Detection of spleen, kidney and liver infarcts by abdominal computed tomography does not affect the outcome in patients with left-side infective endocarditis

Extra-cardiac abdominal complications are common in left-side infective endocarditis (LS-IE). The aim of this work was to study whether patients with LS-IE presenting splenic, renal, or liver (SRL) involvement seen in abdominal computed tomography (CT) had different clinical features, therapeutic plans, and outcome than those without these findings on CT.From January 2008 to April 2010, multidisciplinary teams have prospectively collected all consecutive cases of IE, diagnosed according to the Duke criteria, in which abdominal CT was performed.A total of 147 patients with LS-IE had abdominal CT. Fifty (34%) had SRL lesions: 46 splenic, 15 renal, 1 liver infarct, and 2 liver abscesses. Patients with SRL lesions were mainly men (P = .01), had liver disease (P = .001) with natural valve (P = .050) and mitro-aortic valve involvement (P = .042), splenomegaly (P = .001), nonabdominal emboli (P = .001), and a greater number and larger vegetation (>15 mm, P = .049) in the mitro-aortic valves (P = .051) than patients with normal abdominal CT. The site of acquisition, clinical characteristics, microbiology, surgical treatment, days of hospitalization, hospital death, and 1-year mortality were similar in patients with and without SRL emboli on CT. In the stepwise logistic regression analysis, male gender (odds ratio [OR] = 3.6, 95% confidence interval [CI] = 1.4-9.1), liver disease (OR = 8.3, 95% CI = 2.1-31.8), and nonabdominal emboli (OR = 5.2, 95% CI = 2.3-11.7) were independently associated with SRL lesions.Male patients with native LS-IE who had liver disease and nonabdominal emboli had more frequent abdominal lesions seen on CT. The presence of SRL infarcts on abdominal CT scan performed on patients with LS-IE seems to have poor practical implications, and as a consequence, its realization should only be considered when there are symptoms or signs that suggest them.

Acute brucellosis associated with leukocytoclastic vasculitis and splenic infarct

Brucellosis is globally the most prevalent multisystem infection of zoonotic origin, while it is still one of the most important public health problems in Turkey as non-pasteurised milk and dairy products are consumed. Early diagnosis is vital to prevent the possibly lethal complications caused by the disease. However, diagnosis might be delayed as the disease does not have a single and typical manifestation and presents with various symptoms of different systems. Brucellosis and associated splenic infarct have rarely been studied, there being few cases in the literature. One of the rare involvements in this disease is dermatological involvement, which has been found in less than 10 percent of brucellosis cases. In this study, we discuss a 17 year old male patient who was admitted to our hospital due to fever, abdominal pain, arthralgia and rash on legs, diagnosed with brucellosis through brucellosis tube agglutination test and found to have splenic infarct upon examination and leukocytoclastic vasculitis according to the skin biopsies in the light of the present literature.

Meningitis and splenic infarction due to disseminated Mycobacterium genavense infection in an HIV patient. Case report and review of the literature

We report a case of disseminated infection with Mycobacterium genavense in a 58 year old HIV positive woman presenting with fever, diarrhea, abdominal pain and weight loss. She had a striking hepatosplenomegaly, abdominal lymphadenopathy, anaemia and thrombopenia. Direct smears and cultures of blood, stool, sputum, urine and bone marrow were negative for common and opportunistic microorganisms. Splenectomy revealed numerous acid fast bacill. Lumbar puncture also showed acid fast bacilli at direct examination. Specific PCR and 16s rRNA gene sequencing identified M. genavense. The outcome was fatal despite antimycobacterial therapy. M. genavense must be included in the differential diagnosis of fever, weight loss, lymphadenopathy and splenomegaly in immunocompromised patients. Prompt diagnosis is based on molecular biology methods. Empirical therapy, using at least three antimycobacterial agents, including clarithromycin should be introduced in case of high clinical suspicion.

