Endocarditis infecciosa de válvula nativa: factores asociados a resultados adversos / Mortality predictors in patients with native valve infec tive endocarditis

Resumen Introducción : La mortalidad de la endocarditis infec ciosa (EI) en Argentina continúa siendo elevada. El obje tivo del trabajo fue describir las características clínicas e identificar factores asociados a mortalidad en pacientes con EI de válvula nativa. Métodos : Estudio de cohorte retrospectiva que inclu yó pacientes adultos con diagnóstico de EI de válvula nativa internados durante 2011-2021. Resultados : Se incluyeron 129 pacientes con una edad promedio de 66±17 años. El organismo responsa ble más frecuente (38.8%, n = 50) fue el Staphylococcus aureus (SA). El 63.6% presentó criterios de indicación quirúrgica. La mortalidad durante la internación fue del 22.5%. En el análisis multivariado que incluyó índice de comorbilidad Charlson, infección por SA y la presencia de criterios de indicación quirúrgica, se observó un OR ajustado de mortalidad de 1.32 (IC95% 1.10-1.57; p = 0.003), 2.75 (IC95% 1.11-6.8; p = 0.028) y 4.14 (IC95% 1.34-12; p = 0.013), respectivamente. En el análisis mul tivariado para mortalidad alejada que agregó el criterio quirúrgico y la realización de cirugía durante la inter nación, se observó un OR ajustado de 1.62 (IC95% 1.31- 2.00; p < 001), 0.77 (IC95% 0.31-1.93; p = 0.58), 7.49 (IC95% 2.07-27.07; p = 0.002) y 0.21 (IC95% 0.06-0.70; p = 0.01), respectivamente. Conclusiones : La mortalidad de la EI se asoció al grado de comorbilidad previa, a la forma de presenta ción y, en relación inversa, a la realización oportuna del tratamiento quirúrgico.

Abstract Introduction : Mortality of infective endocarditis (IE) in Argentina continues to be high. The aim objective was to describe the clinical characteristics and identify factors associated with in-hospital and long-term mortality in patients with native valve IE. Methods : Retrospective cohort study including adult patients with diagnosis of native valve IE, hospitalized during 2011-2021. Results : A total of 129 patients with a mean age of 66±17 years were included. The most frequent respon sible organism was Staphylococcus aureus (SA) (38.8%). Surgical indication criteria were present in 63.6% of the patients. Mortality during hospitalization was 22.5% .In the multivariate analysis that included Charlson comorbidity index, SA infection and the presence of surgical indication criteria, an adjusted OR of mor tality of 1.32 (95%CI 1.10-1.57; p = 0.003), 2.75 (95%CI 1.11-6.8; p = 0.028) and 4.14 (95%CI 1.34-12; p = 0.013), respectively, was observed. In the multivariate analysis for long term mortality, that added surgical indication criteria and the performance of surgery during hospitalization, an adjusted OR of 1.62 (CI95% 1.31-2.00; p<001), 0.77 (95%CI 0.31-1.93; p = 0.58), 7.49 (95%CI 2.07-27.07; p = 0.002) and 0.21 (95%CI 0.06-0.70; p = 0.01), respec tively, was observed. Conclusions : Mortality in IE was associated with the degree of previous comorbidity, with the presence of surgical indication criteria and, inversely, with the timely completion of surgical treatment.

Capacidad predictiva de diferentes puntajes de riesgo quirúrgico en la endocarditis infecciosa / Predictive Capacity of Different Surgical Risk Scores in Infective Endocarditis

RESUMEN Introducción. La endocarditis infecciosa (EI) es una enfermedad potencialmente mortal que puede requerir tratamiento quirúrgico. A pesar de ser fundamentales en la toma de decisiones, los puntajes de riesgo quirúrgico no fueron generados específicamente para estratificar el riesgo de esta enfermedad. Objetivos. Evaluar la capacidad predictiva de los puntajes de riesgo quirúrgico ajustados a la EI. Material y métodos. Estudio unicéntrico observacional y retrospectivo de 270 pacientes mayores de 18 años que cursaron internación por EI en actividad desde 06/2008 hasta 02/2023, de los cuales 70 (26 %) fueron sometidos a cirugía cardíaca central. Se excluyeron las endocarditis asociadas a dispositivos, y los pacientes que no se sometieron a cirugía cardíaca. Los puntajes de riesgo quirúrgico analizados fueron: EuroSCORE II, EURO-IE, STS-IE y PALSUSE (Prótesis, Edad >70, (Large) gran destrucción, Staphylococcus, Urgencia, Sexo femenino, EuroSCORE >10). La capacidad predictiva de cada puntaje se evaluó por medio del estadístico C, calculando el área bajo la curva de la relación sensibilidad/1-especificidad, con sus respectivos intervalos de confianza (IC) 95%, y su significación estadística. Resultados. La mediana (rango intercuartílico, RIC) de edad fue de 60 años (48-67) y la de los días de internación fue de 23 (17-39). Cuarenta y un pacientes (58,57 %) tenían una válvula protésica. Respecto a los gérmenes causales, el Staphylococcus fue responsable del 30 % de las infecciones. Las principales indicaciones de tratamiento quirúrgico fueron la insuficiencia cardíaca (44 %), el absceso (19%) y la disfunción protésica (12 %). Se objetivó absceso anular en el 28,57 % de los pacientes. La necesidad de cirugía de urgencia fue del 45,71 % y de emergencia del 7,14 %. La mortalidad hospitalaria fue del 21,42 %. La capacidad predictiva de todos los puntajes fue estadísticamente significativa, excepto el STS- IE . El STS-IE presentó un área bajo la curva (ABC) de 0,586 (IC 95% 0,429-0,743). El EuroSCORE II, un ABC de 0,685 (IC 95 % 0,541-0,830); el EURO-IE presentó un ABC de 0,695 (IC 95 % 0,556-0,834) y el PALSUSE un ABC de 0,819 (IC 95% 0,697-0,941). Conclusión. Los resultados de este estudio sugieren que el score PALSUSE fue mejor predictor de riesgo quirúrgico en pacientes con EI activa, en comparación con los puntajes Euroscore II, EURO-IE y STS-IE.

