Clinical presentation of infective endocarditis

Infective Endocarditis Following Post-COVID Organizing Pneumonia Complicated by Multiple Splenic Abscesses and Glomerular Nephritis

The association of glomerular nephritis and infective endocarditis with liver abscesses is a clinically complex entity that often makes the diagnosis challenging. Here, we report a case of a 50-year-old woman who presented with a febrile illness of two weeks' duration along with myalgia and malaise of four days' duration. She had a background history of well-controlled type 2 diabetes mellitus for five years with a past history of ischemic heart disease diagnosed five years ago. At the time of presentation, she was on long-term steroids for post-coronavirus disease (COVID) organizing pneumonia diagnosed three months back. With serial investigations, she was found to have subacute bacterial endocarditis with multiple liver and splenic abscesses. She was managed with antibiotics as per local protocols after which she made a successful recovery of her clinical status. The uniqueness of this case is the development of rare complications of subacute bacterial endocarditis in the background of immunosuppression.

Perceived Stress in Relation to Demographics and Clinical Forms among Patients with Infective Endocarditis: A Cross-Sectional Study

(1) Background: Infective endocarditis (IE) is a disease of the endocardial surface of the heart, caused by infection of the native or prosthetic valve or an indwelling cardiac device. Apart from IE predisposing risk factors that include heart conditions and medical procedures, the novel trajectories from demographic factors to perceived stress conditions have been under investigation in recent years. The aim of the present study was to evaluate the associations between perceived stress and demographic characteristics as well as clinical forms of IE among survivors of IE in Kaunas, Lithuania. (2) Methods: A cross-sectional study among IE cases (n = 135) at the Lithuanian University of Health Sciences Kaunas Clinics Cardiology department during the period 2014-2017 was performed. Data about IE clinical features, sociodemographic characteristics and perceived stress level (Perceived Stress Scale (PSS-10)) upon diagnosis were collected. Package "SPSS 25.0" was used in the statistical analysis. Logistic regression analysis was performed including gender, previous occupation, place of residence and clinical forms of IE in the analysis of perceived stress among survivors of IE. The STROBE checklist for cross-sectional studies was used in this study. (3) Results: Perceived stress was experienced by 54.8 percent of the respondents. In the final model, the OR (odds ratio) of perceived stress for females was 2.07 as compared to men; for rural residents, the OR was 2.25 as compared to urban residents. These results were statistically significant. A tendency for increased OR of perceived stress for low-skilled workers as compared to high-skilled ones and classical IE clinical form as compared to non-classical form was observed, but these results were not statistically significant. (4) Conclusions: The present study is an attempt to focus the attention of IE researchers on the effects of psychological state in the disease development. Differences in perceived stress and some demographic characteristics, as well as tendencies of IE clinical forms, were observed among survivors of IE in Kaunas, Lithuania.

Infective Endocarditis in High-Income Countries

Infective endocarditis remains an illness that carries a significant burden to healthcare resources. In recent times, there has been a shift from Streptococcus sp. to Staphylococcus sp. as the primary organism of interest. This has significant consequences, given the virulence of Staphylococcus and its propensity to form a biofilm, rendering non-surgical therapy ineffective. In addition, antibiotic resistance has affected treatment of this organism. The cohorts at most risk for Staphylococcal endocarditis are elderly patients with multiple comorbidities. The innovation of transcatheter technologies alongside other cardiac interventions such as implantable devices has contributed to the increased risk attributable to this cohort. We examined the pathophysiology of infective endocarditis carefully. Inter alia, the determinants of Staphylococcus aureus virulence, interaction with host immunity, as well as the discovery and emergence of a potential vaccine, were investigated. Furthermore, the potential role of prophylactic antibiotics during dental procedures was also evaluated. As rates of transcatheter device implantation increase, endocarditis is expected to increase, especially in this high-risk group. A high level of suspicion is needed alongside early initiation of therapy and referral to the heart team to improve outcomes.

Confusion as an Unusual Presentation of Infective Endocarditis

Infective endocarditis (IE) is a rare infection of the inner lining of the heart and valves, mainly affecting those with pre-existing heart problems. Patients usually present with fever and other non-specific systemic symptoms such as malaise, myalgia, and night sweats. However, IE may have unusual presentations, making its diagnosis even more challenging. Here, we report an unusual case of IE presenting as confusion.

A 51-year-old man presented to the emergency department complaining of confusion for three days. Upon physical examination, there was an evident holosystolic murmur at the apex radiating to the axilla and an early decrescendo diastolic murmur at the left lower sternal border. Laboratory tests including white blood cell count and C-reactive protein were elevated. Transthoracic and transesophageal echocardiogram showed severe mitral regurgitation and aortic regurgitation, in addition to the presence of a mobile mass suspected to be vegetation on each of the mitral and aortic valves. Magnetic resonance imaging of the brain was performed which revealed ischemic lesions of possible embolic origin. Mitral and aortic valve replacement was performed successfully, and the patient recovered well.

Our case emphasizes the possibility of unusual presentations in patients with IE, with confusion being one of them. It is important for physicians to always consider the diagnosis of IE in patients presenting with neurological symptoms of unclear origin.

