From flank pain to splenic abscess: a complex case of infective endocarditis with literature review.

BACKGROUND: Infective endocarditis (IE) is a severe condition characterized by inflammation of the heart endocardium and valves, commonly caused by Gram-positive bacteria. Complications such as embolic phenomena and organ abscesses can arise, necessitating timely diagnosis and intervention. CASE PRESENTATION: We report the case of a 20-year-old female with a history of cerebral and splenic infarctions due to IE. The patient presented with left-sided flank pain, urinary burning, and fever. Examination revealed mitral and aortic valve involvement, splenomegaly, and neurological deficits. Despite initial antibiotic therapy, the patient developed a splenic abscess and drug-induced neutropenia. She required aortic valve replacement and was successfully managed with a multidisciplinary approach. CONCLUSION: Multidisciplinary management, including timely surgical intervention and advanced imaging, is essential for favorable outcomes in IE patients. This case underscores the importance of early detection and tailored treatment strategies in managing severe complications associated with IE.

Clinical profile, microbiology and outcomes in infective endocarditis treated with aortic valve replacement: a multicenter case-control study.

BACKGROUND: Aortic valve infective endocarditis (IE) is associated with significant morbidity and mortality. We aimed to describe the clinical profile, risk factors and predictors of short- and long-term mortality in patients with aortic valve IE treated with aortic valve replacement (AVR) compared with a control group undergoing AVR for non-infectious valvular heart disease. METHODS: Between January 2008 and December 2013, a total of 170 cases with IE treated with AVR (exposed cohort) and 677 randomly selected non-infectious AVR-treated patients with degenerative aortic valve disease (controls) were recruited from three tertiary hospitals with cardiothoracic facilities across Scandinavia. Crude and adjusted hazard ratios (HR) were estimated using Cox regression models. RESULTS: The mean age of the IE cohort was 58.5 ± 15.1 years (80.0% men). During a mean follow-up of 7.8 years (IQR 5.1-10.8 years), 373 (44.0%) deaths occurred: 81 (47.6%) in the IE group and 292 (43.1%) among controls. Independent risk factors associated with IE were male gender, previous heart surgery, underweight, positive hepatitis C serology, renal failure, previous wound infection and dental treatment (all p < 0.05). IE was associated with an increased risk of both short-term (≤ 30 days) (HR 2.86, [1.36-5.98], p = 0.005) and long-term mortality (HR 2.03, [1.43-2.88], p < 0.001). In patients with IE, chronic obstructive pulmonary disease (HR 2.13), underweight (HR 4.47), renal failure (HR 2.05), concomitant mitral valve involvement (HR 2.37) and mediastinitis (HR 3.98) were independent predictors of long-term mortality. Staphylococcus aureus was the most prevalent microbe (21.8%) and associated with a 5.2-fold increased risk of early mortality, while enterococci were associated with the risk of long-term mortality (HR 1.78). CONCLUSIONS: In this multicenter case-control study, IE was associated with an increased risk of both short- and long-term mortality compared to controls. Efforts should be made to identify, and timely treat modifiable risk factors associated with contracting IE, and mitigate the predictors of poor survival in IE.

Infective Endocarditis in Patients With Bicuspid Aortic Valves: Unique Clinical and Microbiologic Features.

OBJECTIVE: Patients with bicuspid aortic valves (BAV) are at increased risk of infective endocarditis (IE). Information of the clinical presentation and the microbiology of BAV-associated IE, however, is limited. Therefore, our study aimed to characterise the clinical features native valve endocarditis (NVE) in the setting of BAV and compared them to patients with prosthetic valve endocarditis (PVE) following BAV replacement. METHODS: Adult patients with BAV or history of BAV with aortic valve replacement (AVR) and a definite or possible IE diagnosis within the Mayo Clinic Enterprise (USA) from January 2008 to December 2021, were included. BAV was confirmed by trans-oesophageal echocardiography. IE was defined according to the modified Duke criteria and only an initial episode was included. Statistical analyses were performed to compare clinical characteristics, microbiology, and IE complications. RESULTS: Overall, 161 patients with BAV and IE (NVE [n=60], 37.3%) and PVE [n=101, 62.7%) were included. Mean age±SD was 56.5±16.1 years, and 139 (86.3%) patients were males. PVE patients were older (p<0.01) and had a higher rate of hypertension (p<0.01), chronic heart failure (p<0.01), chronic kidney disease (p<0.01), and perivalvular abscess (p<0.01). BAV patients with NVE had a higher prevalence of isolated mitral valve IE (p<0.01), moderate to severe aortic valve regurgitation (p<0.01) and combined aortic with mitral valve IE (p<0.01). Streptococcus mitis was the most common pathogen in NVE (30.0%) while Staphylococcus aureus was the most common in PVE (15.8%). CONCLUSIONS: Patients with BAV are at risk of both NVE and PVE. Each syndrome has unique clinical features, including microbiologic findings, that should be appreciated in IE diagnosis and management.

