Brucella infective endocarditis. Successful combined medical and surgical therapy

Five cases of Brucella infective endocarditis are described involving a native aortic valve, two native mitral valves, a mitral valve bioprosthesis, and a ventricular septal defect patch. The diagnosis of Brucella infective endocarditis was established from the clinical features, with a high Brucella serologic titer in each case. Blood and tissue cultures were positive in four of five patients. Two-dimensional echocardiograms demonstrated moderately large vegetations on the three affected native valves and the patch and also revealed the development of vegetation on the mitral bioprosthesis as the disease progressed. All the patients were successfully treated by combined surgical and medical therapy, the latter consisting of co-trimoxazole, tetracycline, and streptomycin/gentamicin for 6 weeks; the affected valves and the ventricular septal defect patch were all replaced. There were no operative deaths and there has been no recurrence of infection to date. One patient died suddenly of an unknown cause 1 year after the operation.     

Gemella haemolysans spondylodiscitis: a report of two cases

We report on two cases of infective spondylodiscitis caused by Gemella haemolysans in otherwise healthy patients. This organism has only rarely been identified as a cause of bone and joint infection, with only two previous reports of infective spondylodiscitis. We describe the clinical features, investigations and treatment options.     

Septic necrosis of the odontoid apophysis and cervical spondylodiscitis from Enterococcus faecalis endocarditis: a first report

We describe a 75-year-old male patient who developed a general syndrome, with a fever of 39 degrees C, weight loss, and cervical pain, during the month following a urological procedure. The presence of positive blood cultures for Enterococcus faecalis, aortic vegetations, and severe aortic regurgitation observed with echocardiogram confirmed the diagnosis of infective endocarditis (IE). Magnetic resonance imaging of the spinal cord showed significant erosion and irregularities of the odontoid apophysis, with hyperintensity of bone marrow in T2-weighted images because of edema and inflammation. These findings suggested an infective necrosis of the odontoid apophysis. Despite the common occurrence of rheumatologic manifestations in IE, with prevalence rates of 25% to 44%, spondylodiscitis is rarely observed (5%-13%). The lumbar region is the most commonly involved. We found only one other reported case of cervical spondylodiscitis. The case we describe is the first report of septic necrosis of the odontoid apophysis associated with IE.     

Infective spondylodiscitis in patients on maintenance hemodialysis: a case series

Infective spondylodiscitis is a rare disease. This case review describes the clinical course, risk factors, and outcomes of adult patients on maintenance hemodialysis who presented with infective spondylodiscitis at a single medical center in Taiwan. There were 18 cases (mean age: 64.9?±?10.8 years) over more than 10 years. Analysis of underlying diseases indicated that 50% of patients had diabetes, 55.6% had hypertension, 55.6% had coronary artery disease, 22.2% had congestive heart failure, 22.2% had a cerebral vascular accident, 16.7% had liver cirrhosis, and 11.1% had malignancies. Sixty-one percent of patients had a degenerative spinal disease and the most common symptom was back pain (83.3%). A total of 38.9% of patients had leukocytosis, 99.4% had elevated levels of C-reactive protein, 78.6% had elevated erythrocyte sedimentation rates, and 55.6% had elevated levels of alkaline phosphatase. The average hemodialysis duration was 72.8?±?87.5 months, and 8 patients (44.4%) started hemodialysis within 1 year prior to infective spondylodiscitis. Four patients (22.2%) had vascular access infection-associated spondylodiscitis. The lumbar region was the most common location of infection (77.8%), 44.4% of patients developed abscesses, and Staphylococci were the most common pathogen (38.9%). The mortality rate was 16.7%, all due to sepsis. Thirty-three percent of the survivors had recurrent infective spondylodiscitis within 1 year. Infective spondylodiscitis should be considered in hemodialysis patients who present with prolonged back pain with or without fever. Non-contrast MRI is an appropriate diagnostic tool for this condition. Vascular access infection increases the risk for infective spondylodiscitis in hemodialysis patients.     