Infective Endocarditis Manifesting as Severe Elevation in Serum Aminotransferases in the Absence of Severe Tricuspid Regurgitation, Heart Failure, or Shock: A Diagnostic Challenge

Infective endocarditis (IE) is a challenging condition to diagnose, given its protean clinical signs and symptoms, Elevation in serum aminotransferases in IE is associated with valvular regurgitation, acute heart failure, or congestive hepatopathy. Studies show co-existing liver failure portends worsening outcomes in IE and poses a challenge for successful surgical management. Here we report a diagnostic challenge in a 35-year-old man with IE presenting predominantly with gastrointestinal symptoms and severe elevation in serum aminotransferase. The degree of aminotransferase elevation in our patient prompted consideration of alternative causes like acetaminophen toxicity. Severe elevation in aminotransferases as an initial presentation in the absence of significant valvular regurgitation, acute right heart failure, or shock is uncommon. A high degree of suspicion is required to diagnose IE when patients present with atypical signs and symptoms to avoid delay in initiation of antibiotics and improve overall morbidity and mortality.

Epidemiological and clinical profile of infective endocarditis at a Brazilian tertiary care center: an eight-year prospective study

INTRODUCTION

Infective endocarditis (IE) is a systemic infectious disease requiring a multidisciplinary team for treatment. This study presents the epidemiological and clinical data of 73 cases of IE in Rio de Janeiro, Brazil.

METHODS

This observational prospective cohort study of endocarditis patients during an eight-year study period described 73 episodes of IE in 70 patients (three had IE twice). Community-associated (CAIE) and healthcare-acquired infective endocarditis (HAIE) were diagnosed according to the modified Duke criteria. The collected data included demographic, epidemiologic, and clinical characteristics, including results of blood cultures, echocardiographic findings, surgical interventions, and outcome.

RESULTS

Analysis of data from the eight-year study period and 73 cases (70 patients) of IE showed a mean age of 46 years (SD=2.5 years; 1-84 years) and that 65.7% were male patients. The prevalence of CAIE and HAIE was 32.9% and 67.1%, respectively. Staphylococcus aureus (30.1%), Enterococcus spp. (19.1%), and Streptococcus spp. (15.0%) were the prevalent microorganisms. The relevant signals and symptoms were fever (97.2%; mean 38.6 + 0.05°C) and heart murmur (87.6%). Vegetations were observed in the mitral (41.1%) and aortic (27.4%) valves. The mortality rate of the cases was 47.9%.

CONCLUSIONS

In multivariate analysis, chronic renal failure (relative risk [RR]= 1.60; 95% confidence interval [CI] 1.01-2.55), septic shock (RR= 2.19; 95% CI 1.499-3.22), and age over 60 years (RR= 2.28; 95% CI 1.44-3.59) were indirectly associated with in-hospital mortality. The best prognosis was related to the performance of cardiovascular surgery (hazard ratio [HR]= 0.51; 95% CI 0.26-0.99).

QT Prolongation Complicated with Torsades de Pointes in Prosthetic Mitral Valve Endocarditis: A Case Report

We present the case of a 49-year-old male patient with prosthetic mitral valve endocarditis associated with QT prolongation and torsades de pointes. He was asymptomatic until the end of January 2012, when he was admitted to our hospital emergency unit because of syncope, fever, and suspicion of endocarditis. Cardiologic evaluation was requested and the transthoracic (TTE) and transesophageal (TEE) echocardiograms revealed vegetations on the prosthetic mitral valve. All cultures were positive for methicillin-sensitive Staphylococcus aureus. The corrected QT (QTc) interval was markedly prolonged upon admission (QTc 540 ms). He experienced torsades de pointes (TdP) several times and he was recovered after bystander cardiopulmonary resuscitation. The clinical course and the long QTc interval with deep inverted T wave were completely normalized 4 weeks after. He continued on triple antibiotic therapy for 45 days with a good revolution. The clinical features and the possible mechanisms of QT prolongation (inflammation, infection) of this patient are discussed.

Native valve Brucella endocarditis

OBJECTIVE

Brucellosis is frequently seen in Mediterranean and Middle East countries, including Turkey. We report the medical and surgical management of 31 cases of native endocarditis.

MATERIAL AND METHOD

Thirty-one patients were admitted to our clinic with suspected Brucella Endocarditis. The diagnosis was established by either isolation of Brucella species, or the presence of antibodies. Following preoperative antibiotic therapy patients underwent valve replacement with excessive tissue debridement. Patients were followed up with Brucella titers, blood cultures, and echocardiography.

RESULTS

On admission all patients were febrile and mostly dyspneic (NYHA Class 3 or 4). The blood tests were normal except for elevated ESR, CRP and serological tests. The aortic valve was involved in 19 patients, mitral valve in 7 patients, and both valves in 5. After serological confirmation of BE, antibiotic therapy was maintained. Twenty-five of the patients received rifampicine, doxycycline, and cotrimaxozole; 2 of them received a combination of rifampicine, streptomycin, and doxycycline; and 4 of them received rifampicine, tetracycline, and cotrimaxozole. Tissue loss in most of the affected leaflets and vegetations were presenting all patients. Valve replacements were performed with mechanical and biologic prostheses. All the patients were afebrile at discharge but received the antibiotics for 101, 2+/-16, 9 days. The follow-up was 37, 1+/-9, 2 months.

DISCUSSION

In our retrospective study, combination of adequate medical and surgical therapy resulted in declined morbidity and mortality rate. The valve replacement with aggressive debridement is the most important part of the treatment, which should be supported with efficient preoperative and long term postoperative medical treatment.

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.