Complete heart block complicating bacterial endocarditis

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.

Perforated cuspal aneurysm of aortic valve following infective endocarditis presenting as complete heart block: a case report and review of literature

Aortic cuspal aneurysm is a rare clinical entity and often occurs as a complication of infective endocarditis. We report a case of a 30-year-old male with no prior comorbid conditions who presented with fever, acute onset shortness of breath, and chest pain along with multiple episodes of syncope. Electrocardiogram revealed complete heart block while two-dimensional echocardiogram was suggestive of perforated aortic cuspal aneurysm with aortic regurgitation. Blood cultures were positive for Streptococcus viridans. The patient was initiated on broad spectrum antibiotics, temporary pacemaker implantation, and subsequently underwent aortic valve replacement followed by permanent pacemaker implantation after 6 weeks. A diagnosis of perforated aortic cuspal aneurysm subsequent to infective endocarditis was made. This was based on clinical presentation, echocardiographic evaluation, blood cultures, and surgical as well as histopathological findings.

In-hospital outcomes and prevalence of comorbidities in patients with infective endocarditis with and without heart blocks: Insight from the National Inpatient Sample

Infective endocarditis (IE) complicated by heart block can have adverse outcomes and usually requires immediate surgical and cardiac interventions. Data on outcomes and trends in patients with IE with concurrent heart block are lacking. Patients with a primary diagnosis of IE with or without heart block were identified by querying the Healthcare Cost and Utilization Project database, specifically the National Inpatient Sample for the years 2013 and 2014, based on International Classification of Diseases Clinical Modification Ninth Revision codes. During 2013 and 2014, a total of 18,733 patients were admitted with a primary diagnosis of IE, including 867 with concurrent heart blocks. Increased in-hospital mortality (13% vs 10.3%), length of stay (19 vs 14 days), and cost of care ($282,573 vs $223,559) were found for patients with IE complicated by heart block. Additionally, these patients were more likely to develop cardiogenic shock (8.9% vs 3.2%), acute kidney injury (40.1% vs 32.6%), and hematologic complications (19.3% vs 15.2%), and require placement of a pacemaker (30.6% vs 0.9%). IE and concurrent heart block resulted in increased requirement for aortic (25.7% vs 6.1%) and mitral (17.3% vs 4.2%) valvular replacements. Conclusion was made that IE with concurrent heart block worsens in-hospital mortality, length of stay, and cost for patients. Our analysis demonstrates an increase in cardiac procedures, specifically aortic and/or mitral valve replacements, and Implantable Cardiovascular Defibrillator/Cardiac Resynchronization Therapy/ Permanent Pacemaker (ICD/CRT/PPM) placement in IE with concurrent heart block. A close telemonitoring system and prompt interventions may represent a significant mitigation strategy to avoid the adverse outcomes observed in this study.

A Rare Case of Infective Endocarditis Caused by Gemella haemolysans

Gemella haemolysans is a gram-positive coccoid, facultative anaerobe of the mucous membranes. In rare cases, it has been identified as an opportunistic pathogen in the development of endocarditis. Here, we describe a case of infective endocarditis in a patient with a bicuspid aortic valve. A 38-year-old man presented with the complaint of exertional dyspnea of one month duration. He was found to have leucocytosis and his blood cultures grew Gemella haemolysans. Trans-esophageal echocardiography showed a bicuspid aortic valve with 1.5 x 1.5 cm vegetative mass, severe aortic regurgitation, and an aortic root abscess. The patient was started on intravenous ampicillin and gentamycin. He then underwent mechanical aortic valve replacement and bovine reconstruction of the left ventricular outflow tract. Our case highlights the importance of considering atypical pathogens as causative agents of infective endocarditis.

Blocking a rash diagnosis: a rare case of infective endocarditis

We report a case of a previously healthy, afebrile patient who presented with subacute bilateral lower extremity rash and complete heart block, which was later found to be secondary to infective endocarditis. His transoesophageal echocardiogram detected multiple vegetations and blood cultures were positive for Granulicatella adiacens, a nutritionally variant streptococcus that is a normal component of oral flora and thought to be responsible for approximately 5% of all cases of streptococcal endocarditis. Due to concerns for renal failure, the patient was treated with an unconventional regimen of ampicillin and ceftriaxone. He underwent a valve replacement and pacemaker placement and has done well since hospital discharge.