ABSTRACT Background. Infective endocarditis (IE) is a life-threatening disease that may require surgical treatment. Despite being fundamental in decision making, surgical scores were not generated specifically to stratify the risk of this disease. Objectives. The objective of this study was to: To evaluate the predictive capacity of surgical risk scores adjusted for IE. Methods. Single-center observational and retrospective study of 270 patients > 18 years, hospitalized for active IE from 06/2008 to 02/2023, of which 70 (26 %) underwent central cardiac surgery. Device-associated endocarditis and patients who did not undergo cardiac surgery were excluded. The surgical risk scores analyzed were: EuroSCORE II, EURO-IE, STS-IE and PALSUSE (Prosthesis, Age >70, large cardiac destruction, Staphylococcus, Urgency, Female gender, EuroScore >10). The predictive capacity of each score was evaluated using the C statistic, calculating the area under the curve of the sensitivity/1- specificity relationship with their respective 95 % confidence intervals (CI), and statistical significance. Results. The median age (interquartile range, IQR) was 60 years (48-67) and the number of days of hospitalization were 23 (17-39). Forty-one patients (58.57 %) had a prosthetic valve. Regarding the causative germs, Staphylococcus was responsible for 30 % of the infections. The main indications for surgical treatment were heart failure (44%), abscess (19 %) and prosthetic dysfunction (12%). Annular abscess was observed in 28.57 % of patients. Urgent surgery was performed in 45.71 % and emergency surgery was performed in 7.14 %. Hospital mortality was 21.42 %. The predictive capacity of all scores was statistically significant, except for the STS-IE. The STS-IE score presented an area under the curve (AUC) of 0.586 (95 % CI 0.429-0.743). The EuroSCORE II, an AUC of 0.685 (95 % CI 0.541-0.830); the EURO-IE presented an AUC of 0.695 (95 % CI 0.556-0.834) and the PALSUSE an AUC of 0.819 (95 % CI 0.697-0.941). Conclusion. The results of this study suggest that the PALSUSE score was a better predictor of surgical risk in patients with active IE, compared to the Euroscore II, EURO-IE and STS-IE scores.

Endocarditis Infecciosa Mural Apical del Ventrículo Izquierdo: Presentación de caso clínico y revisión bibliográfica / Infectious Apical Mural Endocarditis of the Left Ventricle: Clinical case presentation and bibliographic review

RESUMEN La endocarditis mural es una forma infrecuente de infección intracardiaca que afecta al endocardio no valvular que pue- de presentarse con complicaciones similares a la endocarditis infecciosa valvular. Se recomienda la ecocardiografía para confirmar el diagnóstico cuando exista un alto índice de sospecha. Con respecto al tratamiento, existe evidencia limitada acerca de las estrategias terapéuticas en la endocarditis mural, sin embargo en la mayoría de casos reportados se recomienda iniciar antibioticoterapia dirigida asociado a una intervención quirúrgica precoz. A continuación, se presenta un caso clínico de un paciente masculino de 74 años con fenómenos embólicos sistémicos, en quien se documenta por ecocardiograma transesofágico una endocarditis mural en ápex del ventrículo izquierdo asociado a una bacteriemia por Staphylococcus aureus. Este caso pone de manifiesto la importancia de una valoración ecocardiográfica detallada de las válvulas y cámaras cardíacas ante la sospecha de una endocarditis infecciosa.

ABSTRACT Mural endocarditis is an uncommon form of intracardiac infection affecting the non valvular endocardium that can present with complications similar to valvular infective endocarditis. Echocardiography is recommended to confirm the diagnosis when there is a high index of suspicion. Regarding treatment, there is limited evidence about therapeutic strategies in mural endocarditis, however in most reported cases it is recommended to initiate targeted antibiotic therapy associated with early surgical intervention. The following is a clinical case of a 74-year-old male patient with systemic embolic phenomena, in whom a transesophageal echocardiogram documented mural endocarditis in the apex of the left ventricle associated with Staphylococcus aureus bacteremia. This case highlights the importance of a detailed echocardiographic assessment of the cardiac valves and chambers when infective endocarditis is suspected.

