Heterogeneidad del tratamiento para cándida parapsilosis en endocarditis micótica de válvula nativa / Types of treatments for native-valve endocarditis due to candida parapsilosis

Introducción: las infecciones por cándida en el ámbito intrahospitalario han ido en ascenso en las últimas décadas en especial en las unidades de cuidado intensivo (UCI), dado el uso cada vez más frecuente de antibióticos de amplio espectro y de procedimientos invasivos tanto diagnósticos como terapéuticos. Hoy se consideran las especies de cándida como la cuarta causa de infección del torrente sanguíneo en los Estados Unidos de Norteamérica, con alto riesgo de complicaciones que incluyen endocarditis, trombosis y embolismo séptico al sistema nervioso central (SNC) entre otros. En relación con la endocarditis por especies de cándida, se ha considerado de mal pronóstico por el alto riesgo de afectación al SNC, por lo que se ha recomendado el manejo quirúrgico como piedra angular de su tratamiento. Presentación del caso: se describe el caso clínico de un paciente con endocarditis y con candidemia por Candida parapsilosis a quien se le realizó manejo médico.

Nosocomial Candida infections have increased in the last decades particularly in the intensive care units (ICU) due to the rise in broad-spectrum antibiotics usage and invasive diagnostic and therapeutic procedures usage. Today, Candida species are recognized as the fourth causative organisms of endovascular infection in the United States of America posing a high risk of endocarditis, thrombosis and septic embolization to the central nervous system (CNS). Endocarditis due to Candida species is associated with a poor prognosis because of the increased risk of CNS involvement for which surgical approach has been recommended as the cornerstone of therapy. We hereby report a patient with endocarditis and candidemia due to Candida parapsilosis, who received medical management.

Antifungal efficacy of amphotericin b in candida albicans endocarditis therapy: systematic review

Abstract Introduction: Although it is the most common agent among the fungal causes of endocarditis, Candida albicans endocarditis is rare. Objective: To evaluate the efficacy of amphotericin B in the treatment of C. albicans endocarditis beyond a systematic review. Data search: Articles in English, Spanish and Portuguese, conducted in the following databases: MEDLINE, LILACS, IBECS and SciELO, in humans and published in the last 25 years. Study selection: Observational studies, clinical trials, and case series providing data on the amphotericin B use in patients with a C. albicans endocarditis diagnosis without age limitations. Data synthesis: From the initial search (n=79), 25 articles were fully evaluated, of which 19 were excluded for meeting one or more exclusion criteria, remaining five articles (two observational studies and three case series). Patients using amphotericin B demonstrated improvement in survival rates, and its main use was in association with the surgical method as well as with caspofungin association. Conclusion: Literature lacks evidence to conclude about efficacy and safety of amphotericin B in the treatment of fungal endocarditis. Randomized clinical trials are necessary to provide better evidence on the subject.

Tomografía por emisión de positrones en endocarditis infecciosa asociada a dispositivos y válvulas protésicas / Positron emission tomography in infective endocarditis associated with intracardiac devices and prosthetic valves

La endocarditis infecciosa (EI) es una enfermedad grave y potencialmente letal. La capacidad diagnóstica de los criterios de Duke modificados es alta para válvulas nativas, pero decae en el caso de EI de válvulas protésicas o EI asociadas a dispositivos. El ecocardiograma y los hallazgos microbiológicos son fundamentales para el diagnóstico, pero pueden resultar insuficientes en este grupo de pacientes. Nuestro objetivo fue evaluar la utilidad de la tomografía por emisión de positrones y fusión con tomografía computarizada (PET/TC) en pacientes con sospecha de EI, portadores de válvulas protésicas o dispositivos intracardiacos. Se estudiaron 32 pacientes, a los cuales se les realizó un PET/CT con 18F-Flúor desoxiglucosa (18F-FDG). Se consideraron sugestivos de infección aquellos con captación intensa de tipo focal y/o heterogénea con un punto de corte de Standard Uptake Value (SUV) mayor o igual a 3.7. Los diagnósticos iniciales según los criterios de Duke modificados, se compararon con el diagnóstico final establecido por la Unidad de Endocarditis institucional. El agregado del PET/CT a esos criterios, proporcionó un diagnóstico concluyente en 22 de los 32 casos iniciales, reclasificando a 11 casos en EI definitivas y a otros 5 casos como negativos para ese diagnóstico. La EI continúa siendo un grave problema clínico. En aquellos casos donde los criterios de Duke no son suficientes para establecer el diagnóstico y la sospecha clínica persiste, el PET/CT puede ser una herramienta complementaria útil para aumentar la sensibilidad diagnóstica.

Infective endocarditis (IE) is a serious and potentially lethal condition. The diagnostic capacity of the modified Duke criteria is high for native valves, but it declines in the case of EI of prosthetic valves or EI associated with devices. Echocardiography and microbiological findings are essential for diagnosis but may be insufficient in this group of patients. Our objective was to evaluate the usefulness of positron emission tomography and fusion with computed tomography (PET / CT) in patients with suspected IE, carriers of prosthetic valves or intracardiac devices; 32 patients were studied, who underwent PET / CT with 18F-Fluorine deoxyglucose (18F-FDG). Those with intense focal and/or heterogeneous uptake with a Standard Uptake Value (SUV) cut-off point greater than or equal to 3.7 were considered suggestive of infection. The initial diagnoses according to the modified Duke criteria were compared with the final diagnosis established by the Institutional Endocarditis Unit. The addition of PET / CT to these criteria, provided a conclusive diagnosis in 22 of the 32 initial cases reclassifying 11 cases in definitive EI; another 5 cases were negative for that diagnosis. EI continues to be a serious clinical problem. In those cases where the Duke criteria are not sufficient to establish the diagnosis and clinical suspicion persists, PET / CT can be a useful complementary tool to increase the diagnostic sensitivity.

