Tricuspid valve group B streptococcal endocarditis after an elective termination of pregnancy

Cardiovascular complications following medical termination of pregnancy: An updated review

BACKGROUND

Around 1 million cases of medical termination of pregnancy (MTP) take place yearly in the United States of America with around 2 percent of this population developing complications. The cardiovascular (CVD) complications occurring post MTP or after stillbirth is not very well described.

AIM

To help the reader better understand, prepare, and manage these complications by reviewing various cardiac comorbidities seen after MTP.

METHODS

We performed a literature search in PubMed, Medline, RCA, and google scholar, using the search terms "abortions" or "medical/legal termination of pregnancy" and "cardiac complications" or "cardiovascular complications".

RESULTS

The most common complications described in the literature following MTP were infective endocarditis (IE) (n = 16), takotsubo cardiomyopathy (TTC) (n = 7), arrhythmias (n = 5), and sudden coronary artery dissection (SCAD) (n = 4). The most common valve involved in IE was the tricuspid valve in 69% (n = 10). The most observed causative organism was group B Streptococcus in 81% (n = 12). The most common type of TTC was apical type in 57% (n = 4). Out of five patients developing arrhythmia, bradycardia was the most common and was seen in 60% (3/5) of the patients. All four cases of SCAD-P type presented as acute coronary syndrome 10-14 d post termination of pregnancy with predominant involvement of the right coronary artery. Mortality was only reported following IE in 6.25%. Clinical recovery was reported consistently after optimal medical management following all these complications.

CONCLUSION

In conclusion, the occurrence of CVD complications following pregnancy termination is infrequently documented in the existing literature. In this review, the most common CVD complication following MTP was noted to be IE and TTC.

Group B Streptococcus tricuspid valve endocarditis with subsequent septic embolization to the pulmonary artery: A case report following elective abortion

Background

Tricuspid valve endocarditis caused by Group B streptococcus is a rare clinical entity with poor prognosis and has been previously reported following gynecologic procedures.

Case summary

We report a case of an 18-year-old female diagnosed with Group B streptococcus tricuspid valve endocarditis with septic emboli following an elective therapeutic abortion. After six weeks of treatment with ceftriaxone, she returned with recurrent symptoms and was found to have embolized a sizable vegetation to the pulmonary artery with probable lung infarction. She underwent surgical embolectomy and was treated with antibiotics and anticoagulation and was subsequently discharged in stable condition.

Conclusion

Group B streptococcus endocarditis is a serious complication of gynecologic procedures. The role of preoperative antibiotics, postoperative clinical suspicion of endocarditis based on respiratory symptoms and a multidisciplinary approach may lead to enhanced patient outcomes.

Group B Streptococcal Tricuspid Endocarditis: Case Report and Systematic Review

Infective Endocarditis (IE), the microbial infection of the endocardial surface, is categorized by anatomy, microbiology, and valve nativity. Infective endocarditis generally affects older adults, and more commonly presents as a Left-sided IE (LSIE) affecting the mitral or aortic valves. Right-sided IE (RSIE) typically affects younger patients with less pre-existing valvular disease. RSIE is also more commonly associated with intravenous drug use (IVDU) and intra-cardiac instrumentation, such as pacemakers or defibrillators. While Staphylococcus aureus is the most common microorganism responsible for both LSIE and RSIE, Streptococcos agalactiae, or Group B Streptococcus (GBS), accounts for a very small percentage of IE, and, in such instances, rates of tricuspid endocarditis are dramatically lower than LSIE. GBS endocarditis usually affects patients with particular comorbidites, such as diabetes mellitus (DM) and cirrhosis. We present a case of GBS tricuspid endocarditis in a female patient without the typical risk factors for GBS endocarditis. We also present a systematic review of case reports and case series of GBS tricuspid endocarditis highlighting the risk factors, presentation and clinical characteristics, as well as up-to-date outcomes, and mortality rates of GBS endocarditis, a potentially fatal disease entity.