Complete Atrioventricular Block Complicating Mitral Infective Endocarditis Caused by Streptococcus Agalactiae

Patient: Male, 74

Final Diagnosis: Infective endocarditis

Symptoms: Apetite loss • fever

Medication: —

Clinical Procedure: Transesophageal echocardiography

Specialty: Cardiology

Infective Endocarditis Presenting as Complete Heart Block With an Unexpected Finding of a Cardiac Abscess and Purulent Pericarditis

Intracardiac abscess resulting in complete heart block is an infrequent complication of infective endocarditis. Most presentations of endocarditis are limited to valvular and perivalvular structures, with varying degrees of heart block occurring in the minority of cases. We report a case of endocarditis manifesting as chest pain associated with ST segment elevation and complete heart block. The patient expired unexpectedly within a few hours of presentation. Postmortem examination revealed an atrial septal abscess, purulent pericardial collection, and fibrinous pericarditis. Spread of the abscess into the atrial septum was postulated to be the cause of the complete heart block. In endocarditis, the ominous development of heart block and a poor response to antibiotic therapy imply significant extension of the infection. Management therefore requires prompt ventricular pacing with consideration for valve replacement and possible pericardial drainage.

Complete heart block associated with tricuspid valve endocarditis due to extended spectrum β-lactamase-producing Escherichia coli

We report a case of complete heart block associated with tricuspid endocarditis due to extended-spectrum β-lactamase-producing Escherichia coli (ESBL E. coli) following a transrectal prostate biopsy. This is the first report of complete heart block associated with tricuspid native valve endocarditis. In addition, this is also the first reported case of ESBL E. coli causing endocarditis of any kind. Prompt antibiotic therapy resulted in a downgrading of the high-grade conduction block and eventual cure of an associated complication, vertebral osteomyelitis, and discitis. The anatomy and microbiology of endocarditis in the context of heart block are presented and discussed.

Two cases of pulmonary homograft replacement for isolated pulmonary valve endocarditis

Isolated pulmonary endocarditis is rare. Two cases that required surgical treatment are reported: a 35-year-old woman with predisposing factors for right-sided endocarditis who presented with complete heart block; and a healthy 65-year-old man with no predisposing factors who was admitted with septic shock. Both patients presented with septic shock and pulmonary septic emboli requiring urgent surgical treatment. Surgical correction using pulmonary homograft was done, with immediate postoperative recovery. The current literature of isolated pulmonary endocarditis is also reviewed.

Endocarditis and associated complications

Echocardiography is a most useful bedside tool to help in the diagnosis and subsequent management of patients with infective endocarditis. Transesophageal echocardiography provides complementary and often incremental information necessary in making a diagnosis, and in identifying associated intracardiac complications. This chapter will focus on the role of echocardiography in the diagnosis and management of infective endocarditis.

[Severity of aortic ring abscess complicated by cardiac conduction abnormalities]

OBJECTIVE

To determine clinical features, management and prognosis of cardiac conduction abnormalities (CCA) complicating abscessed endocarditis.

METHODS

We have analysed clinical, microbiologic and echocardiographic datas, therapies and outcome of cardiac abscesses complicated by CCA in patient hospitalized between 1995 and 2001 in our centre.

RESULTS

Above 35 cardiac abscesses, six men (mean age 62 years) had CCA complicating six aortic ring abscesses (4 on native valve and 2 on prosthetic valve) with four cases of interventricular septal involvement and fistulization. Severe heart failure is present four times, a septic cerebral embolization twice. Streptococcus and Staphylococcus prevail. Complete atrioventricular block (AVB) reveals endocarditis twice and complicates the evolution three times. Trifascicular block (first degree AVB, left anterior fascicular block and complete right bundle branch block) revealed recurrence of endocarditis. Two patients were treated medically: one died quickly (complete AVB pre-mortem), and the other one had favourable issue (paroxystic complete AVB). Four patients had surgery with temporary pacemaker in three cases (one died) then definitive pacemaker in two cases. At 26.5 month (7-50), the four survivors had no recurrence of endocarditis.