Desempenho do Escore SHARPEN e do Índice de Comorbidade de Charlson para Predição de Mortalidade durante a Internação Hospitalar e após a Alta na Endocardite Infecciosa / Performance of the SHARPEN Score and the Charlson Comorbidity Index for In-Hospital and Post-Discharge Mortality Prediction in Infective Endocarditis

Resumo Fundamento O SHARPEN foi o primeiro escore desenvolvido especificamente para a predição de mortalidade hospitalar em pacientes com endocardite infecciosa (EI), independentemente da realização de cirurgia cardíaca. Objetivos Analisar a capacidade do escore SHARPEN na predição de mortalidade hospitalar e mortalidade após a alta e compará-la à do Índice de Comorbidade de Charlson (ICC). Métodos Estudo retrospectivo do tipo coorte incluindo internações por EI (segundo os critérios de Duke modificados) entre 2000 e 2016. A área sob a curva ROC (AUC-ROC) foi calculada para avaliar a capacidade preditiva. Curvas de Kaplan-Meier e regressão de Cox foram realizadas. Um valor de p < 0,05 foi considerado estatisticamente significativo. Resultados Estudamos 179 internações hospitalares. A mortalidade hospitalar foi 22,3%; 68 (38,0%) foram submetidos à cirurgia cardíaca. Os escores SHARPEN e ICC (mediana e intervalo interquartil) foram, respectivamente, 9(7-11) e 3(2-6). O escore SHARPEN mostrou melhor predição de mortalidade hospitalar em comparação ao ICC nos pacientes não operados (AUC-ROC 0,77 vs. 0,62, p = 0,003); não foi observada diferença no grupo total (p=0,26) ou nos pacientes operados (p=0,41). Escore SHARPEN >10 na admissão foi associado a uma menor sobrevida hospitalar no grupo total (HR 3,87; p < 0,001), nos pacientes não operados (HR 3,46; p = 0,006) e de pacientes operados (HR 6,86; p < 0,001) patients. ICC > 3 na admissão foi associada a pior sobrevida hospitalar nos grupos total (HR 3,0; p = 0,002), de pacientes operados (HR 5,57; p = 0,005), mas não nos pacientes não operados (HR 2,13; p = 0,119). A sobrevida após a alta foi pior nos pacientes com SHARPEN > 10 (HR 3,11; p < 0,001) e ICC > 3 (HR 2,63; p < 0,001) na internação; contudo, não houve diferença na capacidade preditiva entre esses grupos. Conclusão O SHARPEN escore foi superior ao ICC na predição de mortalidade hospitalar nos pacientes não operados. Não houve diferença entre os escores quanto à mortalidade após a alta.

Abstract Background SHARPEN was the first dedicated score for in-hospital mortality prediction in infective endocarditis (IE) regardless of cardiac surgery. Objectives To analyze the ability of the SHARPEN score to predict in-hospital and post-discharge mortality and compare it with that of the Charlson comorbidity index (CCI). Methods Retrospective cohort study including definite IE (Duke modified criteria) admissions from 2000 to 2016. The area under the ROC curve (AUC-ROC) was calculated to assess predictive ability. Kaplan-Meier curves and Cox regression was performed. P-value < 0.05 was considered statistically significant. Results We studied 179 hospital admissions. In-hospital mortality was 22.3%; 68 (38.0%) had cardiac surgery. Median (interquartile range, IQR) SHARPEN and CCI scores were 9(7-11) and 3(2-6), respectively. SHARPEN had better in-hospital mortality prediction than CCI in non-operated patients (AUC-ROC 0.77 vs. 0.62, p = 0.003); there was no difference in overall (p = 0.26) and in operated patients (p = 0.41). SHARPEN > 10 at admission was associated with decreased in-hospital survival in the overall (HR 3.87; p < 0.001), in non-operated (HR 3.46; p = 0.006) and operated (HR 6.86; p < 0.001) patients. CCI > 3 at admission was associated with worse in-hospital survival in the overall (HR 3.0; p = 0.002), and in operated patients (HR 5.57; p = 0.005), but not in non-operated patients (HR 2.13; p = 0.119). Post-discharge survival was worse in patients with SHARPEN > 10 (HR 3.11; p < 0.001) and CCI > 3 (HR 2.63; p < 0.001) at admission; however, there was no difference in predictive ability between these groups. Conclusion SHARPEN was superior to CCI in predicting in-hospital mortality in non-operated patients. There was no difference between the scores regarding post-discharge mortality.

Endodontic treatment as a Reduction in the Risk of infective Endocarditis in a Male Patient with Eisenmenger Syndrome

This case report aimed to describe the importance of endodontic treatment in reducing infectious foci in patients with Eisenmenger syndrome (ES) and describe the characteristics of ES, so that the endodontist can safely treat these patients. A 57-year-old male with ES sought dental care complaining of dental pain. Irreversible pulpitis was diagnosed in tooth 37 and pulp necrosis in teeth 36, 34 and 31. Tests of prothrombin time (PT), activated partial thromboblastin time (APTT) and international normalized ratio (INR) were prescribed to evaluate the profile of coagulation using Marevan and antibiotic prophylaxis with amoxicillin. The endodontic treatments were performed. At the end, the patient reported no pain or discomfort in the teeth and improved masticatory function. The removal of oral infectious foci in patients with ES is important to reduce the risk of IE, which could seriously compromise the health and overall prognosis of the patient.