[Periaortic abscess and infective endocarditis: beware of this dangerous duo]

OBJECTIVE

To determine clinical, echocardiographic features, management and outcomes of patients presenting peri aortic abscess complicating infective endocarditis (IE) and demonstrate the impact of periaortic abscess on morbidity and mortality of these patients.

METHODS

We have analyzed clinical, microbiological, echocardiographic aspects, therapies and outcomes of patients with aortic abscess occurring during IE, and we compared these data with those of patients presenting IE without peri aortic abscess in the same period in the cardiology department of the University Hospital of Marrakech from January 2006 to January 2010.

RESULTS

Above 56 cases of infective endocarditis, 16 patients had an aortic abscess. Mean age was 33 ± 11 years with a clear male predominance in the group IE with abscess versus IE without abscess. Heart failure was noted in all patients in periaortic abscess group, and was more severe in this group compared to control. Streptococcus and staphylococcus predominated with no significant difference between the two groups. Transthoracic echocardiography coupled with transesophageal echocardiography made the diagnosis of aortic abscess witch was isolated in 11 cases and associated with other complications in five cases. In terms of complications, splenic infarction was more frequent in the group with abscess (25 versus 2.5%, P<0.05). There was not a significant difference between the two groups for the others complications. Surgery associated with a double antibiotic therapy was the standard treatment with a variable delay for surgery of four days to four weeks. Hospital mortality in the acute phase was higher in periaortic abscess group (37% versus 10%, P<0.05). The evolution of survivors at six months was favorable.

CONCLUSION

Periaortic abscess complicating IE is associated with a high morbidity and mortality in spite of modern approach as well as on medical or surgical treatment. It requires therefore a strict monitoring of patients with infective endocarditis.

[Splenic infarction in endocarditis: case report]

Splenic infarction is a very rare event though it can occur in a multitude of conditions with general or local manifestations. Splenic involvement in infectious endocarditis can be either infarction or abscess formation. The clinical picture is usually nonspecific and the diagnosis is often not initially suspected. We present a case of a 67 year-old male patient with infectious endocarditis who has been diagnosed with a splenic infarction by abdominal CT scan. The infarction was a result of septic embolization from the infected endocardium. The patient was initially managed conservatively with triple antibiotic therapy and regular follow-up ultrasound scan. The persistence of abdominal symptoms and the suspicion of splenic abscess formation led to the decision of performing splenectomy. Although imaging can characterize the nature of a splenic lesion, it is sometimes impossible to differentiate between infarction and abscess without histopathological confirmation. Splenic infarction should be suspected in all patients with a past history of thromboembolic disease who complain of left upper quadrant pain and present with localized or systemic inflammatory signs. Unfavorable clinical course and suspicion of abscess formation are indications for surgery. The characteristic features of splenic infarction are discussed together with a review of the recent literature.

[Difficulties in the differential diagnosis of splenic infarction and splenic abscess in a patient with active infective endocarditis -- case report and current review]

Systemic embolization is the most common extracardiac complication of active infective endocarditis (IE). The assessment of individual patient risk for embolic events in active IE is very difficult. Staphylococcal or fungal endocarditis, infections caused by HACEK and Abiotrophia spp. microorganisms, anterior mitral leaflet vegetations and vegetations with size >10 mm in TTE are associated with higher rate of arterial embolization. In this report we present a 66-year-old patient with active enterococcal aortic native valve endocarditis, with a history of gastric ulcers and with acute abdominal pain due to splenic infarction. We conclude that abdominal pain, particularly in the left-upper-quadrant, may be a sign of splenic infarction. Confirmation of this complication by ultrasonography provides important information about increased risk of future systemic embolic events.

Isolated splenic infarction owing to group B Salmonella: case report

The clinical spectrum of extra-intestinal salmonellosis, comprising enteric fever and invasive infections owing to non-typhoidal Salmonellae, is well known. We report an otherwise healthy patient with isolated splenic infarction caused by group B Salmonella. She was seropositive for the O antigen of Salmonella group B and stool cultures were positive for group B Salmonellae. After appropriate antimicrobial therapy, her complaints disappeared and microbiological tests for Salmonellae became negative.