CONCLUSION

Severe CCA are classical in aortic ring abscessed endocarditis and associated with increased mortality. Immediate transfert in a dentre with cardiac surgery is necessary. Definitive cardiac pacing can be performed early without leads infection.

Progressive Staphylococcus lugdunensis endocarditis despite antibiotic treatment

A 68-year old man with fever chills and a diastolic murmur was diagnosed with aortic-valve endocarditis caused by coagulase-negative Staphylococcus lugdunensis. The clinical condition initially improved with antibiotic therapy. On day seven, transoesophageal echocardiography revealed large abscesses extending from the aortic root to the left ventricular wall. Emergency cardiac surgery was performed successfully and a stentless bioprosthetic valve was inserted. S. lugdunensis endocarditis is known for its aggressive clinical course with valve destruction, abscess formation and embolic complications despite appropriate antibiotics. Antibiotic treatment alone is associated with a high mortality rate which can be reduced by early valve replacement.

Cardiac conduction abnormalities in endocarditis defined by the Duke criteria

BACKGROUND

Cardiac conduction abnormalities occur in endocarditis and have been associated with infection extension and increased mortality. There have been no prospective studies of electrocardiographic (ECG) conduction changes in endocarditis. We examined the incidence of ECG changes in a large prospective cohort with suspected endocarditis and correlated changes with echocardiographic evidence of invasive infection and mortality.

METHODS

One hundred thirty-seven of 1396 (10%) suspected cases of endocarditis were classified as "definite" or "possible" by the Duke criteria and had an interpretable ECG. ECG conduction changes were classified as old (pre-existing hospitalization), new (evident on admission or developed during hospitalization), or indeterminate. New or indeterminate abnormalities were considered "ECG conduction changes." Echocardiogram results were reviewed to identify infected valves and invasive infection.

RESULTS

ECG conduction changes were present in 36 of 137 (26%) patients. Patients with ECG conduction changes were more often male (69% vs 46%, P =.005) and had prosthetic valves (47% vs 23%, P <.001). There were no significant differences in microbiology results or treatment with cardiac surgery. In 76 (55%) patients, at least one infected valve was identified by echocardiography; 15 of 76 (20%) patients were determined to have evidence of invasive infection. Eight of 15 (53%) invasive infections exhibited ECG conduction changes compared with 16 of 61 (26%) isolated valve infections (P =.046). Eleven of 36 (31%) patients with ECG conduction changes died during hospitalization compared with 15 of 101 (15%) patients without changes (P =.039).

CONCLUSIONS

ECG conduction changes commonly occur in endocarditis despite more sensitive diagnostic criteria and are associated with increased mortality and invasive infection.

Bacillus popilliae endocarditis with prolonged complete heart block

Bacillus popilliae, a fastidious, aerobic, gram-positive, spore-forming bacillus, has never been reported as a pathogen in human infectious diseases. We report the first case of a human infected by the pathogen B. popilliae, which presented as endocarditis involving the bicuspid aortic valve and complicated with prolonged (> 30 days; to our knowledge, the longest in the literature) complete heart block. Although surgery may be warranted by previous reports, the patient was successfully managed by medical treatment instead, because of the absence of evidence from various approaches that support the existence of perivalvular extension of infection.

Surgical treatment of endocarditis

Since early investigators first suggested that the treatment of endocarditis should include valve replacement for infections not readily controlled with medical therapy alone, the role of surgery has become expanded, yet refined, to improve the outcome of patients with this potentially fatal disease. Innovative surgical techniques have also been developed in an effort to improve the results of surgical treatment for complex sequelae of invasive infections. This article examines the current indications for surgical intervention, compares the various surgical options, and assesses the expected short-and long-term outcome after valve replacement for patients with native valve or prosthetic valve endocarditis.

Endocarditis-associated paravalvular abscesses. Do clinical parameters predict the presence of abscess?

