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Background Information on infective endocarditis (IE) caused by the Streptococcus anginosus (S. anginosus) group is scarce. We present a case of IE with multiple splenic septic infarcts that was further complicated by renal involvement and osteomyelitis, caused by S. anginosus in a patient with diabetes. Case 58-year-old male with diabetes presented with fever and bilateral flank pain. His CT showed splenomegaly with multiple splenic infarctions and symmetric bilateral perinephric stranding indicative of nephritis. His Labs showed leukocytosis and two blood culture sets grew S.anginosus. Transesophageal echocardiogram confirmed vegetations on aortic valve (1.3 x 1.0 cm)(Image A, red arrow) and mitral valve (1.4 x 1.0 cm)(Image B, blue arrow). Lumbar spine MRI showed L2-3 vertebral osteomyelitis. [Formula presented] Decision-making Due to patient's normal oxygen saturation and clear lung auscultation and imaging, COVID-19 was ruled out. The etiology of his fever was diagnosed as S. anginosus IE, as evidenced by his vegetations and positive cultures. The patient started on IV antibiotics and IV fluids and was transferred to another facility to receive aortic and mitral bioprostheses. Conclusion This, to the best of our knowledge, is the first documented case of S. anginosus with splenic and renal involvement. The presence of multiple splenic infarcts in immunocompromised patients, in this case in someone with diabetes, should raise suspicion for the presence of vegetations and the diagnosis of S. anginosus IE.Copyright © 2023 American College of Cardiology Foundation
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Background: Transcatheter tricuspid valve-in-valve (TTViV) replacement has become an alternative treatment in high-risk patients with bioprosthetic valve degeneration. This is the first report on the mid to long-term echocardiographic findings of patients who underwent TTViV replacement in a cardiac referral center in Iran. Method(s): Data of 12 patients, consisting of 11 women and 1 man, who underwent TTViV replacement between 2015 and 2021 were reviewed retrospectively. The patients underwent echocardiography before the procedure and at a mean follow-up time of 3.17+/-1.75 years. Result(s): All the patients had New York Heart Association (NYHA) function class III/IV before TTViV. Six patients had tricuspid regurgitation, 1 had tricuspid stenosis, and 5 had both. All the patients had successful TTViV. The mean time from the initial valve surgery to TTViV was 6.25+/-2.45 years. At follow-up, 2 patients had died: 1 due to COVID-19 pneumonia and 1 without a known cause. The remaining 10 patients experienced improvements in the NYHA functional class. Echocardiographic measures showed significant improvements. Transvalvular mean gradient pressure decreased from 7.08+/-1.98 mm Hg to 5.29+/-1.63 mm Hg (P=0.028), tricuspid valve pressure half time decreased from 245.00+/-49.46 ms to 158.64+/-57.41 ms (P=0.011), tricuspid regurgitation gradient decreased from 39.91+/-7.31 mm Hg to 26.72+/-8.99 mm Hg, and left ventricular ejection fraction increased from 47.71+/-4.70% to 49.79+/-4.58% (P=0.046). There was no significant paravalvular or transvalvular leakage at follow-up. Conclusion(s): This is a single-center report on the mid and long-term echocardiographic follow-up of patients after TTViV replacement. Our study showed that TTViV was a safe and efficient method in treating high-risk patients with degenerated bioprosthetic tricuspid valves and had favorable echocardiographic and clinical results. Copyright © 2022 Tehran University of Medical Sciences. Published by Tehran University of Medical Sciences.