Este reporte de caso tuvo como objetivo describir la importancia del tratamiento endodóntico en la reducción de focos infecciosos en pacientes con síndrome de Eisenmenger (SE) y describir las características del SE, para que el endodoncista pueda tratar con seguridad a estos pacientes. Un hombre de 57 años con ES buscó atención dental quejándose de dolor dental. Se diagnosticó pulpitis irreversible en el diente 37 y necrosis pulpar en los dientes 36, 34 y 31. Se solicitaron pruebas de tiempo de protrombina (PT), tiempo de tromboblastina parcial activada (TTPA) y índice internacional normalizado (INR) para evaluar el perfil de coagulación utilizando Marevan y profilaxis antibiótica con amoxicilina. Se realizaron los tratamientos de endodoncia. Al final, el paciente no refirió dolor ni molestias en los dientes y mejoró la función masticatoria. La eliminación de focos infecciosos orales en pacientes con ES es importante para reducir el riesgo de EI, que podría comprometer gravemente la salud y el pronóstico general del paciente.

Candida parapsilosis endocarditis without vegetations at Echocardiography: a case report / Endocarditis por Candida parapsilosis sin vegetaciones ecocardiográficas: Un reporte de caso

ABSTRACT Candida endocarditis is a very serious manifestation of candida infections, and it has increased in incidence over the past years. Of these, C. parapsilosis has been described as a cause of endocarditis in native valves of intravenous drug users and prosthetic valves. We report the case of a female that developed a cerebrovascular accident secondary to emboli from aortic prosthetic valve C. parapsilosis endocarditis, despite apparently normal echocardiography. She received antifungal therapy without surgical intervention.

RESUMEN La endocarditis por Candida spp. es una manifestación muy grave de las infecciones por este patógeno y su incidencia ha ido aumentando en los últimos años. La Candida parapsilosis se ha descrito como causa de endocarditis en válvulas nativas de usuarios de drogas intravenosas y prótesis valvulares. Presentamos el caso de una mujer que desarrolló un accidente cerebrovascular secundario a émbolos fúngicos procedentes de una prótesis valvular aórtica infectada por C. parapsilosis, a pesar de un ecocardiograma sin vegetaciones. La paciente recibió tratamiento antifúngico sin necesidad de intervención quirúrgica.

Embolia pulmonar en endocarditis infecciosa asociada a marcapasos: reporte de un caso y revisión de la literatura

Introducción: Una de las complicaciones más temidas de la endocarditis infecciosa (EI) asociada a marcapasos es la embolia pulmonar. Presentamos el caso de una paciente con diagnóstico actual de EI asociada a marcapasos, que luego de la extracción del dispositivo por vía percutánea presentó síntomas de embolia pulmonar confirmada mediante estudios por imágenes. Objetivos: Conocer el manejo y la evolución intrahospitalarios y a los 18 meses de la embolia pulmonar en el contexto de una endocarditis infecciosa asociada a marcapasos. Materiales y métodos: Búsqueda bibliográfica efectuada en PubMed. Relato del caso clínico: evaluación clínica, presentación de los estudios complementarios y tratamiento. Seguimiento del caso. Resultados: Paciente de 68 años, sexo femenino, con antecedente de implantación de marcapaso definitivo bicameral hace 2 años. Síndrome febril prolongado sin foco aparente, con hemocultivos que fueron positivos para Staphylococcus aureus meticilino-resistente. En el ecocardiograma transesofágico presentaba múltiples vegetaciones en aurícula derecha asociadas con los catéteres. Con base en la anamnesis, el examen físico y los hallazgos en exámenes específicos, se pudo lograr el diagnóstico de EI asociada a marcapasos. Se indicó tratamiento antibiótico y la remoción completa percutánea del dispositivo. Luego del procedimiento presentó disnea súbita confirmándose mediante estudio de centellograma ventilación-perfusión el diagnóstico de embolia pulmonar. Completó el tratamiento antibiótico (vancomicina durante 6 semanas) y fue dada de alta. Durante el seguimiento no presentó nuevas infecciones u otras complicaciones. Conclusión: En nuestro caso, la embolia pulmonar no generó modificaciones en la morbimortalidad intrahospitalaria ni en el seguimiento a 18 meses.

Introduction: One of the most feared infective endocarditis (IE) complications associated with pacemaker is pulmonary embolism. We present the case of a patient with a current diagnosis of pacemaker-associated IE who presented symptoms of pulmonary embolism confirmed by imaging studies after percutaneous removal of the device. Objectives: to know the management and evolution, in-hospital and at 18 months of pulmonary embolism in the context of infective endocarditis associated with pacemaker. Materials and methods: Bibliographic search carried out in PubMed. Clinical case report: clinical evaluation, presentation of complementary studies, and treatment. Follow up on the case. Results: 68-year-old patient with a history of dual chamber permanent pacemaker implantation 2 years ago. Prolonged febrile syndrome with no apparent focus, with positive blood cultures for methicillin-resistant Staphylococcus aureus. The transesophageal echocardiogram showed multiple vegetations associated in right atrial with the catheters. Based on the history, physical examination, and findings in specific tests, the diagnosis of IE associated with DEIP could be achieved. Antibiotic treatment and complete percutaneous removal of the device were indicated. After the procedure, he presented sudden dyspnea, confirming the diagnosis of pulmonary embolism in a ventilation-perfusion scintigram study. She completed the antibiotic treatment (vancomycin for 6 weeks) and was discharged. During follow-up, there were no new infections or other complications. Conclusion: in our patient pulmonary embolism did not generate changes in in-hospital morbidity and mortality or in the 18-month follow-up.