Isolated Streptococcus agalactiae tricuspid endocarditis in elderly patient without known predisposing factors: Case report and review of the literature

Group B streptococcal (GBS) tricuspid infective endocarditis is a very rare clinical entity. It affects intravenous drug users, pregnant, postpartum women, and the elderly. We report the case of a 68-year-old patient without known predisposing factors who presented a GBS tricuspid endocarditis treated by penicillin and aminoglycosides with no response. The patient was operated with a good evolution. Our case is the 25th reported in the literature. GBS disease is increasing in the elderly and is mainly associated to comorbid conditions. Tricuspid infective endocarditis with Group B streptococcus predominantly presents as a persistent fever with respiratory symptoms due to pulmonary embolism. Therefore, it requires a medicosurgical treatment and close follow-up.

Pregnancy and postpartum infective endocarditis: a systematic review

The objective of this review was to describe the clinical characteristics, risk factors, and outcomes of infective endocarditis (IE) in pregnancy and the postpartum period. We conducted a systematic review of Ovid MEDLINE, Ovid Embase, Web of Science, and Scopus from January 1, 1988, through October 31, 2012. Included studies reported on women who met the modified Duke criteria for the diagnosis of IE and were pregnant or postpartum. We included 72 studies that described 90 cases of peripartum IE, mostly affecting native valves (92%). Risk factors associated with IE included intravenous drug use (14%), congenital heart disease (12%), and rheumatic heart disease (12%). The most common pathogens were streptococcal (43%) and staphylococcal (26%) species. Septic pulmonary, central, and other systemic emboli were common complications. Of the 51 pregnancies, there were 41 (80%) deliveries with survival to discharge, 7 (14%) fetal deaths, 1 (2%) medical termination of pregnancy, and 2 (4%) with unknown status. Maternal mortality was 11%. Infective endocarditis is a rare, life-threatening infection in pregnancy. Risk factors are changing with a marked decrease in rheumatic heart disease and an increase in intravenous drug use. The cases reported in the literature were commonly due to streptococcal organisms, involved the right-sided valves, and were associated with intravenous drug use.

"Removal without Replacement" Strategy for Uncontrolled Prosthetic Tricuspid Valve Endocarditis Associated with Abortion Sepsis

Isolated tricuspid valve (TV) endocarditis associated with abortion is a rare entity with a poor prognosis. We report the case of a 22-year-old woman with a diagnosis of isolated prosthetic TV endocarditis secondary to recurrent abortion. The patient had progressed to multiorgan failure and disseminated intravascular coagulation during her clinical course. Because of the high operative risk and uncontrolled infection, we performed an unusual surgical approach that has not previously been reported. Resection of infected valvular tissue without replacement of the prosthesis led to a rapid convalescence period and complete cure.

Postpartum culture negative endocarditis: a case report and review of the current guidelines

Culture-negative endocarditis (CNE) presents physicians with diagnostic and treatment challenges. Postpartum endocarditis is rare and usually culture negative. Empirical antimicrobial regimes lead to the risk of aggressive treatment with potentially toxic drugs. This paper presents a case of postpartum CNE, discussing the issues of diagnosis and treatment. European and American guidelines for CNE are then reviewed and compared.

[Postpartum group B streptococcal endocarditis of the tricuspid valve]

The B streptococcal endocarditis are very rare. They primarily affect the left heart valves, the achievement of the tricuspid valve is exceptional. We report a young patient aged of 36 years who presented in postpartum a tricuspid endocarditis with streptococcus B. She was treated by third-generation cephalosporin and aminoglycoside. The evolution after 5 days of antibiotic therapy was marked by a rapid valvular destruction with worsening tricuspid insufficiency leading to death of the patient. This is the 23rd case of tricuspid endocarditis streptococcal B reported in the literature. The mortality of this disease reached 36% in the absence of surgical treatment. The medico-surgical approach is the treatment of choice for these patients.

Infective endocarditis during pregnancy: case report

A 29-year-old woman was transferred at 31 weeks gestation for management of infective endocarditis (IE). Echocardiography demonstrated vegetations on aortic valve and severe mitral regurgitation. Blood cultures were positive for Streptococcus sanguis. Due to impending hemodynamic collapse, a cesarean section was performed followed by aortic valve replacement and mitral valve repair with a patch of bovine pericardium. At 10-month review, both mother and baby are doing well.