Risk Factors for In-Hospital Mortality in Infective Endocarditis / Fatores de Risco para Mortalidade Hospitalar na Endocardite Infecciosa

Abstract Background: Infective endocarditis (IE) is associated with severe complications and high mortality. The assessment of mortality rates and predictors for fatal events is important to identify modifiable factors related to the pattern of treatment, in order to improve outcomes. Objectives: We sought to evaluate clinical outcomes of patients with IE and to determine predictors of in-hospital mortality. Methods: Retrospective single-center study including patients with IE admitted during a 10-year period (2006-2015). Data on comorbidities, clinical presentation, microbiology and clinical outcomes during hospitalization were evaluated. Risk factors of in-hospital death were analyzed. A p-value < 0.05 was considered significant. Results: A total of 134 cases were included (73% males, mean age of 61 ± 16 years-old). Half of them had previous valvular heart disease. Healthcare-associated IE and negative blood-cultures occurred in 22% and prosthetic IE in 25%. The aortic valve was the one most often affected by infection. Staphylococcus aureus was the most commonly isolated microorganism. Forty-four (32.8%) patients underwent cardiac surgery. The in-hospital mortality rate was 31.3% (42 patients). The identified risk factors for in-hospital mortality were Staphylococcus aureus etiology (OR 6.47; 95% CI: 1.07-39.01; p = 0.042), negative blood-cultures (OR 9.14; 95% CI: 1.42-58.77; p = 0.02), evidence of valve obstruction in echocardiography (OR 8.57; 95% CI: 1.11-66.25; p = 0.039), clinical evolution with heart failure (OR 4.98; 95%CI: 1.31-18.92; p = 0.018) or septic shock (OR 20.26; 95% CI: 4.04-101.74; p < 0.001). Cardiac surgery was a protective factor of mortality (OR 0.14; 95% CI 0.03-0.65; p = 0.012). Conclusion: The risk factors for in-hospital mortality were clinical (heart failure, septic shock), evidence of valve obstruction in echocardiography, Staphylococcus aureus etiology or negative blood cultures. Invasive treatment by surgery significantly decreased the mortality risk.

Resumo Fundamento: A endocardite infecciosa (EI) está associada a complicações graves e alta mortalidade. A avaliação das taxas de mortalidade e preditores de eventos fatais é importante para identificar fatores modificáveis relacionados ao padrão de tratamento, com o objetivo de melhorar os desfechos. Objetivos: Avaliar os desfechos clínicos de pacientes com EI e determinar preditores de mortalidade hospitalar. Métodos: Estudo retrospectivo de centro único, incluindo pacientes com EI admitidos durante um período de 10 anos (2006-2015). Foram avaliados dados de comorbidades, apresentação clínica, microbiologia e desfechos clínicos durante a internação. Foram analisados os fatores de risco de morte hospitalar. Um valor de p < 0,05 foi considerado significativo. Resultados: Foram incluídos 134 casos (73% do sexo masculino, média de idade de 61 ± 16 anos). Metade dos casos apresentava cardiopatia valvar prévia. A EI associada a cuidados de saúde e hemoculturas negativas ocorreram em 22%, e a EI associada a prótese em 25%. A válvula aórtica foi a mais frequentemente afetada por infecção. Staphylococcus aureus foi o microrganismo mais comumente isolado. Quarenta e quatro (32,8%) pacientes foram submetidos à cirurgia cardíaca. A taxa de mortalidade hospitalar foi de 31,3% (42 pacientes). Os fatores de risco identificados para mortalidade hospitalar foram etiologia do Staphylococcus aureus (OR 6,47; IC 95%: 1,07-39,01; p = 0,042), hemoculturas negativas (OR 9,14; IC 95%: 1,42-58,77; p = 0,02), evidência de obstrução valvar na ecocardiografia (OR 8,57; IC 95%: 1,11-66,25; p = 0,039), evolução clínica com insuficiência cardíaca (OR 4,98; IC 95%: 1,31-18,92; p = 0,018) ou choque séptico (OR 20,26; IC 95%: 4,04-101,74; p < 0,001). A cirurgia cardíaca foi um fator protetor de mortalidade (OR 0,14; IC95%: 0,03-0,65; p = 0,012). Conclusão: Os fatores de risco para mortalidade hospitalar foram clínicos (insuficiência cardíaca, choque séptico), evidência de obstrução valvar no ecocardiograma, etiologia do Staphylococcus aureus ou hemoculturas negativas. O tratamento invasivo por cirurgia diminuiu significativamente o risco de mortalidade.

Aortic valve endocarditis due to Bartonella clarridgeiae in a dog in Brazil / Endocardite de válvula aórtica por Bartonella clarridgeiae em um cão no Brasil

Abstract We report the first documented case of endocarditis associated with Bartonella clarridgeiae in a dog in Latin America. Infective vegetative valvular aortic endocarditis was diagnosed in a 10-year-old male mixed breed dog. The dog presented grade V/VI systolic and diastolic murmur, hyperthermia, and progressive weight loss. Cardiomegaly and presence of diffuse alveolar pattern in the lung fields were observed in the thorax radiography evaluation. Irregular and hyperechogenic structures adhered to the aortic leaflets, causing obstruction of the left ventricular outflow tract and severe aortic insufficiency, were observed in the echocardiography evaluation. A vegetative, whitish, hardened structure measuring 1.0 cm in diameter was observed in aortic semilunar valve at necropsy. Based on a combination of pre-enrichment insect-based medium liquid culture, quantitative real-time and conventional PCR assays based on nuoG and gltA genes, respectively, followed by sequencing and phylogenetic inferences, B. clarridgeiae DNA was detected in the patient's aortic valve lesions. Clinical, echocardiographic, anatomopathologic and molecular features supported the diagnosis of severe aortic vegetative endocarditis possibly caused by B. clarridgeiae in a dog in Brazil.