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Transcatheter aortic valve replacement (TAVR) is now the standard of therapy for elderly population with severe aortic stenosis. Several studies have established that the outcomes of TAVR are superior when compared with Surgical aortic valve replacement (SAVR), especially when the access route is transfemoral arterial approach. In the elderly population with advanced age and numerous comorbidities, iliofemoral arterial disease (IAD) is not uncommon and it precludes the use of this route for TAVR. Peripheral Intravascular lithotripsy (IVL) has been previously established as an excellent safe and efficient modality to treat symptomatic occlusive calcific iliofemoral artery disease. The same principle of IVL has been recently used successfully to modify the vascular compliance of heavily calcified iliofemoral arteries thereby enabling large bore sheath advancement and safe passage of TAVR delivery catheter systems. We report the first case of Intravascular lithotripsy facilitated Transfemoral TAVR (TF-TAVR) in India. This case was done in December 2020 by the “femoral route” in order to keep the TAVR procedure simple straightforward and discharge the patient back home quickly in Covid times. The use of Intravascular Lithotripsy (IVL)was based on evidence of good outcomes in trials of peripheral vascular disease of lower limbs as well as from the good outcomes of few registries on IVL facilitated TAVR.1,2,3,4,5,6,8 The second case was done in August 2021 by us for another patient successfully.
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Introduction / Case Presentation:46yo female with a history of CKD, atrial flutter, bioprosthetic valve with mitral ring, and recent COVID-19 pneumonia who presented to the emergency department (ED) with shortness of breath, fevers, and fatigue. Three months prior, she had been diagnosed with severe COVID-19 pneumonia, for which she received dexamethasone, remdesivir, tocilizumab, anakinra, and IVIG. She was discharged to a nursing facility with a prolonged steroid taper, ending 1 month prior to admission.In the ED, the patient had a chest x-ray that demonstrated bibasilar atelectasis and opacification, and a CT chest revealed right lower lobe consolidation and surrounding ground glass opacities. A respiratory pathogen PCR swab was negative. Sputum culture was negative for bacterial and fungal growth. Blood cultures did not grow any organisms. Given recent immunosuppression and imaging findings, a serum Cryptococcal antigen was drawn, which was positive with a titer of 1:128. A transthoracic needle biopsy of the patient's right lower lung was then performed. The specimen did not grow any bacteria or fungi and AFB stain on the tissue was negative. Pathology demonstrated a collection of histiocytes, neutrophils, and necrotic debris. PAS, GMS, and mucicarmine stains were positive for fungal organisms consistent with Cryptococcus species. Discussion: Cryptococcosis is a fungal infection due predominately to one of two encapsulated yeasts, Cryptococcus neoformans or Cryptococcus gattii. C. neoformans is found in soil worldwide, and infection typically begins with spore inhalation. Clinically significant disease is seen mostly in immunocompromised patients.Corticosteroids and interleukin inhibitors, such as anakinra (IL-1) and tocilizumab (IL-6), are used in the treatment of COVID-19. These medications have been associated with increased risk for opportunistic infections, including invasive fungal infections. The diagnosis of pulmonary cryptococcosis may be challenging, as symptoms are often nonspecific and may radiographically resemble bacterial pneumonia, malignancy, or other infections. Serum cryptococcal antigen detection tests may be helpful in establishing the diagnosis, as well as histopathology showing narrow-based budding yeast. Conclusion: Patients with prior COVID-19 infection commonly return to healthcare settings with sequelae of their previous coronavirus infection. In our case, it was the prior treatment of COVID-19, which included immunomodulating therapy, that lead to a secondary pulmonary cryptococcal infection. When evaluating pulmonary processes that evolve after an acute infection with COVID-19, it is important to keep a broad differential, including uncommon and/or opportunistic infectious etiologies, particularly when a patient has received prolonged courses of steroids and tocilizumab.