Candida Tropicalis Endocarditis: A case report and literature review.

Fungi rarely cause infective endocarditis but when they do, they are often associated with poor outcomes. Candida tropicalis accounts for only 10% of Candida endocarditis cases. A case of a 30-year-old male with a history of intravenous drug abuse was reported to the emergency department in August, 2021 with right-sided leg pain and fever for 3 days. A trans-thoracic echocardiogram showed a vegetation on the aortic valve and a computed tomography angiogram showed complete nonopacification of the right-sided common iliac artery and the superficial femoral artery just distal to its branching of the right profunda femoris artery. An emergent right iliofemoral embolectomy was done. Candida tropicalis was isolated from tissue and blood cultures. The patient was successfully treated with aortic valve replacement and intravenous caspofungin. The other reported cases of Candida tropicalis were reviewed and findings were compared with those reported in patients with Candida albicans and Candida parapsilosis endocarditis.

Valvular Endocarditis and Biventricular Heart Failure in the Setting of Tropheryma whipplei Disease.

Whipple disease is a rare systemic illness associated with weight loss, diarrhea, and arthralgia. Asymptomatic carriage is common, but the disease can be complicated by cardiac involvement and may result in culture-negative endocarditis. Cardiac manifestations of the disease can lead to death. This report presents the case of a 66-year-old man with Whipple disease and biventricular heart failure with cardiogenic shock. Medical therapy followed by successful replacement of the aortic and mitral valves resulted in substantial improvement.

Atrioventricular conduction disorders in aortic valve infective endocarditis.

BACKGROUND: Aortic valve infective endocarditis may be complicated by high-degree atrioventricular block in up to 10-20% of cases. AIM: To assess high-degree atrioventricular block occurrence, contributing factors, prognosis and evolution in patients referred for aortic infective endocarditis. METHODS: Two hundred and five patients referred for aortic valve infective endocarditis between January 2018 and March 2021 were included in this study. A comprehensive assessment of clinical, electrocardiographic, biological, microbiological and imaging data was conducted, with a follow-up carried out over 1 year. RESULTS: High-degree atrioventricular block occurred in 22 (11%) patients. In univariate analysis, high-degree atrioventricular block was associated with first-degree heart block at admission (odds ratio 3.1; P=0.015), periannular complication on echocardiography (odds ratio 6.9; P<0.001) and severe biological inflammatory syndrome, notably C-reactive protein (127 vs 90mg/L; P=0.011). In-hospital mortality (12.7%) was higher in patients with high-degree atrioventricular block (odds ratio 4.0; P=0.011) in univariate analysis. Of the 16 patients implanted with a permanent pacemaker for high-degree atrioventricular block and interrogated, only four (25%) were dependent on the pacing function at 1-year follow-up. CONCLUSIONS: High-degree atrioventricular block is associated with high inflammation markers and periannular complications, especially if first-degree heart block is identified at admission. High-degree atrioventricular block is a marker of infectious severity, and tends to raise the in-hospital mortality rate. Systematic assessment of patients admitted for infective endocarditis suspicion, considering these contributing factors, could indicate intensive care unit monitoring or even temporary pacemaker implantation in those at highest risk.

Tropheryma whipplei Endocarditis Presenting as Valvulopathy and Multiple Septic Emboli.