Resumo Relatamos o primeiro caso documentado de endocardite associada à Bartonella clarridgeiae em um cão na América Latina. Endocardite aórtica valvar vegetativa infecciosa foi diagnosticada em um cão sem raça definida de 10 anos de idade. O cão apresentou sopro sistólico e diastólico de grau V / VI, hipertermia e perda progressiva de peso. Cardiomegalia e presença de padrão alveolar difuso nos campos pulmonares foram observados na avaliação radiográfica do tórax. Estruturas irregulares e hiperecogênicas aderidas aos folhetos aórticos, causando obstrução da via de saída do ventrículo esquerdo e insuficiência aórtica grave, foram observadas na avaliação ecocardiográfica. À necropsia, foi observada uma estrutura vegetativa, esbranquiçada e endurecida medindo 1,0 cm de diâmetro na válvula semilunar aórtica. Por meio de uma combinação de cultura líquida baseada em meio de pré-enriquecimento de inseto, ensaios de PCR quantitativa em tempo real e convencional baseados nos genes nuoG e gltA, respectivamente, seguidos de sequenciamento e inferências filogenéticas, DNA de B. clarridgeiae foi detectado no tecido valvular lesionado do paciente. O diagnóstico de endocardite vegetativa aórtica grave, possivelmente causado por B. clarridgeiae em um cão no Brasil, foi apoiado por características clínicas, ecocardiográficas, anatomopatológicas e moleculares.

Endocarditis infecciosa nativa en pediatría: enfoque clínico cardiológico / Native valve infective endocarditis in children: From the focus of clinical cardiology

Objetivos: Analizar las características demográficas, clínicas, microbiológicas, evolución y factores de riesgo de morbimortalidad asociados a la endocarditis de válvula nativa (EIN) en pacientes (p) pediátricos. Población y métodos: Se evaluaron 176 p con EIN, divididos en grupo I: <3meses (27p) y grupo II: >3meses (149p). Resultados: Grupo I: el 66% tenía corazón sano. El microorganismo más frecuente fue Staphylococcus aureus (44,4%). Afectación derecha (77,8%-p<0,0001). Evento principal: infección no controlada (INC) (52%, p=0,0009) y asociada a Candida (p<0,00001). Se indicó tratamiento quirúrgico a 10 p (37%). Mortalidad 29,6%(8p). Grupo II: el 57% presentaba cardiopatía previa. Microorganismos prevalentes: S.aureus (49,1%) y estreptococos del grupo viridans (22,5%). Hubo compromiso predominantemente izquierdo (p=0,001). Eventos: embolias sistémicas (36,2%-p=0,01), perforación valvular (51%-p=0,0005), insuficiencia cardíaca (26%-p=0,03) e INC (21,5%). La embolia sistémica se asoció a S.aureus (p=0,01). El 36,2% requirió cirugía. Mortalidad 6,7% (10p). En el análisis univariado la mortalidad se asoció a edad <3meses (p=0,0003), INC (p=0,002) y S.aureus (p=0,03). En el multivariado la mortalidad se relacionó a edad < 3meses (OR:7,50 ­IC95%:1,77­31,69) y a INC (OR:4,2-IC95%:1,16­15,29). Conclusiones: La EN se presentó en pacientes con corazón sano en el 50% de los casos. El microorganismo más frecuente fue S.aureus. En los <3 meses la infección no controlada fue la complicación más frecuente asociada a Candida, con afectación predominante de cavidades derechas. Los >3meses tuvieron mayor prevalencia de perforación valvular izquierda asociada a embolias sistémicas e insuficiencia cardíaca. El 35% de los p requirió cirugía. Los predictores de mortalidad fueron la edad <3meses y la INC.

Objectives: To analyze demographic, clinical, and microbiological, outcome, and morbidity and mortality risk factors associated with native valve endocarditis (NVE) in pediatric patients (p). Population and methods: 176 p with NVE were evaluated and divided into group I: <3 months (27p) and group II: >3 months (149p). Results: Group I: 66% had a healthy heart. The most common microorganism was Staphylococcus aureus (44.4%). Right-sided involvement (77.8%-p<0.0001). Main event: Uncontrolled infection (UCI) (52%, p-0.0009) and association with Candida (p<0.00001). Surgical treatment was indicated in 10 p (37%). Mortality was 29.6% (8p). Group II: 57% had previous heart disease. Prevalent microorganisms: S. aureus (49.1%) and viridans group streptococci ( (22.5%). Left-sided involvement predominated (p-0.001). Events: systemic embolism (36.2%-p-0.01), valve perforation (51%-p-0.0005), heart failure (26%-p-0.03), and UCI (21.5%). Systemic embolism was associated with S. aureus infection (p-0.01). 36.2% required surgery. Mortality was 6.7% (10p). In univariate analysis, mortality was associated with age <3 months (p-0.0003), UCI (p-0.002), and S. aureus infection (p-0.03). In multivariate analysis, mortality was related to age <3 months (OR:7.50 ­ 95% CI:1.77­31.69) and UCI (OR:4.2 -95% CI:1.16­15.29). Conclusions: NVE was observed in patients with a healthy heart in 50% of cases. The most common microorganism found was S. aureus. In the <3 months group, uncontrolled infection was the most common complication associated with Candida, predominantly affecting the right side. The >3 months group had a higher prevalence of left-valve perforation associated with systemic embolism and heart failure. 35% of p required surgery. Predictors of mortality were age <3 months and UC (AU)