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Background: With the advent of antibiotics to eradicate common sexually transmitted infections (STIs), such as those due to Neisseria gonorrhea, we do not often see their most severe complications. Disseminated gonococcal infection (DGI) occurs in 0.5-3% of all infections, with infective endocarditis (IE) being a complication in 1-2% of patients with DGI. Case: A 30-year-old male with no past medical history, presented for 2 weeks of progressively worsening midline pleuritic chest pain, fevers, chills, malaise and dyspnea. TTE on admission noted severe aortic regurgitation and mild to moderate mitral regurgitation. Follow-up TEE noted destruction of the aortic valve with evidence of para-aortic abscess and a small dissection of the aortic root. Empiric intravenous antibiotic coverage was subsequently initiated. These findings, coupled with 2 blood cultures positive for N. gonorrhea, led to the patient's transfer to our institution for surgical evaluation. Decision-making: There have been about 50 reported cases of N. gonorrhea infective endocarditis since 1949. Treatment of the offending pathogen is made difficult by the infected typically being asymptomatic, which is why the mortality rate remains at about 20%. In our case, the patient was treated empirically for chlamydial co-infection and maintained on IV ceftriaxone until 6 weeks post-operatively. Due to the patient's symptoms and degree of valvular destruction, urgent surgical aortic valve replacement (AVR) was undertaken. The 2015 European Society of Cardiology guidelines for IE management recommend either bioprosthetic or mechanical AVR. A mechanical valve was chosen based on 2020 data indicating that there may be an association between bioprosthesis and higher IE risk. Conclusion: Despite our current ability to eradicate STIs with oral antibiotics, complicated infections like IE are still seen. This is pervasive amongst the sexually active in our underserved populations, augmented by decreased healthcare contact due to the COVID-19 pandemic. Therefore, continued consideration of this diagnosis in patients like ours, as well as a multidisciplinary approach inclusive of surgical evaluation, is imperative.
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Background: Prosthetic valve dehiscence is a manifestation of endocarditis which may be difficult to diagnose based on imaging. Case: A 68-year-old female with mechanical mitral valve replacement (MVR) complicated by recurrent endocarditis requiring two redo MVR presented with subacute chills, nausea, fatigue and dyspnea. Evaluation revealed leukocytosis, elevated NT-proBNP, acute kidney injury, negative blood cultures, and negative SARS-CoV2. Transthoracic echocardiography (TTE) showed normal prosthetic valve function. She was managed for acute decompensated heart failure and placed on empiric antibiotics. She continued to have chills, night sweats and developed hypotension. Blood cultures remained negative, and no source of infection was identified on imaging. Decision-making: To aid in differentiation shock, patient underwent right heart catheterization. This revealed severe cardiogenic shock, with cardiac index of 1.3 L/min/m2. Repeat TTE demonstrated dehiscence of the prosthetic mitral valve, which was confirmed on transesophageal echocardiogram (Figure 1). An intra-aortic balloon pump was placed, and inotropic support provided. Patient underwent successful redo MVR using a bioprosthetic valve. Tissue microbiology was positive for coagulase negative staph. Conclusion: Unmasking the etiology of vague clinical presentations may pose a challenge. Our case highlights the importance of a high index of suspicion and serial imaging when patients present with B-type symptoms. [Formula presented]
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Background: The SARS-CoV-2 pandemia has often oriented the diagnosis of complex pathologies towards CoViD with complications while the main diagnosis could be different. Description of the clinical case: A 76 yo man was hospitalized for confusion and heart failure;in the emergency department, CoViD Ab testing and PCR swab were positive with focal interstitial pneumonia;then splenomegaly, bilateral splenic and renal infarcts and thrombosis of the superior mesenteric artery were confirmed by chest-abdomen CT scan, Doppler US found thrombosis of brachial artery. Antithrombotic therapy was intensified but a new episode of confusion with fever occurred. Brain CT revealed multiple target lesions with hemorrhagic areas, suspected to be neoplastic. LMW heparin was suspended, blood cultures came back positive for Enterococcus faecalis;echocardiography showed a vegetation on the aortic valve;thus the patient's history was reconsidered based on the findings of bacterial endocarditis. When he tested negative, he underwent valve replacement with bioprosthesis. A new positive CoViD swab interrupted the cardiological rehabilitation but finally he was discharged. Conclusions: SARS-CoV-2 pneumonia in this patient was complicated by aortic endocarditis with systemic septic embolization. The antibiotic and steroid therapy administered upon admission may have covered or favored sepsis, that could have been perhaps already onsetting at the time of patient presentation in the ER. The patient's overall hospital stay was 80 days due to recurrent swab positivity even though in the absence of specific symptoms.