Mitral valve repair during acute phase infective endocarditis with extensive destruction of the anterior leaflet rough zone and cerebral infarction

Some reports suggest that mitral valve repair has good outcomes and may, therefore, be the preferred surgical approach in patients with active infective endocarditis (Doukas et al. in Heart 92(3):361-363, 2006); Ruttmann et al. in J Thorac Cardiovasc Surg 130(3):765-771, 2005; Sternik et al. in J Heart Valve Dis 11(1):91-97, 2002). However, in cases of active infective endocarditis of the mitral valve, extensive destruction of valvular tissue may make reliable valve repair difficult. Moreover, the timing of valve repair for active infective endocarditis remains controversial, especially in patients having cerebral complications. We present a case of a 34-year-old woman who had active infective endocarditis of the mitral valve complicated by multiple acute cerebral infarctions from septic embolisation. We could successfully carry out mitral valve repair 36?h after the diagnosis of active infective endocarditis and cerebral infarction was made. Her postoperative course was uneventful, and the patient remained in good health without recurrence of infective endocarditis and neurological complications.     

Surgical treatment of infective endocarditis in childhood--report of 3 cases

This is the case report of 3 surgical patients with infective endocarditis in childhood. Case 1: A 8 year-old boy was admitted with high fever and congestive heart failure. Aureus staphylococci were identified by blood culture. Echocardiogram showed a vegetating mass on the posterior mitral leaflet. This patient was cured by emergency mitral valve replacement during the active phase of infection. Case 2: A 3 year-old girl was admitted with infective endocarditis related to VSD. Viridans streptococci were identified by blood culture. Echocardiogram showed a vegetating mass on the septal tricuspid leaflet. After successful antibiotic therapy, this patient underwent the closure of VSD and tricuspid valvuloplasty. Case 3: A 7 year-old boy was admitted with infective endocarditis related to VSD. Aureus staphylococci were identified with blood culture. Echocardiogram showed a vegetating mass on the anterior tricuspid leaflet and moderate tricuspid regurgitation. After successful antibiotic therapy, this patient underwent the closure of VSD and tricuspid valvuloplasty. We believe that echocardiography plays an important role in the diagnosis and management of infective endocarditis and that tricuspid valvuloplasty is the method of first choice in treatment of the patient with regional tricuspid infective endocarditis.     

61例感染性心内膜炎的诊断与治疗总结

目的 探讨感染性心内膜炎的诊断与外科治疗特点,分析外科治疗对术后短、中期疗效.方法 回顾性分析1995年1月～2008年4月期间61例感染性心内膜炎患者接受手术治疗的临床资料,总结外科治疗经验.结果 术后早期死亡4例(6.6%),术后随访6月～13年.出院患者死亡5例,其他生存患者中心功能Ⅱ级43例,Ⅲ级9例.结论 早期明确诊断、选择合适的手术时机及内、外科综合治疗是感染性心内膜炎成功治疗的关键.     

Group B streptococcal spondylodiscitis in adults: 2 case reports

Streptococcus agalactiae, or group B streptococcus (GBS), has been traditionally considered an infrequent etiologic agent of disease in adults except for urinary tract infection in pregnant women. Attention has recently been drawn to other adult infections caused by GBS such as skin and soft tissue infections, bacteriemias, pneumonia, meningitis, endocarditis, peritonitis, and bone and joint infections. We present two adult patients with GBS spondylodiscitis and review 30 cases of GBS spinal infection previously reported in the literature. This series clearly illustrates that GBS has recently been recognized as an emerging cause of vertebral infections in adults, particularly in those with chronic underlying diseases, although it can also affect immunocompetent patients without debilitating conditions. Although uncommon, GBS should be considered in the differential diagnosis of infective spondylodiscitis in nonpregnant adults, whatever the patient's immunological status.     