Embolia pulmonar en endocarditis infecciosa asociada a marcapasos: reporte de un caso y revisión de la literatura / Pulmonary embolism in infective endocarditis associated with pacemaker: report of a case and review of the literature

Introducción: Una de las complicaciones más temidas de la endocarditis infecciosa (EI) asociada a marcapasos es la embolia pulmonar. Presentamos el caso de una paciente con diagnóstico actual de EI asociada a marcapasos, que luego de la extracción del dispositivo por vía percutánea presentó síntomas de embolia pulmonar confirmada mediante estudios por imágenes. Objetivos: Conocer el manejo y la evolución intrahospitalarios y a los 18 meses de la embolia pulmonar en el contexto de una endocarditis infecciosa asociada a marcapasos. Materiales y métodos: Búsqueda bibliográfica efectuada en PubMed. Relato del caso clínico: evaluación clínica, presentación de los estudios complementarios y tratamiento. Seguimiento del caso. Resultados: Paciente de 68 años, sexo femenino, con antecedente de implantación de marcapaso definitivo bicameral hace 2 años. Síndrome febril prolongado sin foco aparente, con hemocultivos que fueron positivos para Staphylococcus aureus meticilino-resistente. En el ecocardiograma transesofágico presentaba múltiples vegetaciones en aurícula derecha asociadas con los catéteres. Con base en la anamnesis, el examen físico y los hallazgos en exámenes específicos, se pudo lograr el diagnóstico de EI asociada a marcapasos. Se indicó tratamiento antibiótico y la remoción completa percutánea del dispositivo. Luego del procedimiento presentó disnea súbita confirmándose mediante estudio de centellograma ventilación-perfusión el diagnóstico de embolia pulmonar. Completó el tratamiento antibiótico (vancomicina durante 6 semanas) y fue dada de alta. Durante el seguimiento no presentó nuevas infecciones u otras complicaciones. Conclusión: En nuestro caso, la embolia pulmonar no generó modificaciones en la morbimortalidad intrahospitalaria ni en el seguimiento a 18 meses.

Introduction: One of the most feared infective endocarditis (IE) complications associated with pacemaker is pulmonary embolism. We present the case of a patient with a current diagnosis of pacemaker-associated IE who presented symptoms of pulmonary embolism confirmed by imaging studies after percutaneous removal of the device. Objectives: to know the management and evolution, in-hospital and at 18 months of pulmonary embolism in the context of infective endocarditis associated with pacemaker. Materials and methods: Bibliographic search carried out in PubMed. Clinical case report: clinical evaluation, presentation of complementary studies, and treatment. Follow up on the case. Results: 68-year-old patient with a history of dual chamber permanent pacemaker implantation 2 years ago. Prolonged febrile syndrome with no apparent focus, with positive blood cultures for methicillin-resistant Staphylococcus aureus. The transesophageal echocardiogram showed multiple vegetations associated in right atrial with the catheters. Based on the history, physical examination, and findings in specific tests, the diagnosis of IE associated with DEIP could be achieved. Antibiotic treatment and complete percutaneous removal of the device were indicated. After the procedure, he presented sudden dyspnea, confirming the diagnosis of pulmonary embolism in a ventilation-perfusion scintigram study. She completed the antibiotic treatment (vancomycin for 6 weeks) and was discharged. During follow-up, there were no new infections or other complications. Conclusion: in our patient pulmonary embolism did not generate changes in in-hospital morbidity and mortality or in the 18-month follow-up.

Endocarditis infecciosa y eritema multiforme minor

El eritema multiforme es una reacción inmunomediada que envuelve la piel y algunas veces a la mucosa. Las infecciones y medicamentos constituyen las causas más comunes. Típicamente se presenta como lesiones "en diana" sobreelevadas con centro pálido y borde eritematoso o lesiones atípicas como vesículas o ampollas. Se presenta el caso de una mujer de 68 años que acude por tumoración a nivel del antebrazo derecho con signos inflamatorios más fiebre, se constata por ecografía aneurisma micótico en dicho miembro y se realiza ecocardiografía transtorácica donde se observan vegetaciones en válvulas aortica y mitral. Durante la internación presenta aparición de lesiones ampollosas con bordes eritematosos distribuidas en tronco y brazos con biopsia que informa erupción liquenoide ampollosa compatible con eritema multiforme minor.

Erythema multiforme is an immune-mediated reaction that involves the skin and sometimes the mucosa. Infections and medications are the most common causes. Typically presents as raised "target" lesions with a pale center and erythematous border or atypical lesions such as vesicles or bullae. We present the case of a 68-year-old woman who presented with a tumor on the right forearm with inflammatory signs plus fever, a mycotic aneurysm was confirmed by ultrasound in the limb and a transthoracic echocardiography was performed where vegetations were observed on the aortic and mitral valves. During hospitalization, she presented bullous lesions with erythematous borders distributed on the trunk and arms with a biopsy that reported bullous lichenoid eruption compatible with erythema multiforme minor.