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Background: Heart disease is the leading non-obstetric cause of maternal death during pregnancy. In this field, the emergence of pandemic COVID-19 has caused the worst-case scenario considering that pregnant women are more susceptible to viral infections, and preexisting cardiac disease is the most prevalent co-morbidity among COVID-19 deaths. Purpose: To assess the maternal and fetal outcomes of COVID-19 during pregnancy of women with heart diseases. Methods: During the year 2020, among 82 pregnant women with heart disease followed consecutively at the Instituto do Coração-InCor, seven of them with an average age of 33.2 years had COVID-19 during their pregnancies. The underlying heart diseases were rheumatic valve disease (5 pt), congenital heart disease (1 pt) and one case with acute myocarditis, without preexisting cardiopathy. The prescription (antibiotics, inotropes, corticosteroids and others) used was according to the clinical conditions required for each patient, however subcutaneous or intravenous heparin was used in all patients. Results: Only one case had an uneventful maternal-fetal course, the other six women required hospitalization / ICU for an average of 25.3 days, including the need for mechanical ventilation in two of them. Serious complications were related to respiratory failure (ADRS), recurrent atrial flutter with hemodynamic instability, acute pulmonary edema, and cardiogenic shock associated with sepsis which caused two maternal deaths. There were two emergency mitral valve interventional, percutaneous balloon valvuloplasty and valve bioprosthesis replacement, respectively. There were five premature births with an average gestational age of 34.2 weeks of gestation, which resulted in one stillbirth. Pathological findings of three placental and the six-months follow-up of the babies did not confirm vertical transmission of COVID-19. Conclusions: The uncertain evolution given of the overlapping complications of three conditions-COVID-19, pregnancy, and heart disease-implies an increased risk for women with heart diseases of childbearing age, for whom pregnancy should be discouraged and planned after vaccination.
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Symptoms mimicking COVID-19 infection, pulmonary emboli, or septicemia delayed diagnosis of aortic bioprosthesis failure. A 71-year-old man was admitted emergently with shortness of breath, fever, cough, and chest pain. Echocardiography performed after 2 days showed diastolic regurgitation in an aortic perimount pericardial bioprosthesis implanted 12 years previously. An urgent reoperation disclosed that one pericardial cusp was torn from the stent of the valve. We have not previously encountered sudden pericardial leaflet dehiscence of an internally mounted pericardial valve that caused heart failure and found no literature report like our finding.
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The COVID-19 pandemic has presented countless new challenges for healthcare providers including the challenge of differentiating COVID-19 infection from other diseases. COVID-19 infection and acute endocarditis may present similarly, both with shortness of breath and vital sign abnormalities, yet they require very different treatments. Here, we present two cases in which life-threatening acute endocarditis was initially misdiagnosed as COVID-19 infection during the height of the pandemic in New York City. The first was a case of Klebsiella pneumoniae mitral valve endocarditis leading to papillary muscle rupture and severe mitral regurgitation, and the second a case of Streptococcus mitis aortic valve endocarditis with heart failure due to severe aortic regurgitation. These cases highlight the importance of careful clinical reasoning and demonstrate how cognitive errors may impact clinical reasoning. They also underscore the limitations of real-time reverse transcription-polymerase chain reaction (RT-PCR) for SARS-CoV-2 testing and illustrate the ways in which difficulty interpreting results may also influence clinical reasoning. Accurate diagnosis of acute endocarditis is critical given that surgical intervention can be lifesaving in unstable patients.