Spondylodiscites à streptocoque du groupe B chez l’adulte : 2 nouveaux cas et analyse des 32 cas publiés

Streptococcus agalactiae, or group B streptococcus (GBS), has been traditionally considered an infrequent etiologic agent of disease in adults except for urinary tract infection in pregnant women. Attention has recently been drawn to other adult infections caused by GBS such as skin and soft tissue infections, bacteremias, pneumonia, meningitis, endocarditis, peritonitis, and bone and joint infections. We present two adult patients with GBS spondylodiscitis and review 30 cases of GBS spinal infection previously reported in the literature. This series clearly illustrates that GBS has recently been recognized as an emerging cause of vertebral infections in adults, particularly in those with chronic underlying diseases, although it can also affect immunocompetent patients without debilitating conditions. Although uncommon, GBS should be considered in the differential diagnosis of infective spondylodiscitis in nonpregnant adults, whatever the patient’s immunological status.     

Infective endocarditis associated with spondylodiscitis and frequent secondary epidural abscess

BACKGROUND: Although many patients with IE complain of joint, muscle, and back pain, infections at these sights are rare. Indeed, in patients with back pain and endocarditis, less than 4% actually demonstrate spondylodiscitis. CASE DESCRIPTION: We recently encountered 4 patients with this complication, one each caused by Staphylococcus aureus, Streptococcus bovis, Streptococcus mitis, and Enterococcus faecalis, and wondered whether the nature of the infecting organism determined the development of spondylodiscitis and epidural abscess. In a literature review, 36 patients with endocarditis and spondylodiscitis were identified. Only 9 (25%) were caused by Streptococcus viridans and the remainder by staphylococci, enterococci, and other streptococci. Usually more than 50% of all cases of IE were caused by Streptococcus viridans, although more recent studies would indicate an incidence of about 40%. CONCLUSION: We conclude that spondylodiscitis with epidural abscess is more likely to occur in those patients with endocarditis who are infected by organisms with pyogenic potential.     

Renal pathological findings in infective endocarditis.

BACKGROUND: Accounts of renal pathological findings in infective endocarditis are mostly based on studies from many years ago. We reviewed a group of patients with infective endocarditis in the light of modern concepts of renal pathology, including the largest reported series of renal biopsies in this condition. METHODS: Renal tissue was available for retrospective study from 62 patients with confirmed infective endocarditis out of 354 diagnosed with the disease between 1981 and 1998 inclusive. Twenty patients had a renal biopsy and 42 a necropsy. RESULTS: Common renal lesions noted were localized infarcts in 31%, noted only in necropsy material, and acute glomerulonephritis in 26%, noted in biopsy and necropsy material. The commonest type of glomerulonephritis was vasculitic, without deposition of immunoproteins in glomeruli. Of the renal infarcts over half were due to septic emboli, mostly in patients infected with Staphylococcus aureus. Acute interstitial nephritis was found in 10% but was more common in biopsy material and seemed attributable to antibiotics. Renal cortical necrosis found in 10% was apparent only at necropsy. There were various other findings in the kidney. CONCLUSIONS: The kidneys are commonly affected in infective endocarditis by a variety of complications of clinical significance. The commonest type of glomerulonephritis does not appear to be attributable to deposition of immune complexes. A renal biopsy may be helpful in the investigation of renal impairment in a patient with infective endocarditis.     

感染性心内膜炎诊断和手术适应症的研究进展

感染性心内膜炎是一种严重威及生命的心血管疾病。早期明确诊断、早期手术治疗是治疗感染性心内膜炎的关键。适当的早期手术可以避免死亡和严重并发症,但手术的最佳时机仍不清楚。这需要临床工作者通过多学科合作来对早期手术的益处与风险进行权衡,以确保为患者提供早期手术的机会。目前,感染性心内膜炎早期手术治疗的主要适应症是:心力衰竭、不受控制的感染和预防栓塞。在这里,我们就感染性心内膜炎的诊断、抗菌治疗和手术治疗的适应症展开讨论。     

Transpedicular Curettage and Drainage of Infective Lumbar Spondylodiscitis: Technique and Clinical Results

Background

Infective spondylodiscitis usually occurs in patients of older age, immunocompromisation, co-morbidity, and individuals suffering from an overall poor general condition unable to undergo reconstructive anterior and posterior surgeries. Therefore, an alternative, less aggressive surgical method is needed for these select cases of infective spondylodiscitis. This retrospective clinical case series reports our novel surgical technique for the treatment of infective spondylodiscitis.