A broad-range PCR technique for the diagnosis of infective endocarditis

Abstract Infective endocarditis (IE) remains a severe and potentially fatal disease demanding sophisticated diagnostic strategies for detection of the causative microorganisms. The aim of the present study was to develop a broad-range 16S ribosomal RNA gene polymerase chain reaction in the routine diagnostic of IE for the early diagnosis of fatal disease. A broad-range PCR technique was selected and evaluated in terms of its efficiency in the diagnosis of endocarditis using 19 heart valves from patients undergoing cardiovascular surgeries at the Habib Bourguiba Hospital of Sfax, Tunisia, on the grounds of suspected IE. The results demonstrated the efficiency of this technique particularly in cases involving a limited number of bacteria since it helped to increase detection sensitivity. The technique proved to be efficient, particularly, in the bacteriological diagnosis of IE in contexts involving negative results from conventional culture methods and other contexts involving bacterial species that were not amenable to identification by phenotypic investigations. Indeed, the sequencing of the partial 16S ribosomal RNA gene revealed the presence of Bartonella henselae, Enterobacter sp., and Streptococcus pyogenes in three heart valves with the negative culture. It should be noted that the results obtained from the polymerase chain reaction-sequencing identification applied to the heart valve and the strain isolated from the same tissue were not consistent with the ones found by the conventional microbiological methods in the case of IE caused by Gemella morbillorum. In fact, the results from the molecular identification revealed the presence of Lactobacillus jensenii. Overall, the results have revealed that the proposed method is sensitive, reliable and might open promising opportunities for the early diagnosis of IE.

The frequency of infective endocarditis in candida bloodstream infections: a retrospective study in a child hospital

Abstract Introduction: Fungal endocarditis is reported less frequently than bacterial endocarditis, with an incidence of 0-12% of the total pediatric infective endocarditis. Objective: In this study, the incidence of infective endocarditis in Candida bloodstream infections in a tertiary hospital during the periods of 2007 and 2016 was reviewed. Methods: Patients with positive blood or catheter cultures in terms of Candida spp. during the study period of January 2007 and January 2016 were analyzed in terms of Candida infective endocarditis. Infective endocarditis was defined according to the modified Duke criteria. The outcome, possible associated predisposing factors for Candida endocarditis were determined. Results: 221 patients and 256 attacks with positive blood or catheter cultures in terms of Candida were included in the study. The most common Candida species was Candida parapsilosis, isolated in 157 (61.3%) attacks, followed by Candida albicans in 70 (27.3%). Neurological diseases (23%), hemato-oncological diseases (12.1%), previously known heart diseases (8.2%), inborn errors of metabolism (9%) were common comorbidities. Twelve (5.4%) patients had a previous history of cardiac surgery. Among the 221 patients, Candida endocarditis was present in only two (0.9%) of them. Conclusion: Although Candida infective endocarditis is an uncommon but frequently fatal infection in pediatrics, echocardiography should be performed routinely for patients with positive blood or catheter cultures in terms of Candida. Prompt and effective antimicrobial therapy might prevent cardiac surgery in selected cases, however this could not be a general rule for all patients.

Endocarditis infecciosa asociada a catéter de hemodiálisis: hallazgos clínicos y ecocardiográficos / Infective endocarditis associated with hemodialysis catheters: clinical and ehocardiographic findings

Resumen: Hallazgos clínicos y ecocardiográficos en pacientes con endocarditis infecciosa (E.I.) asociada a catéter de hemodiálisis (CHD) fueron comparados con sujetos controles con E.I. "habitual". Pacientes y métodos: Del total de registros ecocardiográficos de una Clínica privada de Antofagasta entre 2009 y 2014, 4 pacientes presentaban E.I. asociada CHD (E.I.-CHD) y 16 otro tipo de E.I. (controles). Se compararon ambos grupos clínicamente y en las distintas modalidades de ecografía, para evaluar el aporte de cada una de ellas en el diagnóstico, manejo y comprensión del mecanismo de producción de la E.I. Resultados: El periodo del inicio de los síntomas hasta la hospitalización y el comprendido entre ésta hasta el fallecimiento fue variable, con tendencia a fallecimiento más precoz en el grupo E.I.-CHD (promedio 14,6 vs 20,6 días en el grupo control). La edad en E.I.-CHD fue mayor (65 versus 62.2 años), con mayor incidencia de las 3 comorbilidades más frecuentes: hipertensión arterial (100% versus 56,25%), diabetes mellitus (75% versus 50%) e insuficiencia cardíaca (75% versus 31,25%). La mortalidad fue 18.75% en el grupo control y 75% en la E.I.-CHD. En los pacientes con E.I.-CHD se aisló: Cándida (50%), Bacilos gram negativo (Stenotrophomonas maltophilia) (25%) y SAMR (25%) mientras que en el grupo control fueron aislados Enterococcus faecalis (25%), Streptococcus viridans (12.5%), Streptococcus spp (6.25%), Staphylococcus aureus (6.25%), Streptococcus grupo C (6.25%), Abiotrophia defectiva (6.25%) y Streptococcus pneumoniae (6.25). En 31.25% de los casos los hemocultivos fue-ron negativos. La localización más frecuente de las vegetaciones en los pacientes con E.I.-CHD correspondió a la pared de AD, sitio de impacto del jet del CHD, en un 100%, seguida por CHD 50%, tricúspide 25% y aórtica 25%. En los controles las localizaciones fueron 75% en válvula aórtica y 25% en válvula mitral. En el grupo de E.I.-CHD, la mitad presentó disfunción sistólica e insuficiencia valvular, mientras que en el grupo control fue predominante la insuficiencia valvular (62,5%) seguida por la perforación de velo (25%). Conclusión: En las E.I.-CHD se aislaron gérmenes asociados a un peor pronóstico (hongos o bacterias atípicas), con altísima mortalidad. La localización principal de las vegetaciones fue en la pared de la aurícula derecha (AD), alrededor de la desembocadura de la vena cava inferior (VCI), sitio de impacto del jet del CHD, y en el tercio distal del catéter. Clinical and echocardiographic findings in patients with infective endocarditis (I.E.) associated to the presence of hemodialysis catheters (HDC) were compared to those in subjects with other types of I.E.