A 63-year-old man was admitted to the hospital for nausea, vomiting, and right flank pain. He was found to have septic emboli in multiple organs secondary to aortic valve endocarditis. He was started on broad-spectrum antibiotics and underwent valve replacement. Blood cultures from admission were negative, but a blood polymerase chain reaction (PCR) test for fastidious difficult-to-culture pathogens showed a positive result for Tropheryma whipplei. Valve histopathological evaluation confirmed Tropheryma whipplei endocarditis. He was treated with intravenous penicillin followed by oral trimethoprim-sulfamethoxazole. A high index of suspicion for causes of culture-negative endocarditis needs to be maintained when blood cultures are negative despite clear evidence of endocarditis especially with large vegetation sizes and other complications such as septic emboli. Multiple imaging modalities are available to assist with diagnosis including transthoracic and transesophageal echocardiogram as well as cardiac computed tomography. A blood PCR test can identify the implicated pathogen in a more expeditious manner compared to valve histopathological evaluation. Treatment is complex and usually requires surgical intervention and prolonged antimicrobial therapy.

Infective endocarditis and septic arthritis caused by Corynebacteriumstriatum.

Corynebacterium striatum occasionally causes nosocomial infections, such as catheter-related bloodstream infection and pneumonia; however, C. striatum-related infective endocarditis or septic arthritis is uncommon. We present the case of an 85-year-old woman with infective endocarditis at the native valve and septic arthritis at the native shoulder joint caused by C. striatum. The patient was admitted for a 10-day history of fever and right shoulder pain. She had no history of artificial device implantation, injury, arthrocentesis, or hospitalization. A physical examination revealed conjunctival petechiae, a systolic heart murmur, and right shoulder joint swelling. C. striatum was observed in two blood culture sets. Transesophageal echocardiography revealed vegetation in the right aortic coronary cusp. Arthrocentesis at the right shoulder aspirated pyogenic fluid and C. striatum was detected in the culture. The patient was diagnosed with infective endocarditis and septic arthritis caused by C. striatum, and ampicillin was administered based on antimicrobial susceptibility test results. The patient's condition was initially stable; however, she developed pulmonary congestion on day 56 and eventually died. An autopsy demonstrated perforation of the aortic left coronary cusp with vegetation. C. striatum may cause native valve endocarditis and native joint septic arthritis.

Non-typhoidal Salmonella enteritidis prosthetic valve endocarditis.

In this case, we present a rare cause of prosthetic valve endocarditis. A man in his 80s presented to the emergency department with fever and diarrhoea. The patient underwent a transcatheter aortic valve replacement 17 years earlier. A negative PCR result in faeces for Salmonella and positive blood cultures with Salmonella gave rise to the suspicion of an intravascular Salmonella infection, which was confirmed with a positron emission tomography. Due to the low prevalence of Salmonella endocarditis, there is no consensus on the most effective treatment. Guidelines recommend early surgery and long-term antimicrobial treatment in endocarditis with Gram-negative bacteria. In this case, surgery was not deemed feasible given the patient his advanced age and multiple comorbidities. Despite treatment with intravenous antibiotics, the patient succumbed to progression of endocarditis 37 days after admission.

Metagenomic analysis of oral plaques and aortic valve tissues reveals oral bacteria associated with aortic stenosis.

OBJECTIVES: Bacteria derived from the oral cavity enter the bloodstream and cause the onset of various systemic diseases, including heart valve disease. However, information on the oral bacteria involved in aortic stenosis is limited. MATERIALS AND METHODS: We comprehensively analyzed the microbiota in aortic valve tissues collected from aortic stenosis patients using metagenomic sequencing and investigated the relationships between the valve microbiota, the oral microbiota, and oral cavity conditions. RESULTS: Metagenomic analysis revealed the presence of 629 bacterial species in five oral plaques and 15 aortic valve clinical specimens. Patients were classified into two groups (A and B) according to their aortic valve microbiota composition using principal coordinate analysis. Examination of the oral conditions of the patients showed no difference in the decayed/missing/filled teeth index. Bacteria in group B tend to be associated with severe disease, and the number of bacteria on the dorsum of the tongue and the positive rate of bleeding during probing were significantly higher in this group than in group A. The pathophysiology of aortic stenosis may be related to the presence of oral bacteria such as Streptococcus oralis and Streptococcus sanguinis following bacteremia. CONCLUSIONS: Systemic inflammation in severe periodontitis may be driven by the oral microbiota, supporting the indirect (inflammatory) association between oral bacteria and aortic stenosis. CLINICAL RELEVANCE: Appropriate oral hygiene management may contribute to the prevention and treatment of aortic stenosis.

