viridans was confirmed by blood cultures, and administration of cefazoline and gentamycin was initiated. During the antibiotic therapy, abdominal and left calf pain developed, and abdominal computed tomography showed splenic and right renal infarct. He also complained intermittent headache and visual distrubance. Brain computed tomography and four vessels angiography showed a small aneurysm in right hemisphere and other small aneurysm in fronto-occipital area of left middle cerebral artery. No more systemic embolization developed until the completion of six weeks of antibiotic therapy. The patient underwent mitral valve replacement with #29 Carpenitier-Edwards Bioprosthesis. At operation, the anterior and posterior mitral leaflets were found perforated and covered with leaflets were found perforated and covered with multiple vegetations. Follow-up cerebral angiography taken at seventh postoperative day, showed enlargement of cerebral aneurysm. Clipping of saccular aneurysms on left M3 and M4 were performed and complete resolution of aneurysm was confirmed by brain computed tomography. On operative finding, an aneurysm was found on with saccular type. The patient was dischanged without complication on eighth postoperative day.

Clinical implication of serum TNF-alpha and IL-1beta measurement in patients with sepsis / 결핵

BACKGROUND: It is well known that when macrophages are stimulated with endotoxin, they produce a wide variety of cytokine mediators, including TNF-α and IL-1β. However, there is an alterationnin the macrophages responsiveness when they are challenged with repeated bouts of endotoxin, termed 'endotoxin tolerance' which is regarded as a self-protective phenomenon from continuous stimulation. In this study, endotoxin tolerance in the peripheral blood monocytes of sepsis patients was evaluated. METHODS: Fourteen patients with organism-documented sepsis were included. The severity of illness was evaluated by APACHE IIscore. Peripheral blood monocytes were isolated from the patients and diluted to 1×105/well. After stimulation with endotoxin(LPS of E. coli O114:B4, 100 ng/ml), they were incubated at 37℃ in 5% CO2 incubator for 24 hours. Supernatant was collected for the measurement of TNF-αand IL-1β with ELISA method. Peripheral blood monocytes of seven healthy volunteers were used as control. RESULTS: The APACHE IIscore(mean±SD) of the patients at the time of blood sampling was 12.2±5.7. The primary infection foci were urinary tract infection, pneumonia, subacute bacterial endocarditis, and catheter related infection, etc. The causative organisms were gram negative rods(10 cases), gram positive cocci(6 cases) with two cases of mixed infection. Serum TNF-α could be measured in 4 cases with 29.9±27.7 pg/ml. Serum IL-1β was measureable in only one patient. The TNF-α level of supernatant of cultured peripheral blood monocytes was 2,703±2,066 pg/ml in patients and 2,102±1,914 pg/ml in controls. The IL-1β level of supernatant was 884±1,050 pg/ml in patients and 575±558 pg/ml in controls. There was no difference of TNF-α and IL-1β level between patients and controls. CONCLUSION: We cannot prove the phenomenon of endotoxin tolerance in this study. Future study needs to be focused on the more severe sepsis patients who were taken for sampling earlier. Addition of serum to the culture medium could be an another valuable option for the success of this study.

Giant Aneurysm of a Congenital Coronary Arteriovenous Fistula Arising from the Left Coronary Artery

Congenital coronary arteriovenous fistula is a rare condition which is an abnormal communication of the coronary artery with the right ventricle, right atrium, left atrium or left ventricle. Coronary artery aneurysm is an uncommon disease which is defined as coronary dilatation which exceeds the diameter of normal adjacent segments or the diameter of the patient's largest coronary vessel by 1.5 times. In young ages, symptoms are unusual, but significant symptoms and complications such as congestive heart failure, subacute bacterial endocarditis, coronary steal syndrome, aneurysm formation, rupture, and pulmonary hypertension may appear among the older age group. We report a case of giant aneurysm of a congenital coronary arteriovenous fistula between left co-ronary artery and right ventricular outflow tract with significant left to right shunt confirmed in a 84-year old female with a brief review of literature.

A Case of RPGN associated with toxic epidermal necrolysis / 대한내과학회지

RPGN is a catastrophic form of acute glomerulonephritis characterized by an abrupt onset and rapid deterioration of renal function resulting in oliguria within weeks or months. RPGN is seen in a variety of systemic disorders, including systemic lupus erythematosus, poly arteritis nodosa, Wegener's granulomatosis and subacute bacterial endocarditis. In addition, RPGN is seen in association with a variety of primary renal diseases such as poststreptococcal glomerulonephritis, membranoproliferative glomerulonephritis, and IgA nephropathy, Goodpasture's syndrome. Toxic epidermal necrolysis(TEN) is a drug induced life threatening disease characterized by extensive epidermal detachment, necrosis, and mucosal erosion. TEN may involve liver, lung, intestine, and kidney. But renal involvement has seldom been reported. We report on a 63-year-old patient who developed a RPGN with a TEN. Renal biopsy showed pauci-immune crescentric glomerulonephritis and skin biopsy showed edematous change with extravasated erythrocytes in upper dermis and several individually necrotic keratinocytes. ANCA and FANA test was negative. Our patient recovered renal function with steroid pulse therapy. The pathophysiology of TEN is unresolved but abnormal cytokine release(e.g., tumor necrosis factor) has been implicated in pathogenesis of TEN. Because various cytokines have direct toxic effect on kidney structure, the tubular and glomerular damage may be related to the cytokines involved in TEN. To our knowledge, this is the first case documenting the presence of RPGN in patients with TEN. And there maybe some relations between PRGN and TEN which require further study.

Effects on Surgical Repair of VSD by TATV / 대한흉부외과학회지

Perimembranous ventricular septal defects(PMVSDs) are the most common type of ventricular septal defects(VSDs) and consist morphologically of deficiency of the membranous septum and variable portions of the adjacent muscular septum. Repair of VSD has begun via a right ventriculotomy. Even with this exposure, however, it mght lead to ventricular dysfunction. Transatrial exposure of VSDs is known to a versatile approach to PMVSDs and even malalignment defects can be repaired by this METHOD: Although transatrial exposure can be improved by taking down the atrioventricular valve at the annulus, surgeons have been hesitant to do so because of concern for valvular competence. Therefore, this study was undertaken to clarity the effects of transannular approach of tricuspid valve (TATV) at operation of PMVSD. During last 5 years, twenty eight cases from 96 patients of PMVSD were closed by TATV and follow up study was done from 3 months to 33 months and results were obtained as follows. 1. Age at operation was from 4 months to 38 years and most patients(17, 62%) were above 5 years. 2. Preoperative pulmonary-systemic flow ratio(Qp/Qs) was ranged from 1 to 2.8 and 22 patients(79%) were less than 2. 3. Peak systolic pulmonary artery pressure was below 30mmHg in 8, 30-50mmHg in 17, above 50mmHg in 3 patients and 25 patients(89%) were less than 50mmHg. 4. Preoperative tricuspid regurgitation(TR) is none in 12, trivial in 6, mild in 3, moderate in 5, severe in 2 patients but postoperative TR was none in 18, trivial in 6, mild in 4 patients, so TR in most patients had decreased or not. 5. Indications for operation were based on the presence of a significant shunt. However, in patients with small shunts, indications for operation were included additional factors, tricuspid valve pouch, RVOT obstruction(right ventricular outflow tract obstruction), subacute bacterial endocarditis and associated anomalies. 6. There were no hospital deaths and residual shunts in postoperative echocardiography. Therefore, TATV is especially a good method in PMVSD where patients have trcuspid valve pouch. And it is a safe and effective technique that improves exposure for PMVSD repair and does not adversely affect tricuspid valvular competence.