STUDY OBJECTIVE

To determine whether standard clinical and transthoracic echocardiographic criteria considered to be suggestive of the presence of endocarditis-associated paravalvular abscess are predictive of which patients would benefit from reliable but invasive transesophageal echocardiographic investigations for abscess.

DESIGN

Retrospective chart review.

SETTING

A 630-bed university hospital.

PATIENTS

Forty-eight patients with 51 episodes of definite endocarditis and 24 paravalvular abscesses.

MEASUREMENTS AND RESULTS

A comparison of abscess and nonabscess populations revealed that clinical parameters (patient demographics, valvular involvement, presence of a prosthesis, infection with a virulent organism, pericarditis, persistent fever, persistent bacteremia, congestive heart failure, history of intravenous drug use, embolization) and transthoracic echocardiographic parameters were insensitive predictors of the presence of abscess. The only statistically significant correlate was the presence of previously undetected atrioventricular or bundle branch block. Paravalvular abscesses were common in our population and were associated with increased mortality. Improved survival correlated with the absence of mitral valve involvement and the absence of moderate-to-severe congestive heart failure.

CONCLUSIONS

Given the accuracy and safety of transesophageal echocardiography and the unreliability of clinical and transthoracic echocardiographic criteria, we recommend that transesophageal echocardiography be considered in all endocarditis patients with previously unrecognized conduction disturbances, aortic or prosthetic valve involvement, or both, or indications for valve replacement, or all of the foregoing.

Management of Brucella endocarditis with aortic root abscess

Three cases of Brucella endocarditis with aortic root abscess are reported. Two patients were successfully managed by a combination of medical therapy and surgery. The third patient died suddenly 36 hours after admission to hospital.

The relationship between new cardiac conduction defects and extension of valve infection in native valve endocarditis

New conduction defects in the setting of native valve infective endocarditis (IE) are commonly believed to be associated with direct extension beyond the free valve area. At University Hospital in Newark, among 100 cases of IE, in none of five instances of associated conduction defects (excluding first-degree heart block) was this the case. In neither of two instances of direct extension of valve infection was this accompanied by a new conduction defect. To explore this relationship, autopsy, surgical, and echocardiographic findings from other institutions were combined with these data. Among 47 instances of new conduction defects in IE, only 60% could be related to direct extension of valve infection. The cause was coronary embolization in 4% and unknown in 36%. Among 119 cases of complicated valve lesions, significant conduction defects were documented by ECG in only 15%. In IE the appearance of new conduction abnormalities may often result from causes other than extension of valve infection. Furthermore, complicated valve lesions may often be present without electrocardiographic evidence, indicating interruption of normal conduction pathways.

Effect of electrical stimulus parameters on the development and propagation of action potentials in short excitable fibres

Intracellular action potentials (IAPs) produced by short fibres in response to their electrical stimulation were analysed. IAPs were calculated on the basis of the Hodgkin-Huxley (1952) model by the method described by Joyner et al. (1978). Principal differences were found in processes of activation of short (semilength L less than 5 lambda) and long fibres under near-threshold stimulation. The shorter the fibre, the lower was the threshold value (Ithr). Dependence of the latency on the stimulus strength (Ist) was substantially non-linear and was affected by the fibre length. Both fibre length and stimulus strength influenced the IAP amplitude, the instantaneous propagation velocity (IPV) and the site of the first origin of the IAP (and, consequently, excitability of the short fibre membrane). With L less than or equal to 2 lambda and Ithr less than or equal to Ist less than or equal to 1.1Ithr, IPV could reach either very high values (so that all the fibre membrane fired practically simultaneously) or even negative values. The latter corresponded to the first origin of the propagated IAP, not at the site of stimulation but at the fibre termination or at a midpoint. The characters of all the above dependencies were unchanged irrespective of the manner of approaching threshold (variation of stimulus duration or its strength). Reasons for differences in processes of activation of short and long fibres are discussed in terms of electrical load and latency. Applications of the results to explain an increased jitter, velocity recovery function and velocity-diameter relationship are also discussed.