Abstracts: Methods: Between 2009 and 2014 an echocardiographic diagnosis of I.E. was established in 4 subjects with a hemodialysis catheter in place and 16 patients had a common variety of I.E. (controls). Clinical and echocardiographic findings, including echocardiographic modalities were compared between groups. Results: Time from onset of symptoms and time to patient death were shorter in I.E.-HDC patients compared to controls (mean 14.6 vs 20.6 days, respectively. I.E. -HDC patients tended to be older (65.0 vs 62.2 years old). The incidence of main comorbidities was higher in I.E.-HDC: hypertension (100% vs 56.2%), diabetes (75 vs 59%) and heart failure (75% vs 31.2%), respectively. Mortality was much higher in I.E-HDC (74% vs 18%). Infective agents also differed between groups: I.E.-HDC was associate to C albicans (50%), Gram negative rods (Stenotrophomonas maltophilia) (25%) y SAMR (25%). In contrast, the agents involved in controls were E faecalis (25%), S viridans (12.5%), S. group C (6.25%), S aureus (6,25%), group C Streptococcus (6.25%), Abiotrophic defectiva (6.25%) and S pneumoniae (6.25%). Overall, blood cultures were negative in 31.2% patients. Among patients with I.E.-HDC vegetations were most commonly found at the right atrial wall (100%), on the catheter (50%), at the tricuspid valve (25%) and at the aortic valve (25%). In non I.E.-HDC, vegetations were located at the aortic valve (75%) and the mitral valve (25%). Half the patients with I.E.- HDC patients presented ventricular dysfunction and valvular regurgitation while control patients had predominantly valvular insufficiency (62.5%) or leaflet perforation (25%). Conclusion: Mortality in I.E.-HDC patients was very high, associated to the presence of aggressive microbial or fungal agents. Vegetations were most commonly located at the right atrial wall, around de junction with the inferior vena cava and on the catheter itself.

Activador tisular del plasminógeno recombinante para el tratamiento de la vegetación intracardíaca en un lactante de muy bajo peso al nacer / Recombinant tissue plasminogen activator treatment for intracardiac vegetation in a very low birth weight infant

Las nuevas opciones de tratamiento prolongan la hospitalización y aumentan las infecciones intrahospitalarias bacterianas y fúngicas, pero también mejoran la sobrevida de los recién nacidos hospitalizados en la unidad de cuidados intensivos neonatales. Las infecciones fúngicas invasivas en neonatos están asociadas con una morbimortalidad significativa. También pueden diseminarse a órganos específicos y causar endocarditis, endoftalmitis, artritis séptica, nefropatía obstructiva y meningitis. En el caso de la endocarditis, se recomiendan tratamientos antimicóticos sistémicos agresivos y, en algunos casos, la intervención quirúrgica del neonato. Informamos el caso de un lactante prematuro, de bajo peso al nacer, con vegetación intracardíaca. Esta es una complicación rara y potencialmente mortal de infecciones fúngicas invasivas. El paciente recibió tratamiento con caspofungina y un activador tisular del plasminógeno recombinante, en vez de una intervención quirúrgica.

Developing treatment options have resulted in prolonged admission and increased bacterial and fungal nosocomial infections as well as improved survival in neonatal intensive care unit. Invasive fungal infections in newborns are associated with significant morbidity and mortality and can cause endorgan dissemination such as endocarditis, endophthalmitis, septic arthritis, obstructive nephropathy and meningitis. Endocarditis requires aggressive systemic antifungal therapy and sometimes surgical intervention in neonates. We report a low birth weight premature infant with intracardiac vegetation that is rare and a life-threatening complication of invasive fungal infections. He was treated with caspofungin and recombinant tissue plasminogen activator in stead of surgical intervention.

Endocarditis Infecciosa: caracterización clínica de la enfermedad: revisión de casos de los últimos 5 años / Infective endocarditis: clinical experience in the last five years

Antecedentes: La Endocarditis infecciosa es una enfermedad grave y su incidencia ha aumentado en el último tiempo. En Chile faltan estudios observaciona-les que representen adecuadamente nuestra realidad local y nacional. Objetivo: Describir las características clínicas, ecográficas y bacteriológicas de los pacientes con Endocarditis Infecciosa del Hospital Carlos Van Buren de Valparaíso, entre los años 2012 y 2016. Métodos: Se realizó un análisis descriptivo de 35 pacientes con diagnóstico de Endocarditis infecciosa, recolectándose variables clínicas, imagenológicas y de laboratorio. Para describir los resultados se utilizó frecuencias, medianas y figuras. Resultados: Se observó un aumento de casos de Endocarditis infecciosa en los últimos dos años. Del total de pacientes con Endocarditis infecciosa, 28 casos (80%) eran de válvula nativa, siendo el compromiso más frecuente el de válvula aórtica. Se observó un aumento de las comorbilidades no cardíacas y de los casos provocados por el grupo Staphylococcus. Los síntomas más comunes fueron compromiso del estado general y fiebre, y las complicaciones más frecuentes fueron insuficiencia renal aguda, insuficiencia cardíaca aguda y fenómenos embólicos. Un total de 14 pacientes fallecieron producto de la infección, las complicaciones y cirugía. Conclusiones: Se realiza una caracterización actualizada de la enfermedad. Se necesitan más estudios con un mayor número de paciente para un mejor entendimiento de nuestra realidad.

