Infective Endocarditis due to Bartonella spp. and Coxiella burnetii: Experience at a Cardiology Hospital in Sao Paulo, Brazil

Bartonella spp. and Coxiella burnetii are recognized as causative agents of blood culture-negative endocarditis (BCNE) in humans and there are no studies of their occurrences in Brazil. The purpose of this study is to investigate Bartonella spp. and C. burnetii as a causative agent of culture-negative endocarditis patients at a cardiology hospital in São Paulo, Brazil. From January 2004 to December 2004 patients with a diagnosis of endocarditis at our Institute were identified and recorded prospectively. They were considered to have possible or definite endocarditis according to the modified Duke criteria. Those with blood culture-negative were tested serologically using the indirect immunofluorescent assay (IFA) for Bartonella henselae, B. quintana, and C. burnetii. IFA-IgG titers >800 for Bartonella spp. and C. burnetii were considered positive. A total of 61 patients with endocarditis diagnosis were evaluated, 17 (27%) were culture-negative. Two have had IgG titer greater than 800 (>/=3,200) against Bartonella spp. and one against C. burnetii (phase I and II>/=6,400). Those with Bartonella-induced endocarditis had a fatal disease. Necropsy showed calcifications and extensive destruction of the valve tissue, which is diffusely infiltrated with mononuclear inflammatory cells predominantly by foamy macrophages. The patient with C. burnetii endocarditis received specific antibiotic therapy. Reports of infective endocartitis due to Bartonella spp. and C. burnetii in Brazil reveal the importance of investigating the infectious agents in culture-negative endocarditis.

Histoplasmosis as a late infectious complication following heart transplantation in a patient with Chagas' disease

Infectious complications following heart transplantation are an important cause of morbidity and mortality. Generally, bacterial infections are predominant; however, fungal infections can be responsible for up to 25% of infectious events. We report the case of a patient who presented with histoplasmosis as an infectious complication five years after heart transplantation due to a chagasic cardiopathy. This association has rarely been reported in the international literature.

Hepatic and pulmonary biopsy by mini-thoracotomy and transdiaphragmatic access

Frequently, immunodeficient patients have more than one organ or system affected by opportunistic infection or neoplasia, requiring quick and precise diagnostic investigation. In some situations, different invasive diagnostic procedures may be necessary. Open lung biopsy is sometimes necessary to clarify the pulmonary diagnosis. Laparoscopy may be useful to clarify liver or other peritoneal diseases. Some specific patients might require both procedures. In this way it is proposed that the surgeon, through a microthoracotomy used for the pulmonary biopsy, has access to the diaphragm. A small phrenotomy is performed and then a liver needle biopsy under direct vision. The described technique of simultaneous open lung and hepatic biopsy permits better handling of the needle and hemostasis of the hepatic lesion at the puncture site. This method has been used since 1994 on 16 HIV-positive patients, all having clinical and laboratory manifestations of lung disease associated with liver disease of unknown etiology. No complications related to the method were observed. It is significant that different etiologies for the lung and liver disease were found in 50% of the cases. We conclude that the presented technique is simple, useful, and safe.

[Infective endocarditis in 100 patients subjected to heart transplantation]

PURPOSE

An analysis of occurence, etiology, clinical aspects and death rate of infectious endocarditis cases involving patients who underwent heart transplantation.

METHODS

100 consecutive heart transplant patients were analysed; follow-up varied from three to 90 (medium of 25.38, SD +/- 27.97) months. Diagnostic criteria for endocarditis were those of the epidemiology and quality control service, Heart Institute, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, that agree with those of the Center for Disease Control. Diagnosis was established mostly by blood cultures, echocardiograms, either transthoracic or esophageal and autopsy.

RESULTS

Six cases of endocarditis were recognized, with four deaths; in three of those we found severe systemic compromise. All cases had fever as an important symptom.

CONCLUSION

Death risk seems high of infectious endocarditis after heart transplantation. The cause of this high risk appears to be linked to the bacteria themselves, to association with other clinical situations and to the use of immunosuppresive agents. We recommend a high index of suspition when risk factors are present in order to make a rapid diagnosis soon enough in the natural history of the disease; treatment has to be started as soon as possible.

Epidemiologic investigation of an outbreak of coagulase-negative Staphylococcus primary bacteremia in a newborn intensive care unit

Infections due to coagulase-negative Staphylococcus (CNS) are an ever-increasing nosocomial problem, particularly in the pediatric population. The authors describe a cluster of three primary bloodstream infections due to CNS in a newborn intensive care unit that occurred between November 23 and December 2, 1992. Two children died as a direct consequence of the bacteremia; at autopsy, one had a large bacteria-containing thrombus extending from the insertion site of a central catheter to the superior vena cava. The children were placed in isolation, and the nursing and medical staff were given topical nasal mupirocin. Plasmid analysis performed later disclosed three different blood isolates that also were different from any of the staff's nasal isolates. The authors concluded that molecular methods such as plasmid analysis are important tools in identifying true outbreaks and can prevent needless interventions, such as those during this cluster.