Bentall-De Bono Reoperation Associated With Pseudoaneurysm and Infectious Endocarditis

Abstract We present the case of a 55-year-old patient who underwent the Bentall-De Bono procedure with mechanical prosthesis in 2005 and was admitted to the emergency department in July 2020 with mixed shock. Complementary exams showed an abscess involving the prosthetic tube, two thirds of the aortic valve circumference and the left ventricle, with a neocavity of about 45 mm in diameter from the aortic sinus to the ascending aorta. The patient underwent surgical repair, with a new procedure using the Bentall-De Bono technique, now associated with coronary artery bypass grafting with a great saphenous vein graft between the aorta and the anterior descending artery. Culture of samples collected intraoperatively showed Staphylococcus epidermidis. The patient received antibiotic therapy for 30 days, evolving favorably, and is under regular outpatient follow-up.

The Bacterial Profile of Aortic Infectious Endocards: Experience of the Cardiology Department, Mohammed VI University Hospital of Marrakech, Morocco

Introduction: Infective endocarditis is defined as infection of a native or prosthetic heart valve, endocardial surface, or cardiac device. The causes and epidemiology, as well as the microbiology of the disease have evolved over the last few decades with the doubling of the average age of patients and an increased prevalence in patients with indwelling cardiac devices. Patients and Methods: This is a retrospective study, including all subjects over 20 years of age who presented with infective endocarditis of the aortic valve, hospitalized between January 2019 and December 2022, in the Department of Cardiology and Vascular Diseases at ERRAZI Hospital-Mohammed VI University Hospital in Marrakech. Clinical, paraclinical and therapeutic data were collected for each case using an exploitation form. Results: Over the study period, 46 patients had presented with aortic positional AR, with a sex ratio that was equal to 1.8. The mean age of the patients was 43±12.5 years. Endocarditis on aortic prosthesis was found in 15%. The valves were rheumatic in 85%. The presumed portal of entry was cutaneous in 45%, oral and ENT in 33%, urinary in 15%, and digestive in 7%. In our series, 21 out of 26 patients presented a biological inflammatory syndrome. At least one or more blood cultures were positive in 38% of cases. Coagulase-negative Staphylococcus was the most common germ in aortic infective endocarditis, found in 40% of positive blood cultures. All the patients in our series had received a combination of broad-spectrum intravenous antibiotic therapy, initially probabilistic, taking into consideration the portal of entry. Adapted after antibiogram results. The evolution during the hospitalization, was marked by an improvement of the clinical state in only 12%, a perioperative death in 38%, and a worsening of the clinical state in 50%, with an average duration of hospitalization of 14 days. In our series, 60% of the patients with positive blood cultures died, whereas there was 75% survival in the group with negative blood cultures. Conclusion: Infective endocarditis is a serious disease because of its high morbidity and mortality. Despite improvements in diagnostic testing, antimicrobial therapy, and surgical intervention, changes in the epidemiology of IE, including the increase in healthcare-associated infections and the virulence of staphylococcus aureus as the causative organism, increase the risk of complications and death in the acute phase of IE. Action must be taken to prevent infective endocarditis, especially in this rheumatically endemic area.

Pacemaker Infective Endocarditis: Diagnostic and Therapeutic Particularities in 2 Case Reports Including One of the Left Heart

Pacemaker infective endocarditis is a more real diagnostic problem than a therapeutic one. The precise impact is not well known. Its incidence is poorly known, and it is a serious infection with an estimated mortality of around 25%. It is with this in mind that we report 2 clinical cases with a literature review. Case 1: An 88-year-old patient with a double chamber pacemaker was admitted for febrile syndrome with a fever at 39.2°. Transthoracic and transesophageal echocardiography (TOE) found an image of vegetation on the aortic valve measuring 9mm, located on the noncoronary cusp, and overflowing on the right coronary cusp. An inflammatory syndrome was found on blood tests. Blood culture, wound swab culture, and bacteriological study of material after removal revealed Staphylococcus Aureus Meti S. The patient was initially put on Vancomycin with a loading dose of 2g / 24h then 1g / 24h, and the pacemaker was extracted. Case 2: A 68-year-old with a double chamber pacemaker (PM) was admitted for fever at 39 ° c with suppuration of the PM pocket. Echocardiography identified an image on the tricuspid valve measuring 14x8 mm evoking vegetation given the context. Two blood cultures and swabs isolated a Staphylococcus aureus. The patient was administered Triaxon 2g / day for 4 weeks and gentamycin 180 mg for 15 days. The pacemaker was removed. Pacemaker Infective endocarditis is rare, poorly understood, very serious, and potentially fatal, accounting for up to about 7% in some case series. In half of the cases, they affect the endocavitary leads, but also the valves, and in 45% of cases the infection of the pocket. The average age is 65 years. The clinical symptoms are disparate making the diagnosis more difficult, it must be evoked in case of unexplained fever in a patient implanted with a Pacemaker. Bactericidal dual therapy should be administered after blood cultures in case of strong suspicion of infective endocarditis (IE) and adapted after identification of the germ in question. Most authors are adamant about extracting any pacemaker whenever possible.