Background: Infective endocarditis is a severe illness the incidence of which has increased over time. There are relatively few observational studies that adequately represent the characteristics of the disease in Chile. Aim: To describe clinical, echographic and bacteriological characteristics of patients with infective endocarditis at Carlos van Buren Hospital in Valparaíso, between 2012 and 2016. Methods: A descriptive analysis of 35 patients diagnosed with infective endocarditis was performed. Cinical, imaging findings and laboratory variables were collected. Relative frequencies, medians and figures were used to describe the results. Results: We observed an increase in cases of infective endocarditis in the last two years. Of all patients diagnosed with infective endocarditis, 80% had native valve involvement, more frequently at the aortic valve. There was an increase in non-cardiac comorbidities and Staphylococcus was identified as the main etiology. Weakness and fever were the most common symptoms, whereas more common complications were acute kidney and heart failure and embolic phenomena. A total of 14 patients died of infection, complications or after surgery surgery. Conclusions: An updated characterization of Infective endocarditis at a Chilean hospital is presen-ted. However, more studies are needed with a larger number of patients for a better characterization of the disease in our country.

Fungal endocarditis

ABSTRACT Fungal endocarditis is a rare and fatal condition. The Candida and Aspergillus species are the two most common etiologic fungi found responsible for fungal endocarditis. Fever and changing heart murmur are the most common clinical manifestations. Some patients may have a fever of unknown origin as the onset symptom. The diagnosis of fungal endocarditis is challenging, and diagnosis of prosthetic valve fungal endocarditis is extremely difficult. The optimum antifungal therapy still remains debatable. Treating Candida endocarditis can be difficult because the Candida species can form biofilms on native and prosthetic heart valves. Combined treatment appears superior to monotherapy. Combination of antifungal therapy and surgical debridement might bring about better prognosis.

Endocarditis micótica en un recién nacido de extremadamente bajo peso al nacer: A propósito de un caso / Fungal endocarditis in an extremely low birth weight infant: Case report

Las tasas de supervivencia de los recién nacidos prematuros se han incrementado gracias a los avances tecnológicos y los conocimientos en constante evolución, aunque la sepsis de aparición tardía es más frecuente debido a los períodos prolongados de hospitalización de estos niños. Presentamos el caso de un recién nacido prematuro de extremadamente bajo peso al nacer hospitalizado con síndrome de dificultad respiratoria, enterocolitis necrosante y sepsis fúngica con endocarditis por Candida albicans. Se le administró tratamiento antimicótico hasta que se resolvió la vegetación fúngica. La sepsis y la endocarditis de origen micótico podrían ser una causa de morbilidad significativa en los recién nacidos prematuros. En este artículo revisamos las publicaciones científicas recientes acerca de los factores de riesgo, el diagnóstico, el tratamiento y la prevención de la sepsis fúngica en estos neonatos de alto riesgo.

Survival rates of premature infants have increased with developing technology and evolving knowledge but late-onset sepsis is more frequent due to prolonged hospitalization periods of these infants. We report the case of an extremely low birth weight premature infant who was admitted with respiratory distress syndrome, developed necrotizing enterocolitis and fungal sepsis with endocarditis by Candida albicans. He was treated with antifungal therapy until fungal vegetation resolved. Fungal sepsis and endocarditis may be an important morbidity in preterm infants; we review the recent literature about the risk factors, diagnosis, treatment and prevention of fungal sepsis in these high risk infants.

Endocarditis y artritis séptica por Salmonella no Typhi productora de β-lactamasas de espectro extendido: A case report / Endocarditis and arthritis caused by extended spectrum β-lactamase-producing non-Typhi Salmonella

We present the case of a patient with endocarditis and arthritis caused by extended spectrum β-lactamase producing non-Typhi Salmonella, with incomplete response (defined as persistence of Salmonella in joint fluid) to initial instituted treatment (trimethoprim-sulfamethoxazole) and posterior recovery with ertapenem. The disease was associated with implantable central venous catheter infection. Five percent of patients with non-Typhi Salmonella gastroenteritis develop bacteremia. Infective endocarditis and joint infection has been reported in 1,4% and less than 1% of cases, respectively.

Se presenta el caso de un paciente con endocarditis y artritis séptica por Salmonella no Typhi productora de β-lactamasas de espectro extendido que presentó una respuesta incompleta (definida como la persistencia de Salmonella en el líquido articular) al tratamiento inicial con cotrimoxazol y que posteriormente mejoró con ertapenem. La enfermedad se asoció al uso de un catéter venoso implantable. El 5% de los pacientes con gastroenteritis por Salmonella no Typhi desarrolla una bacteriemia. La endocarditis infecciosa y la artritis ha sido reportada en 1,4-5% de los casos y en menos de 1%; respectivamente.