Methods

Between January 2005 and July 2011, among 48 patients who were diagnosed with pyogenic lumbar spondylodiscitis or tuberculosis lumbar spondylodiscitis, 10 patients (7 males and 3 females; 68 years and 48 to 78 years, respectively) underwent transpedicular curettage and drainage. The mean postoperative follow-up period was 29 months (range, 7 to 61 months). The pedicle screws were inserted to the adjacent healthy vertebrae in the usual manner. After insertion of pedicle screws, the drainage pedicle holes were made through pedicles of infected vertebra(e) in order to prevent possible seeding of infective emboli to the healthy vertebra, as the same instruments and utensils are used for both pedicle screws and the drainage holes. A minimum of 15,000 mL of sterilized normal saline was used for continuous irrigation through the pedicular pathways until the drained fluid looked clear.

Results

All patients'' symptoms and inflammatory markers significantly improved clinically between postoperative 2 weeks and postoperative 3 months, and they were satisfied with their clinical results. Radiologically, all patients reached the spontaneous fusion between infected vertebrae and 3 patients had the screw pulled-out but they were clinically tolerable.

Conclusions

We suggest that our method of transpedicular curettage and drainage is a useful technique in regards to the treatment of infectious spondylodiscitic patients, who could not tolerate conventional combined anterior and posterior surgery due to multiple co-morbidities, multiple level infectious lesions and poor general condition.     

Severe cardiogenic shock due to acute onset of an aorto-to-right atrial shunt in a patient with aortic valve endocarditis

INTRODUCTION

Heart failure is the most common cause of death due to infective endocarditis. We report a case of a patient presenting with severe shock due to an infection-associated left-to-right cardiac shunt.

PRESENTATION OF CASE

A 62-year-old man, who underwent aortic valve replacement five years previously, was admitted to ICU due to acute hemodynamic deterioration. A few days earlier, he had a septic episode with blood cultures positive for Staphylococcus aureus and clinical features of infective endocarditis. In ICU, transthoracic echocardiography revealed shunting from the aortic root to the right atrium resulting in severe cardiogenic shock.

DISCUSSION

This case report describes a near fatal complication of infective endocarditis, detected by routine use of transthoracic echocardiography.

CONCLUSION

Our case outlines the relevance of early cardiac surgery strategies in patients with infective endocarditis and we briefly discuss the current literature.     

Aspergillus prosthetic valve endocarditis.

The clinical, laboratory, and histopathological features of seven cases of Aspergillus fumigatus prosthetic valve endocarditis are presented. The exact nature of the lesion, a combination of infective fungal endocarditis and thrombosis on the prosthetic valve, is discussed and the difficulties in clinical diagnosis are emphasized. Helpful indications were sudden unexplained heart failure with the appearance of new murmurs, and emboli to large or medium-sized systemic arteries. Fever and anaemia were inconstant, and in no case was blood culture or precipitin investigation helpful. Spore contamination of operating theatre air was the likely source of infection, and measures taken to overcome this and other predisposing factors are discussed. Since medical diagnosis is usually late and the few reported cures in this condition have included replacement of the prosthesis, early surgical intervention combined with antifungal chemotherapy is advised.     