Electrocardiographic findings in infective endocarditis

Management of infective endocarditis includes early recognition of complications and prompt intervention when necessary to avert an untoward result. Among the most serious potential complications of this disorder are those that involve the heart itself. Although the ECG is often normal or nearly so in patients with endocarditis, at other times apparently minor abnormalities may be harbingers of potentially fatal complications. The ECG therefore plays an important role in the initial and ongoing evaluation of patients in whom endocarditis is suspected.

Cardiac conduction abnormalities complicating native valve active infective endocarditis

Two hundred eleven episodes of native valve active infective endocarditis treated at the Massachusetts General Hospital between 1975 and 1983 were reviewed. The aortic (36%) and mitral (33%) valves were most frequently involved, but in 21% of the cases the site of infection could not be localized. Streptococcal (50%) and staphylococcal (35%) species were the most frequently isolated pathogens. New or changing ("unstable") conduction abnormalities developed in 9% of the patients, while an additional 7% had conduction abnormalities of "indeterminate" age. Unstable conduction block was more likely to develop in patients with aortic valve infective endocarditis than in those with mitral infection. Surgery was performed in 23% of the patients. Unstable conduction abnormalities were significantly associated with valve replacement, but in a multivariate analysis, this effect could be explained by the site of valvular infection. The mortality rate was 20%. Patients with unstable conduction abnormalities had a significantly higher mortality rate, even after other significant predictors of death (age, type of causative organism) were taken into account. Patients whose conduction changes persisted had a worse prognosis than those with transient conduction abnormalities. Although more hemodynamically compromised, patients with unstable conduction block who underwent valve replacement did at least as well as those given medical therapy alone. Patients with native valve active infective endocarditis in whom persistent, unstable conduction abnormalities develop without other identifiable cause, especially in the presence of aortic valve infection, should be considered for valve replacement.

Mycotic aneurysms of the aortic root. A pathologic study of 20 cases

Twenty specimens of heart with mycotic aneurysms at the aortic root were studied. In ten cases, mycotic aneurysm followed infection of the aortic valve. In one case, it developed following infection of an aortic jet lesion, and in nine patients, the aneurysm was at the seat of a prosthetic aortic valve. In seven of the 11 cases with a natural aortic valve, the valve was either unicuspid or bicuspid. A retrospective evaluation of the data on the clinical records of the 20 patients revealed that infective endocarditis or noncardiac postoperative sepsis was present in 11. The most frequently isolated microorganism was Staphylococcus aureus. Conduction disturbances were found in six patients, all of them with involvement of the atrioventricular node by the aneurysm. Perforation into intracardiac cavities was found in four, two into the right ventricular infundibulum and one each into each atrium. Pericardial tamponade was caused by bleeding from the aneurysm in two cases, and myocardial infarction was a probable consequence of coronary arterial compression by the aneurysm in two cases. Mycotic aneurysms of the aortic root, in spite of their being partially or completely healed of active infection, carry a high risk of the complications enumerated. Among the 20 cases, cultures were positive in 11 and negative in nine. Staphylococcus aureus was cultured from five of the cases.

Myocardial abscess with complete heart block complicating anaerobic infective endocarditis

Myocardial abscess caused by anaerobic infection is rare and usually occurs in cases of myocardial infarction, in which it may be related to areas of low oxygen tension. Bacteroides CDC group F-1 infective endocarditis complicated by an aortic valve ring abscess with resultant complete heart block developed in a patient with steroid dependent systemic lupus erythematosus. The genitourinary system was the presumed source of the infection. Endocarditis developed after an elective abortion, despite antibiotic prophylaxis according to American Heart Association recommendations. This case shows that an anaerobic abscess of the aortic valve ring can affect contiguous vital structures of the conducting system. Immunosuppression may increase the risk of anaerobic infection after genitourinary procedures, and in this situation the recommended antibiotic prophylaxis may be inadequate.