Analysis of the SHARPEN Score in the Prediction of In-Hospital Mortality of Patients With Infective Endocarditis Undergoing Cardiac Surgery

Abstract Background The SHARPEN score was developed to predict in-hospital mortality in patients hospitalized for infective endocarditis (IE), undergoing or not undergoing cardiac surgery. A comparison with other available scores has not yet been carried out. Objective To evaluate the performance of the SHARPEN score in predicting in-hospital mortality in patients hospitalized for IE undergoing cardiac surgery and compare it with that of both nonspecific and IE-specific surgical scores. Methods Retrospective cohort study including all admissions of patients ≥18 years who underwent cardiac surgery due to active IE (modified Duke criteria) at a tertiary care university hospital between 2007 and 2016. The SHARPEN score was compared to the EuroSCORE, EuroSCORE II, STS-IE, PALSUSE, AEPEI, EndoSCORE and RISK-E scores. Differences P<0.05 were considered statistically significant. Results A total of 105 hospitalizations of 101 patients (mean age 57.4±14.6 years; 75.2% male) were included. The median SHARPEN score was 11 (9-13) points. The observed in-hospital mortality was 29.5%. There was no statistically significant difference in observed vs. estimated mortality (P = 0.147), with an area under the ROC curve of 0.66 (P = 0.008). In comparison with the other scores, no difference was observed in discriminative ability. The statistics of the SHARPEN score at a cutoff >10 points — positive predictive value (PPV): 38.1%, 95%CI:30.4-46.6; negative predictive value (NPV): 80.0%, 95%CI:69.8-87.4; and accuracy: 58.1%, 95%CI:48.1-67.6 — showed overlapping 95%CIs, indicating no significant difference between scores. Conclusions The SHARPEN score did not present parameters with a significant difference in relation to the other scores analyzed; despite the easy obtainment of its few variables, it has limited applicability in clinical practice, like other existing scores.

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.

Echocardiographic Aspect of Infectious Aortic Endocarditis: Experience of the Cardiology Department, Mohammed VI University Hospital of Marrakech, Morocco

Introduction: Infective Endocarditis (IE) is a serious disease whose prognosis depends on early management. Aortic localization is characterized by its progression to myocardial failure and the high number of complications motivating early recourse to surgery. The diagnosis of AR is based on microbiological and imaging studies. Echocardiography is the recommended imaging modality to make the diagnosis, assess the impact and guide surgery. Materials and Methods: This is a retrospective study, including all subjects over 20 years of age who presented with infective endocarditis of the aortic valve, hospitalized between January 2019 and December 2022, in the Department of Cardiology and Vascular Diseases at the ERRAZI-CHU Mohammed VI Hospital in Marrakech. Clinical, paraclinical and therapeutic data were collected for each case using an exploitation form. Results: During the study period, 26 patients had presented with aortic positional AR, with a sex ratio that was equal to 1.8. The mean age of the patients was 43±12.5 years. A known history of valvular disease was found in 57% of the cases. Among the native valvular diseases, rheumatic origin was found in 85%. The most common valvular lesions were represented by vegetations (88%), which were mobile in 56%, measuring between 10 and 20 mm in half of the cases, their most predominant localization was on the ventricular side with a tilt.IE on severe IAo was found in 90% of cases. The most common associated valvulopathies were MI (53%), RAo (38%) and MR (34%), whose severity was variable. The association of aortic disease with mitral disease was the most frequent association. Echocardiographic complications were presented by fistulas, perforations and peri-aortic abscesses (2 cases each) which were correlated with severe AI. Regarding the impact of the aortic AR on the LV, we noted a marked dilatation in 42% of cases with a preserved ejection fraction in 74%. A quarter of our patients had undergone transesophageal echocardiography in addition to transthoracic echocardiography, with an average time between admission and completion of 3 days. The indication of its realization was posed in front of the doubt of the visualization of an image of vegetations or suspicion of complications not visualized with the TTE. Valvular lesions found on TEE were essentially vegetations in 45% of cases, prolapses in 22% of cases, as well as abscesses, para-prosthetic leaks and prosthesis deinsertion found in 11% of cases. Conclusion: Aortic AR remains a frequent pathology in our context. Aortic insufficiency is the most predisposing valvulopathy and the most common sonographic appearance is vegetations. The results of our study have shown that complications of AE occur preferentially in patients with severe aortic insufficiency.

Double Outlet Right Ventricle Infective Endocarditis: A Rare Combination and a Therapeutic Challenge

Infective endocarditis involving the right side of the heart occurs rarely and often involves the tricuspid valve. The isolated pulmonary valve infective endocarditis (IPVIE) is a less common condition that occurs in specific population. The double outlet right ventricle (DORV) is an unusual congenital heart disease. The association of DORV and IPVIE darkens the prognosis. We report two cases of the association of DORV and IPVIE. The transthoracic echocardiography (TTE) is the base to the diagnosis. Right sided infective endocarditis in the lack of a guided strategy remains a therapeutic challenge.