Enterobacter agglomerans spondylodiscitis: a possible, unrecognized complication of tetracycline therapy

STUDY DESIGN: This case report describes infection in a lumbar disc in a healthy young man with an organism of low pathogenicity. The patient was taking a prolonged course of antibiotics at the time the infection occurred. OBJECTIVE: To describe this unique case of infective spondylodiscitis. SUMMARY OF BACKGROUND DATA: To the authors' knowledge, spinal infection with Enterobacter agglomeranshas never been reported. This organism is a transient gut colonizer, and may have established itself secondary to the patient's prolonged ingestion of tetracycline for acne. METHODS: This 22-year-old farmer had spontaneous lumbar back pain. Radiologic investigations showed an abnormality in the L4-L5 disc region, and together with other investigations, were suggestive of infection. The diagnosis was confirmed by surgical aspiration. RESULTS: Antibiotic therapy was administered, and the patient made a complete recovery. Follow-up radiographs showed a complete loss of the L4-L5 disc space with only minimal bone destruction. CONCLUSION: A unique cause of infective lumbar discitis is presented. Several features of this case are unusual. The magnetic resonance findings were not readily diagnostic. The cultured organism is usually nonpathogenic. The infection may have been secondary to prolonged tetracycline therapy.     

Surgical treatment of active valvular infective endocarditis

A review is presented of 20 patients consecutively operated on for acute valvular endocarditis. The diagnosis was established from at least two of the criteria: (a) typical clinical features, (b) two blood cultures positive for the same causal microorganism, and (c) echocardiographic evidence of vegetations. In all cases there was histologic evidence of active infection in the surgical specimen. Only three of the 20 patients had no previous cardiac disease. The most common causal agent was Staphylococcus aureus. The indications for surgery were refractory cardiac failure or infection (18 and 2 cases, respectively). Aortic valve replacement was performed in 16 of the 20 cases, suggesting that aortic valvulopathy aggravates the course of infective endocarditis and increases the risk of heart failure. The overall mortality rate was 30%. All surviving patients were infection-free at postoperative bacteriologic follow-up. Surgery is considered to be the management of choice in active valvular, therapy-resistant bacterial endocarditis with or without cardiac failure.     

Clinical outcomes of percutaneous suction aspiration and drainage for the treatment of infective spondylodiscitis with paravertebral or epidural abscess

Background Context

Patients with infective spondylodiscitis who failed conservative treatment are generally indicated for open surgery. However, some patients are poor candidates for standard surgery, hence the need to evaluate less invasive approaches. Good outcomes were previously reported for percutaneous suction aspiration and drainage (PSAD) in the treatment of infective spondylodiscitis resistant to conservative therapy. We recently extended the surgical approach of PSAD to allow drainage of paravertebral or epidural abscesses in patients with progressive infective spondylodiscitis.

Candida albicans spondylodiscitis

Candida spondylodiscitis is a rare complication of a haematogenous dissemination of a candida infection, that usually affects immunocompromised patients. We present a case of a Candida albicans spondylodiscitis in a patient in whom a bacterial origin was suspected because of the antecedent of a Staphylococcus aureus bacteriaemia. After unfavourable evolution with initial antibiotic treatment, the correct diagnosis was reached after culture of the material obtained from surgical debridement. The clinical, diagnostic features, and the literature are reviewed.     

32例感染性心内膜炎治疗的临床分析

目的探讨左心IE与右心IE两者临床表现及治疗上的差异。方法对中山大学第二附属医院2000年1月～2004年12月住院的32例IE病人分成左心IE组、右心IE组进行回顾性对照分析。结果左心IE中内科治疗15例,其中治愈4例;外科治疗10例并全部治愈,其中行瓣膜置换术9例,瓣膜修复整形术1例;右心IE中内科治疗2例,其中治愈1例;外科治疗5例,其中行三尖瓣置换术4例,三尖瓣膜修复整形术1例;手术治疗5例中治愈4例,1例因术后多器官功能障碍综合症死亡。结论右心IE与左心IE临床表现不同,突出表现在肺部病变:右心IE表现为急性肺炎或肺栓塞的临床症状;左心IE表现为瓣膜功能障碍。对于IE瓣膜病变的手术方式应根据瓣膜损坏程度来决定,左心IE以瓣膜置换为主,右心IE尽量争取瓣膜修复整形。