Bacteriemias por Streptococcus gallolyticus (ex S. bovis) y su relación con patología colónica o hepatobiliar y endocarditis / Streptococcus gallolyticus (ex S. bovis) bacteremia and its relationship with colonic or hepatobiliary disease and endocarditis

Background: Bacteremia due to Streptococcus bovis (now S. gallolyticus) has been traditionally associated to colon or hepatobiliar disease and endocarditis but there is no information on this matter in Chile. Aims: To describe clinical features of adult patients suffering bacteremia by S. bovis/S. gallolyticus, identify the source of the bacteremia and the frequency of endocarditis. Methods: Retrospective-descriptive study using laboratory records. Results: Between January 2003 and August 2014, 23 S. bovis/S. gallolyticus bacteremic events were identified among 22 patients. Mean age was 72.7 years (range 46-96). Co-morbidities were frequent (9.1 to 47.6%). The primary source of bacteremia was intestinal in 52.2%; hepatobiliar in 17.4% and in 34.8% it was not elucidated. Six patients had infective endocarditis (26.1%) and one patient had espondylodiscitis (4.3%). S. bovis represented 39.1% of isolates (all until 2008), S. gallolyticus subsp pasteurianus 39.1% and, S. gallolyticus subsp infantarius and S. gallolyticus subsp gallolyticus 8.7% each one, respectively. Association studies between the bacteremic source or endocarditis with specific S. gallolyticus subspecies were limited by the small number of isolates. Seven patients (30.4%) underwent surgical interventions. In-hospital mortality reached 21.7% (n = 5). Conclusions: Although infrequent, bacteremic events by S. gallolyticus/S. bovis have increased in-hospital mortality, require surgical intervention and affect older patients with co-morbidities. Near two-thirds suffer from colonic or hepatobiliary disease that act as the primary source of bacteremia. In addition, near one fourth is affected by infective endocarditis. Detection of S. gallolyticus/S. bovis in blood cultures prompts a thorough clinical evaluation in order to clarify the source of the bloodstream infection and the presence of complications.

Antecedentes: Los cuadros de bacteriemia por Streptococcus bovis (actualmente S. gallolyticus) han sido tradicionalmente asociados a patología colónica o hepatobiliar y endocarditis pero no se conoce de estudios en Chile que hayan abordado este tema. Objetivos: Describir aspectos clínicos de pacientes adultos afectados por bacteriemias por S. bovis/S. gallolyticus, identificar la fuente de la bacteriemia y la frecuencia de endocarditis. Métodos: Diseño de tipo retrospectivo, descriptivo, con el registro de casos bacteriemia. Resultados: Entre enero de 2003 y agosto de 2014 se identificaron 23 eventos de bacteriemia por S. bovis/S. gallolyticus en 22 pacientes. La edad promedio fue de 72,7 años (rango 46-96). La prevalencia de diferentes co-morbilidades fue elevada (9,1 a 47,6%). El foco primario de la bacteriemia fue intestinal en 52,2%, hepatobiliar en 17,4% y, en 34,8% no se aclaró el foco. Seis pacientes presentaron endocarditis infecciosa (26,1%) y uno espondilodiscitis (4,3%). S. bovis representó 39,1% de los aislados (todos hasta el 2008), S. gallolyticus subsp pasteurianus 39,1%, S. gallolyticus subsp infantarius y S. gallolyticus subsp gallolyticus 8,7%, respectivamente. Los estudios de asociación estuvieron limitados por el bajo número de aislados. Siete pacientes (30,4%) debieron ser intervenidos quirúrgicamente. La mortalidad hospitalaria fue de 21,7% (n: 5). Conclusiones: Aunque infrecuentes, los eventos de bacteriemia por S. gallolyticus/S. bovis tienen una elevada mortalidad hospitalaria, requieren con frecuencia procedimientos quirúrgicos y afectan a pacientes mayores con co-morbilidades. Cerca de dos tercios padecen de una patología colónica o hepatobiliar que actúa como foco primario y cerca de un cuarto presenta endocarditis infecciosa. La detección de este grupo bacteriano en los hemocultivos requiere una evaluación para establecer el origen de la bacteriemia y la presencia de complicaciones.

Healthcare-Associated Infective Endocarditis: a Case Series in a Referral Hospital from 2006 to 2011 / Endocardite Infecciosa Associada aos Cuidados de Saúde: Série de Casos em Hospital de Referência entre 2006 e 2011

Background: Healthcare-associated infective endocarditis (HCA-IE), a severe complication of medical care, shows a growing incidence in literature. Objective: To evaluate epidemiology, etiology, risk factors for acquisition, complications, surgical treatment, and outcome of HCA-IE. Methods: Observational prospective case series study (2006-2011) in a public hospital in Rio de Janeiro. Results: Fifty-three patients with HCA-IE from a total of 151 cases of infective endocarditis (IE) were included. There were 26 (49%) males (mean age of 47 ± 18.7 years), 27 (51%) females (mean age of 42 ± 20.1 years). IE was acute in 37 (70%) cases and subacute in 16 (30%) cases. The mitral valve was affected in 19 (36%) patients and the aortic valve in 12 (36%); prosthetic valves were affected in 23 (43%) patients and native valves in 30 (57%). Deep intravenous access was used in 43 (81%) cases. Negative blood cultures were observed in 11 (21%) patients, Enterococcus faecalis in 10 (19%), Staphylococcus aureus in 9 (17%), and Candida sp. in 7 (13%). Fever was present in 49 (92%) patients, splenomegaly in 12 (23%), new regurgitation murmur in 31 (58%), and elevated C-reactive protein in 44/53 (83%). Echocardiograms showed major criteria in 46 (87%) patients, and 34 (64%) patients were submitted to cardiac surgery. Overall mortality was 17/53 (32%). Conclusion: In Brazil HCA-IE affected young subjects. Patients with prosthetic and native valves were affected in a similar proportion, and non-cardiac surgery was an infrequent predisposing factor, whereas intravenous access was a common one. S. aureus was significantly frequent in native valve HCA-IE, and overall mortality was high. .