Detection of endocarditis-associated perivalvular abscesses by two-dimensional echocardiography

The development of a perivalvular abscess as a complication of infective endocarditis adds appreciably to the expected morbidity and mortality of patients, but such abscesses are seldom recognized by available noninvasive techniques. Therefore, two-dimensional echocardiographic findings in 22 patients with perivalvular abscess found at surgery or necropsy were compared with those in 24 patients without abscess in a retrospective but blinded study. Forty-six valves were examined (31 aortic and 15 mitral, 35 prosthetic and 11 native); 4.0 +/- 2.4 days (range 0 to 7) elapsed between echocardiography and surgery or necropsy. Patients with perivalvular abscess had a somewhat higher incidence of serious complications (emergency repeat valve replacement or death) than did patients with endocarditis alone (63 versus 35%, respectively, p less than 0.05). No single echocardiographic finding was frequently seen with a perivalvular abscess. A "typical" echo-free abscess was noted in only one patient; however, the presence of one or more of the following had a positive predictive value of 86% and a negative predictive value of 87% for the presence of perivalvular abscess: prosthetic valve rocking; sinus of Valsalva aneurysm, anterior aortic root thickness of 10 mm or greater, posterior aortic root thickness of 10 mm or greater or perivalvular density in a septum of 14 mm or greater. These predictive values, of course, apply only to patients with infective endocarditis going to surgery, and may assist the surgeon in knowing whether or not to expect an abscess.(ABSTRACT TRUNCATED AT 250 WORDS)

Heart block during bacterial endocarditis: a review of the literature and guidelines for surgical intervention

The management of patients with bacterial endocarditis complicated by atrioventricular block is based on uncontrolled data, mostly from retrospective surgical and autopsy series. It is difficult to advance broad recommendations on the basis of such a biased population. Nevertheless, it is the firm opinion of many experienced clinicians that heart block developing as the result of aortic endocarditis signals myocardial abscess formation, and thereby is an indication for early surgery. I present a patient with aortic and mitral endocarditis in whom first degree heart block developed and then disappeared over five days; she was successfully managed with medical therapy alone. This case illustrates that some patients with endocarditis and heart block will not require surgery. In this setting, I propose the following guidelines in selecting patients for operation: 1) the observed appearance or progression of heart block; 2) the presence of aortic valve involvement; 3) the persistence of heart block, despite at least one week of optimal antibiotics; and 4) the elimination of other potential causes of conduction abnormalities.

Aortic valve endocarditis complicated by complete heart block

A 34-year-old man with severe aortic incompetence caused by Streptococcus viridans developed severe central chest pain followed by complete heart block, multifocal ventricular extrasystoles, lengthening of the QTc and signs of cerebral emboli and pulmonary oedema. Early antibiotic therapy along with pacing, non-invasive investigations coupled with early surgery contributed significantly to the patient's survival.

Late prosthetic valve endocarditis: clinical features influencing therapy

To assess the clinical features which might influence therapy, we studied 43 patients with late prosthetic valve endocarditis (LPVE). Twenty patients (47 per cent) survived. Of patients with streptococcal LPVE 61 per cent (11 of 18) survived compared to 36 per cent (nine of 25) of the patients with nonstreptococcal LPVE (p less than 0.10). Among patients with new regurgitant murmurs 33 per cent (nine of 27) survived versus 69 per cent (11 of 16) with such murmurs (p less than 0.03). Of patients with moderate to severe congestive heart failure (CHF) 16 per cent (three of 19) survived compared to 71 per cent (17 of 24) with mild or no CHF (p less than 0.001). The concurrence of two of these three features, i.e., nonstreptococcal etiology, a new regurgitant murmur or moderate to severe CHF, was associated with a mortality rate of 50 to 90 per cent. Persistent fever during therapy, a regurgitant murmur, atrioventricular conduction disturbances and relapse frequently reflected myocardial invasion. In view of the poor outcome with medical therapy and late reoperation, early surgical intervention should be considered when two of the three features noted are present or when myocardial invasion is suspected.

Endogenous E. coli endophthalmitis

A case of Escherichia coli septicemia with associated metastatic en dophthalmitis and endocarditis is presented. The ocular signs and symptoms were the initial manifestations of sepsis. Irreversible damage to the eye occurred in less than 24 hours. The pattern of metastatic bacterial endophthalmitis has changed since the introduction of potent antimicrobial agents, with an increased incidence of Gram-negative bacillemia. E. coli endophthalmitis carries a poor prognosis. Early diagnosis and systemic treatment will prevent the life-threatening complications of sepsis.