[Infections in 100 heart transplantation patients]

PURPOSE

A prospective study of infective agents in diagnosed infections and deaths by specific agents in cardiac transplant patients.

METHODS

Infections occurring in a series of 100 consecutive cardiac transplant patients after transplantation with definite infectious diagnosis were studied; follow-up after transplantation was 3 to 90 (medium 25.38 +/- 25.97) months. Diagnostic criteria for defining infections were those used in the Epidemiology and Quality Control Division of the INCOR, that are the same published by the Centers for Disease Control. The following parameters were analysed: infections/patient/time, causes of infection and organs infected, clinical presentation and clinical aspects of infections, methods used for the infective diagnosis and relationship between rejection episodes and infection. Death caused by infections and survival rates per infection were also studied.

RESULTS

Bacterial infections were more frequent (56.3% of all infections), followed by viral infections (19.6%), fungal infections (18%) and protozoal infections (6.1%). Of all deaths after transplantation, 25% were caused by infections.

CONCLUSION

Infections are an important cause of mortality and morbidity in this patient population; our data are in accordance to the other reported series.

[Hospital bacteremia at the "Instituto do Coração do Hospital das Clínicas da FMUSP": a four-year retrospective study]

We conducted a retrospective study to establish mortality rates and prevalence of nosocomial bacteremias at our institute. We found 1.21 nosocomial bacteremias per 100 hospital discharges with an overall Mortality rate of 29.5%. Primary bacteremias increased during the four-year-study-period from 31 to 41%. Staphylococcus, both coagulase-positive and coagulase-negative, was the bacteria most frequently isolated. An abrupt increase in the isolation of P.aeruginosa occurred in 1992. We concluded that a blood-culture surveillance program is required for determining an endemic rate.

[Heart transplantation: donor with Chagas' disease and clinical course of the receptor]

Because of an operational misshape, a female patient received a heart transplant whose donor was chronically infected by Trypanosoma cruzi. After 3 months, transmission of the parasite has not been detected, what deserves communication, considering the clinical and scientific implications of the case.

Cytomegalovirus and other herpesviruses infections in heart and bone marrow transplant recipients

From January 1988 to January 1989 all the heart transplant and bone marrow recipients at the Instituto do Coração of the Hospital das Clínicas of the University of São Paulo Medical School were studied for the incidence and morbidity associated with herpesviruses infections after transplantation. Five bone marrow and 5 heart transplant recipients were followed for a mean of 4.2 months post-transplantation. All the patients were seropositive for cytomegalovirus (CMV) before admission and 80% experienced one or more recurrences during the observation period. Of the 12 episodes of CMV infection, that were identified in this study, 83% were accompanied by clinical or laboratory abnormalities. However, there was only one case of severe disease. The overall incidence of infection for herpes simplex (HSV) was 50%. Although most of HSV reactivations were oral or genital, one case of HSV hepatitis occurred. One of the 6 episodes of HSV infections that were treated with acyclovir showed an unsatisfactory response and was successfully managed with ganciclovir. All the individuals had anti-varicella zoster virus antibodies, but none of them developed infection. The study emphasizes the importance of active diagnostic surveillance of herpesvirus infections in transplant patients. Both CMV and HSV reactivations showed high incidence and important morbidity and thus, deserve prophylactic therapy.

[Preoperative HIV infection in cardiovascular surgery]

PURPOSE

To evaluate patients in the preoperative period of cardiovascular surgery for HIV antibody in the serum.

MATERIAL AND METHODS

1200 patients older than 15 years tested for HIV antibody before cardiovascular surgery with an enzyme immunoassay test (ELISA). When the results were ELISA positive ou inconclusive, another sample was collected for confirmatory test (Western Blot). We also analysed risk factors, clinical status of HIV infection and postoperative evolution.

RESULTS

ELISA test for HIV antibody were negative in 1180 (98.3%) patients, inconclusive in 14 and positive in 6. One ELISA inconclusive and six ELISA positive patients resulted Western Blot positive. All of the seven patients were asymptomatic (group II) in relation to HIV infection, including four bisexual men, two transfusion recipients men and a woman with an undetermined source of infection. Only the two transfusion recipients had their risk factor identified before testing. All of them were submitted to surgery with no immediate postoperative complication.

CONCLUSION

Seven (0.58%) patients had HIV antibody (Western Blot assay) but in only two risk factors were identified by routine preoperative anamnesis.

[Varicella during pregnancy: report of 13 cases and review of the recent literature]

Varicella occurs infrequently during pregnancy, but its natural history is not well defined and it is not certain that it is more severe in pregnant women that in other adults. For this reason a survey of 34 adult patients with varicella, admitted to Hospital das Clínicas--FMUSP from 1976 to 1986 was carried out. There were included 13 pregnant women and 21 other immunocompetent adults (11 males and 10 females). Average age in pregnant patients was 21.4 years; 24.6 years in adult females and 25.9 in adult males. In the latter group 10 patients had complications (47.6%) and in the pregnant group only four (30.7%). In three pregnant women (23%) and in four non pregnant women (36.3%) pneumonitis occurred. Pregnant women with pneumonitis developed respiratory failure, a feature not seen among immunocompetent adults.