Tricuspid valve endocarditis with Group B Streptococcus after an elective abortion: the need for new data

Streptococcus agalactiae, commonly known as Group B streptococcus (GBS), was originally discovered as a cause of bovine mastitis. GBS colonizes the genital tract of up to 40% of women and has become a major pathogen in neonatal meningitis. GBS endocarditis is thought to be an uncommon manifestation of this infection and carries a higher mortality compared to other streptococcal pathogens. Studies have shown that endocarditis after abortion has an incidence of about one per million. However, this figure was published prior to routine use of echocardiography for diagnosis. The American Heart Association has recently declared transesophageal echocardiography the gold standard for endocarditis diagnosis. This case report illustrates that, given the potentially devastating consequences of endocarditis, there is a need for updated studies to adequately assess the true incidence of this infection. Pending the outcome of these studies, routine GBS screening and prophylactic antibiotics prior to abortion should be recommended.

Wound erysipelas following appendectomy caused by group B beta-hemolytic Streptococcus (Streptococcus agalactiae)

BACKGROUND

Case description of a patient who developed erysipelas of the surgical wound following appendectomy for acute appendicitis, and literature review of invasive group B streptococcal infections.

METHODS

A 65-year-old man with perforated appendicitis underwent urgent appendectomy and drainage. Antibiotic prophylaxis with tobramycin (100 mg) and metronidazole (500 mg) was administered. At surgery, a phlegmon was identified with free perforation of the appendix and purulent peritoneal fluid. Appendectomy, irrigation with 0.9% NaCl solution, and drainage with a Silastic closed-suction drain was performed. A literature search in all languages was performed using MEDLINE, using the search terms surgical site infection, wound infection, group B streptococcus, Streptococcus agalactiae, necrotizing fasciitis, and postoperative infection.

RESULTS

Erysipelas of the surgical wound developed on the fourth postoperative day. Intravenous penicillin and amoxicillin/clavulanic acid were administered empirically. Culture of the wound drainage identified Streptococcus agalactiae and a few colonies of Escherichia coli. The broad-spectrum antibiotic was discontinued, and a 10-day course of penicillin was completed.

CONCLUSIONS

Erysipelas of the surgical wound is unusual, and infection with group B streptococci is rare compared with infection by group A streptococci. Streptococcus agalactiae is recognized to be increasingly virulent, with an increasing predilection for bacteremic infections in healthy hosts. Although Streptococcus agalactiae remains highly susceptible to antimicrobial agents effective against gram-positive cocci, the changing epidemiology and potentially invasive nature of these infections should have clinicians alert to the possibility of infection caused by group B streptococci.

Group B streptococcal endocarditis in obstetric and gynecologic practice

Background: We describe a case and review ten other instances of group B streptococcal endocarditis in the setting of obstetric and gynecologic practice reported since the last review in 1985.

Case: Abortion remains a common antecedent event, but in contrast to earlier reports, most patients did not have underlying valvular disease, the tricuspid valve was most often involved, and mortality was low. Patients with tricuspid valve infection tended to have a subacute course, whereas those with aortic or mitral involvement typically had a more acute, fulminant course.

Conclusion: Despite an improvement in mortality, morbidity remains high, with 8 of 11 patients having clinically significant emboli.

Bacterial endocarditis complicating pregnancy: case report and systematic review of the literature

INTRODUCTION

Infectious endocarditis is a rare life-threatening complication of pregnancy. We report a pregnancy complicated by a 3.5-cm infected vegetation of the tricuspid valve initially presenting as unilateral hip pain as well as systematic review of this entity.

SOURCES

A MEDLINE review of the English language literature from 1965 to present using the search terms 'endocarditis', 'pregnancy' and 'infection' as well as review of references was performed.

RESULTS

Sixty-eight cases of infectious endocarditis complicating pregnancy were identified. The calculated maternal and fetal mortality rates were 22.1% and 14.7% respectively.

CONCLUSIONS

With persistent symptomatic lesions, delivery should be considered without regard to measures of fetal lung maturity because of high fetal mortality rates.