Fundamento: A endocardite infecciosa associada aos cuidados de saúde (EI-ACS) é uma complicação grave associada aos cuidados médico-hospitalares, com uma incidência crescente na população. Objetivo: Avaliar a EI-ACS com relação à sua epidemiologia, etiologia, fatores de risco de aquisição, complicações, tratamento cirúrgico e quadro clínico. Métodos: Este estudo de caráter observacional e prospectivo avaliou uma série de casos reportados entre 2006 e 2011 em um hospital público no Rio de Janeiro. Resultados: Cinquenta e três pacientes com EI-ACS de um total de 151 casos de endocardite infecciosa (EI) foram incluídos no estudo, dos quais 26 (49%) eram do sexo masculino (idade média de 47 ± 18,7 anos), e 27 (51%) eram sexo feminino (idade média de 42 ± 20,1 anos). Quadros clínicos agudos de EI ocorreram em 37 casos (70%) e quadros subagudos em 16 casos (30%). A válvula mitral foi afetada em 19 casos (36%), e a valva aórtica em 12 casos (36%). As válvulas cardíacas protéticas foram afetadas em 23 casos (43%), e as válvulas cardíacas nativas em 30 casos (57%). O acesso venoso profundo foi usado em 43 pacientes (81%). Hemoculturas negativas foram observadas em amostras de 11 pacientes (21%). Nas hemoculturas positivas, Enterococcus faecalis foi identificado em 10 casos (19%), Staphylococcus aureus em 9 casos (17%) e Candida sp. em 7 casos (13%). Febre ocorreu em 49 pacientes (92%), esplenomegalia em 12 pacientes (23%), novo sopro de regurgitação valvar em 31 pacientes (58%) e proteína C reativa elevada em 44 pacientes (83%). O ecocardiograma apresentou critérios principais em 46 casos (87%). Trinta e quatro pacientes (64%) foram submetidos à cirurgia cardíaca. A mortalidade ocorreu em 17 casos (32%). Conclusão: EI-ACS afeta ...

Clinical spectrum of fever of unknown origin among adult Egyptian patients admitted to Ain Shams university hospitals: a hospital based study

This prospective study was designed to analyze the clinical spectrum of fever of unknown origin [FUO] among adult Egyptian patients admitted to Ain Shams University Hospitals during the period from May 2009 till the end of December 2010. All Egyptian patients fulfilling the criteria of FUO admitted during this period were followed up till reaching the diagnosis. 93 patients were included in the study. They were 48 [51.6%] females and 45 [48.4%] males, their ages ranged from 15 to 65 years [34.39 +/- 13.6]. Infections were the commonest cause of FUO[41.94%] followed by malignancies[30.11%]. While autoimmune diseases represented 15.05% and in 12.9% of patients the diagnosis was not established. Brucellosis and infective endocarditis were the commonest infections, while hematological malignancies were the commonest oncological diseases. Systemic lupus erythematosus [SLE] was the commonest auto-immune disease. Brucellosis, infective endocarditis, hematological malignancies and SLE must be considered in the differential diagnosis of adult FUO in Egypt

Endocardite infecciosa com apresentação inicial de abdome agudo / Infective endocarditis with initial presentation of acute abdomen

Paciente de 35 anos de idade foi atendido em Serviço de Emergência com seis horas de dor em fossa ilíaca direita e febre. Feita hipótese diagnóstica de apendicite aguda e realizada laparotomia exploradora. com apendicectomia. O paciente retornou ao hospital três dias após alta hospitalar. prostrado. febril. com alteração de fala. diminuição de nível de consciência e com hemiparesia completa à esquerda. CT scan de crânio e punção de líquor normal. RMN de encéfalo revelou aspectos compatíveis com AVC isquêmico vertebro-basilar. Ecocardiograma transesofágico demonstrou vegetação em valva aórtica e insuficiência aórtica moderada e hemoculturas foram positivas para Enterococcus bovis.

A 35-year-old patient was seen in an Emergency Department. with six hours of pain in the right iliac fossa and fever. The hypothesis diagnosis was acute appendicitis and an exploring laparotomy for appendectomy was carried out. The patient returned to the hospital three days after having been discharged. debilitated. feverish. having alterations in speech. reduction in the level of consciousness and complete hemiparesis to the left. The computed tomography scan of the skull and the liquor puncture were normal. Cerebral magnetic resonance image showed aspects compatible with vertebrobasilar ischemic stroke. Transesphofagic echocardiogram showed vegetation of the aortic valve and moderate aortic insufficiency. Blood cultures were positive for Enterococcus bovis.

Infective endocarditis among hospitalized intravenous drug user patients in the south west of Iran

To determine the frequency of Infective Endocarditis [IE], clinical, echocardiographic and microbiological status at a teaching hospital in Ahvaz, South West Iran. Medical records of 323 Intravenous Drug User [IDU] inpatients from 2001 to 2006 were reviewed, out of which 33 cases that fulfilled the Duke criteria for diagnosis were included in the present study. The patients' characteristics, clinical findings, microbiological findings, echocardigraphic and comorbidities data were extracted. Data of patients with IE and without IE were compared in SPSS using t-test and chi square test. Patients with IE were 32 male and one female cases with a mean age of 26.2 years. Non IE patients were 288 male and two female cases with mean age of 37.8 years. Nineteen of our patients were HIV positive. There was statistically significant difference between HIV-positive and HIV-negative patients. Weight loss and fever were the commonest clinical findings. Staphylococcus aureus was the most common organism [24.2%] followed by coagolase negative staphylococcus [15.1%], most of them were methiciline resistant. Tricuspid valve was involved in 33.3% of cases. Frequency of Infective Endocarditis [IE] among Intravenous Drug User [IDU] is higher than reported in earlier studies. HIV infection increases the risk of IE. Methicilin resistant Staphylococcus aureus is the commonest organism. Tricuspid is the commonest involved cardiac valve