Invasive Aortic Valve Endocarditis: Clinical and Tissue Findings From a Prospective Investigation.

BACKGROUND: Advanced aortic valve infective endocarditis (IE) with progression and destruction beyond the valve cusps-invasive IE-is incompletely characterized. This study aimed to characterize further the invasive disease extent, location, and stage and correlate macroscopic operative findings with microscopic disease patterns and progression. METHODS: A total of 43 patients with invasive aortic valve IE were prospectively enrolled from August 2017 to July 2018. Of these patients, 23 (53%) had prosthetic valve IE, 2 (5%) had allograft IE, and 18 (42%) had native aortic valve IE. Surgical findings and intraoperative photography were analyzed for invasion location, extent, and stage. Surgical samples were formalin fixed and analyzed histologically. The time course of disease and management were evaluated. RESULTS: Pathogens included Staphylococcus aureus in 17 patients (40%). Invasion predominantly affected the non-left coronary commissure (76%) and was circumferential in 15 patients (35%) (14 had prosthetic valves). Extraaortic cellulitis was present in 29 patients (67%), abscess in 13 (30%), abscess cavity in 29 (67%), and pseudoaneurysm in 8 (19%); 7 (16%) had fistulas. Histopathologic examination revealed acute inflammation, abscess formation, and lysis of connective tissue but not of myocardium or elastic tissue. Median time from onset of symptoms to antibiotics was 5 days, invasion confirmation 15 days, and surgery 37 days. Patients with S aureus had a 21-day shorter time course than patients non-S aureus. New or worsening heart block developed in 8 patients. CONCLUSIONS: Advanced invasive aortic valve IE demonstrates consistent gross patterns and stages correlating with histopathologic findings. Invasion results from a confluence of factors, including pathogen, time, and host immune response, and primarily affects the fibrous skeleton of the heart and expands to low-pressure regions.

Findings of prosthetic valve endocarditis in the balloon-expandable trans-catheter aortic valve: review of the literature and tips of management.

Prosthetic valve endocarditis after transcatheter aortic valve implantation (TAVI) is a rare complication associated with a high mortality rate. Nonetheless, the rapid expansion of TAVI in recent years has proportionally increased the number of patients exposed to the risk of developing transcatheter valve infection. A 71-year-old female with recent history of TAVI was diagnosed with prosthetic valve obstruction secondary to endocarditis. The characteristics of clinical presentation of endocarditis in the balloon-expandable transcatheter valve and the intra-operative findings are discussed with a review of the literature and tips of management.

Modified commando procedure in complicated infective endocarditis ─ a case series.

BACKGROUND: Complicated infective endocarditis (IE) with perivalvular abscess and destruction of intervalvular fibrous body (IFB) has high mortality risk and requires emergent or urgent surgery mostly. CASE PRESENTATION: We presented four patients with complicated infective endocarditis combined with perivalvular abscess and IFB destruction. Three patients had prosthetic valve endocarditis and one patient had native valve endocarditis. They all received modified Commando procedure successfully. No surgical mortality or re-exploration for bleeding. CONCLUSIONS: We suggest that modified Commando procedure may have some benefit in improving survival rate of patients with complicated IE and reducing complications.

Bartonella species as a cause of culture-negative endocarditis in South Africa.