Diagnostic Use of Serum Ferritin as a Predictor of Hospital Outcome at Admission in Patients with Infective Endocarditis

Background: Infective endocarditis (IE) is characterised by a concentration of infection inside the heart; it is caused by a bacterial or fungal infection of the endocardial surface of the heart; and it is linked with substantial morbidity and death.The aim of this research was to assess serum ferritin as an admission predictor of in-hospital prognosis in subjects with IE. Methods: This case control researchincluded60subjects diagnosed with IEon the basis of the modified duke's criteria.Subjects were allocated equally into two groups: group I: IE subjects who were further subdivided into two groups based on presence or absence of major adverse cardiovascular events (subgroup A: 19 patients who showed IE complications or major adverse cardiac events during hospitalization and subgroup B: 11 patients who showed a smooth course during hospitalization without major adverse cardiac events or IE complications) and IE subjects as well as age and sex matched 30 healthy subjects. Results: serum ferritin level were significantly increased in group I than group II (P value<0.05). Serum ferritin level was significantly increased in subgroup A than subgroup B (P value<0.001). serum ferritin can significantly predict bad outcome (P value<0.001) with AUC of 0.964 (95% CI: 0.881 – 0.995). At cut off >1200, serum ferritin can significantly predict bad outcome with 94.44% sensitivity, 92.86% specificity, 85% PPV and 97.5% NPV. Conclusions: Serum ferritin was significantly increased in IE subjects who experiencedproblems on admission as compared to IE subjects who didn’t.

Endocarditis de la válvula aórtica causada por Brucella melitensis / Aortic valve endocarditis caused by Brucella melitensis

La endocarditis bacteriana secundaria a la infección por Brucella spp., en este caso B. melitensis, como complicación de la brucelosis humana tiene una incidencia baja y, aunque es la presentación clínica con la que se asocia más frecuentemente la mortalidad, no todos los casos son letales, si son tratados oportunamente. Se describe el caso clínico de una endocarditis bacteriana por B. melitensis, diagnosticada en un adulto por el aislamiento del microorganismo en el hemocultivo. Paciente del sexo masculino, de 40 años, con antecedentes de realizar partos en el ganado bovino y consumir leche no pasteurizada. Acudió al médico por presentar durante siete días de evolución de las siguientes manifestaciones clínicas: fiebre, mialgias, artralgias, tos seca y pérdida de peso (15 kg). El hemograma informa: leucopenia, trombocitopenia y anemia; mientras que en un ecocardiograma transesofágico se observó vegetación en la válvula aórtica con una disminución de la función sistólica y en el hemocultivo se aisló B. melitensis. Debido a estos antecedentes, se inició el tratamiento antibacteriano con rifampicina, doxiciclina y gentamicina. El paciente se recuperó y tuvo una evolución clínica satisfactoria. La brucelosis es una enfermedad infrecuente. Debe considerarse en toda persona con fiebre de foco desconocido que resida en zonas endémicas o esté expuesto al cuidado de animales de granja. En esta enfermedad se impone un diagnóstico y tratamiento preciso, por ser una complicación con alta letalidad.

Bacterial endocarditis, secondary to Brucella spp. infection, in this case by B. melitensis, as a complication of human brucellosis has a low incidence. Although it is the clinical presentation most frequently associated with mortality, not all cases are lethal if timely treatment is provided. We describe a clinical case of bacterial endocarditis due to B. melitensis in a 40-year-old male patient with a history of conducting cattle deliveries and consuming unpasteurized milk, diagnosed after isolating the microorganism in blood culture. He presented with the following clinical manifestations after seven days of evolution: fever, myalgias, arthralgias, dry cough and weight loss (15 kg). The hemogram revealed leukopenia, thrombocytopenia, and anemia; while a transesophageal echocardiogram showed vegetation on the aortic valve with decreased systolic function, and B. melitensis was isolated in a blood culture. Considering this medical history, antibacterial treatment was initiated with rifampicin, doxycycline and gentamicin. The patient recovered and had satisfactory clinical evolution. Brucellosis is a rare disease. It should be considered in any person with a fever of unknown origin who lives in endemic areas or is exposed to the care of farm animals. Endocarditis is a highly lethal complication of human brucellosis; therefore, it requires a precise diagnosis and treatment.

Infective Endocarditis: Experience of the Cardiology Department of the Mohammed VI University Hospital

Introduction: Infective endocarditis (IE) is a rare but potentially serious disease. It causes a high mortality and a high level of morbidity and complications. Its epidemiological, clinical and microbiological characteristics have changed in recent years. The Aim of our Work: Is to study the epidemiological, clinical, bacteriological, ultrasonographic, therapeutic and evolutionary data of IE between January 2017 and October 2022 in the Mohammed VI University Hospital and to compare them to the global profile. Materials and Methods: Retrospective study including 110 patients hospitalized for a definite IE, according to the modified DUKE criteria, in the cardiology department of the Mohammed VI University Hospital over a period of 5 years and 10 months from January 2017 to October 2022. Results: The average age of our patients was 43 years with a male predominance. The bacterial graft was on native valve in 80% with predominance of rheumatic origin (69%), on cardiac prosthesis in 10% of patients, on healthy heart (4%) and congenital heart disease (6%). The most frequent portal of entry was dental (30%). Blood cultures were positive only in 33% of patients, isolating a staphylococcus (16%), a streptococcus (14%) and a GNB (3%). Transthoracic echocardiography (TTE) showed vegetation in 108 cases, valve perforation in 7 cases, cord rupture in 1 patient and perivalvular abscess in 10 cases. Seventy-seven percent of patients had surgical treatment with a mean delay of 29 days. The overall mortality was 24% with heart failure (p<0.001), renal failure (p=0.004) and neurological complications (p=0.002) as predictive factors of mortality. Conclusion: Infective endocarditis remains a real health problem with a consequent mortality and morbidity. The population is often young, revealing the IE by complications; its prevention is the best way to improve its prognosis.