[Brucellosis and splenic infarction: a case in pediatric age]

Splenic infarction has been associated with haematologic and tromboembolic disorders and, more rarely, with infectious diseases. A case of splenic infartion during an attack of brucellosis is reported. Symptoms included persistent left upper quadrant pain and fever. An abdomen scan confirmed the presence of a triangular area of hypodensity in the spleen. Serum and culture exams confirmed the diagnosis of brucellosis. The patient recovered once a course of antibiotic therapy was completed, after 2 and half months.

Total splenic infarct due to Aspergillus and AIDS

Invasive aspergillosis is a rare but important cause of morbidity and mortality in patients with AIDS. In the majority of patients, invasive aspergillosis involves the lungs. Extrapulmonary involvement with total splenic infarction has not been previously described. We illustrate a patient who developed total splenic infarction and septic emboli to the brain from Aspergillus.

Tc-99m leukocyte scintigraphy in infective endocarditis

A 56-year-old man with Staphylococcal aureus septicemia and clinically suspected infective endocarditis was imaged using Tc-99m HMPAO leukocytes. Although abnormal uptake was seen at 3 hours after injection, 24-hour images demonstrated marked concentration of radiolabeled leukocytes in a myocardial abscess and large posterior parietal infarct. In addition, multiple splenic infarcts were shown. The Tc-99m labeled leukocyte scan proved to be an excellent whole body screening procedure for diagnosing sites of infection and infarction in this patient.

A case of Trichosporon beigelii endocarditis 8 years after aortic valve replacement

We report a case of Trichosporon beigelii endocarditis in a 77-year-old diabetic man who presented with an embolic stroke 8 years ago after a porcine aortic valve replacement. He was treated successfully with amphotericin, rifampin, and replacement of the original porcine valve; however, he died suddenly 8 months later from unknown causes. Blood cultures 2 months prior to death were negative. The first manifestation of the endocarditis was a left hemiparesis followed some days later by a splenic infarction. Transthoracic echocardiography failed to demonstrate the aortic vegetation, which was clearly visualized subsequently by transesophageal echocardiography. The literature on Trichosporon beigelii endocarditis is reviewed.

Splenic septic emboli in endocarditis

The significance of septic emboli to the spleen is inferred by the frequency of septic emboli in general seen in patients with left-sided infective endocarditis who are referred for valve replacement. To determine the proper management of splenic infarcts and abscess due to septic emboli, we retrospectively reviewed the records of 108 patients with left-sided endocarditis who underwent valvular surgery at the University of Illinois Hospital from 1980 through 1988. Intravenous drug abuse was the etiology in 68% (n = 73). The incidence of splenic infarcts and abscess was 19% (n = 20), but an incidental finding of splenic infarcts was found in 38% (n = 11) of 29 asymptomatic patients who had computed tomograms. Streptococci and staphylococci were the causative organisms in 85% (n = 17). Localized findings were absent in 90% of splenic infarcts and abscesses. Abdominal computed tomograms were diagnostic of the sequelae of splenic septic emboli in 100%. No patient had intra-abdominal bleeding complications associated with cardiopulmonary bypass. Splenectomy was performed in 50% (n = 10) of patients 3-24 days (mean, 11.2 days) after valve replacement. Indications for splenectomy included persistent sepsis in 60% (n = 6), large (greater than 2 cm) and peripheral lesions in 30% (n = 3), and splenic rupture in 10% (n = 1). Perioperative mortality of patients who underwent splenectomy was 30% (n = 3). The following conclusions can be drawn: 1) Splenic septic embolus is common in endocarditis. 2) Abdominal computed tomography should be performed for all patients.(ABSTRACT TRUNCATED AT 250 WORDS)