Previous reports have highlighted the high prevalence of blood culture negative endocarditis (BCNE) in South Africa. The Tygerberg Endocarditis Cohort (TEC) study is an ongoing prospective cohort study of patients with confirmed or suspected IE presenting to Tygerberg Academic Hospital, Cape Town, South Africa. Current analysis includes patients that presented between November 2019 and August 2020. Forty four (44) patients have been included in this ongoing study. Fourteen of the 44 patients (31.8%) had BCNE. Further analysis of the patients with BCNE identified Bartonella species as the most common causative organism (n=6; 43%). Other causes included Mycoplasma species (n=2). No cause could be identified in 4 of the 44 patients (9%). Bartonella quintana was identified with PCR of valvular tissue as the causative organism in 4 of the 5 patients that underwent urgent surgery. The patients with Bartonella IE (n=6) had an average age of 39 years with equal gender distribution. The common clinical features were clubbing (n=5; 83%), anemia (n=4; 66.6%), haematuria (n=3; 50%), acute on chronic severe regurgitant lesion (n=3; 50%) and acute severe regurgitant lesion (n=2; 33.3%).The aortic valve was involved in 5 of 6 patients. During a mean follow-up period of 251 days after diagnosis, no major adverse events occurred. Bartonella-associated IE is an important cause of BCNE in the Western Cape of South Africa. Imaging findings (in patients with BCNE) of significant valvular destruction with large vegetations on the aortic valve not affected by congenital or rheumatic valve disease should raise the suspicion of Bartonella-associated IE.

Infective endocarditis in patients with liver cirrhosis: a systematic review.

Liver cirrhosis is an increasing cause of mortality and morbidity in developed countries. Infective Endocarditis (IE) is an uncommon disease with notable morbidity and mortality. Even though cirrhosis is associated with immune dysfunction and increased occurrence of bacterial infection, IE is infrequently diagnosed in these patients. Thus, the purpose of this study was to systematically review all published cases of IE in patients with cirrhosis in the literature. A systematic review of PubMed, Scopus and Cochrane (through 23th April 2020) for studies providing epidemiological, clinical, microbiological as well as treatment data and outcomes of IE in patients with cirrhosis was performed. A total of 78 studies, containing data of 602 patients, were included. A prosthetic valve was present in 17.8%, while the most common causative pathogen was S. aureus in 26% followed by Streptococcus spp in 16.8%. Aortic valve was the most commonly infected site, followed by mitral valve. Diagnosis was set with a transthoracic ultrasound in 55.2%, while the diagnosis was set at autopsy in 16.7%. Fever and heart failure were the most common clinical presentations. Aminoglycosides, vancomycin, and cephalosporins were the antimicrobials most frequently used for treatment. Clinical cure was noted in 68.2%, while overall mortality was 41.4%. This systematic review thoroughly describes IE in patients with liver cirrhosis and provides information on epidemiology, clinical presentation, treatment and outcomes.

Infective endocarditis by Acinetobacter species: a systematic review.

A. baumannii - A. calcoaceticus complex infections are increasingly frequent, especially in intensive care units. Such infections are associated with a mortality that can be as high as 62%. On the other hand, infective endocarditis (IE) is an uncommon disease with notable morbidity and mortality. Even though IE is rarely caused by Acinetobacter species, these infections can be particularly problematic due to increasing antimicrobial resistance. The purpose of this study was to systemically review all published cases of IE by Acinetobacter species in the literature. A systematic review of PubMed, Scopus and Cochrane library (through 25 April 2020) for studies providing epidemiological, clinical, microbiological as well as treatment data and outcomes of IE by Acinetobacter species was performed. A total of 35 studies, containing data of 37 patients, were included. A prosthetic valve was present in 40.5%, while the most common causative pathogen was A. baumannii - A. calcoaceticus complex, followed by A. lwoffii. Aortic valve was the commonest infected site, followed by mitral valve. Diagnosis was set with transthoracic echocardiography in 48.6%, while the diagnosis was set at autopsy in 20%. Fever and sepsis were the commonest clinical presentations, followed by heart failure and embolic phenomena. Aminoglycosides, cephalosporins and carbapenems were the commonest antimicrobials used. Clinical cure was noted in 70.3%, while overall mortality was 32.4%. Development of heart failure was independently associated with mortality by IE. This systematic review thoroughly describes IE by Acinetobacter and provides information on epidemiology, clinical presentation, treatment and outcomes.