Native valve infective endocarditis due to sequence type 97 community-associated methicillin-resistant Staphylococcus aureus complicated by meningitis and multiple septic emboli in a young healthy adult

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) can cause a wide variety of infections, ranging from skin and soft tissue infections to life-threatening invasive diseases such as necrotizing pneumonia and infective endocarditis. Here, we present a case of a healthy young female presenting with fever, headache and nausea, who was diagnosed with mitral valve infective endocarditis due to CA-MRSA and whose course was complicated by meningitis and multiple septic emboli. The causative MRSA strain belonged to sequence type 97 and harbored SCCmec Ⅳc but not lukS/F-PV genes. ST97, which is frequently isolated from livestock animals and known as a common lineage of livestock-associated MRSA, may cause invasive infection in the community.     

小儿感染性心内膜炎的病原菌变迁及其诊治

目的：分析小儿感染性心内膜炎病原菌的变迁及临床诊治。方法：回顾分析30年中75例感染性心内膜炎患儿的临床资料。1972年1月一1986年12月19例(Ⅰ组)，1987年1月一2001年12月56例(Ⅱ组)。结果：75例患儿占住院患儿总数的0．4lgN，Ⅱ组的患病率高于I组(0．5lgN、0．26他，P＜0．05)。66例有基础心脏病，术后感染性心内膜炎的发病率差异无显性(Ⅱ组为5．23他、I组为2．94他，P＞0．05)。75例中有66例有心脏病基础。58例血培养阳性，l例左房室瓣组织培养阳性，16例细菌培养阴性。总的细菌培养阳性率为78．7％(1组为52．6％，Ⅱ组为87．5％)。I组中常见病原菌为腐生葡萄球菌(21．1％)、金黄色葡萄球菌(10．5％)和草绿色链球菌(10．5％)。Ⅱ组则为表皮葡萄球菌(46．4％)和金黄色葡萄球菌(17．9％)oI组治愈10例，死亡9例；Ⅱ组治愈46例，死亡10例。两组差异有显性(P＜0．02)。细菌培养阳性的治愈率(48／59，81．4％)显高于细菌培养阴性的治愈率(8／16，50％)，P＜0．05。结论；小儿感染性心内膜炎的病原菌以表皮葡萄球菌最常见，提高血培养的阳性率可提高治愈率。     

Infective endocarditis complicated with cerebral and splenic infarction in a hemodialysis patient

BACKGROUND:

Infective endocarditis (IE) has a high risk of morbidity and mortality. Complications are often due to systemic embolization. We treated a 47-year-old hemodialysis man with infective endocarditis complicated with cerebral and splenic infarction.

METHODS:

The patient was brought to the emergency department because of altered mental status and fecal incontinence. Although he did not meet the Duke Criteria for IE diagnosis, clinical suspicions of IE warranted further diagnostic studies. Magnetic resonance imaging of the brain revealed cerebral infarction with abnormal neurological findings. An abdominal computerized tomography revealed an incidental and unexpected splenic infarction without physical findings. Echocardiography revealed a vegetative growth (−1.2×1 cm) over the mitral posterior leaflet with severe mitral valve regurgitation. Based on these results, the patient was diagnosed with IE complicated with severe cerebral and splenic infarction.

RESULTS:

The patient was treated with intravenous teicoplanin including gentamicin, subcutaneous low molecular weight heparin, and oral acetylsalicylic acid. Mitral valve replacement surgery was performed after the patient improved clinically.

CONCLUSION:

Emergency physicians should be aware of the life-threatening complications of IE, which may be presented subtly or without clinical evidence.KEY WORDS: Infective endocarditis, Cerebral infarction, Splenic infarction     

Aspergillus fumigatus endocarditis of the mitral valve in a heart transplant recipient: a case report

Aspergillus endocarditis is a rare event after heart transplantation. We report a case of Aspergillus fumigatus endocarditis after orthotopic heart transplantation. The patient was treated with a combination of voriconazole and caspofungin without valve replacement and survived for 168 days after the diagnosis. Previously reported cases are reviewed.     

Infective endocarditis caused by multidrug-resistant Streptococcus mitis in a combined immunocompromised patient: an autopsy case report

An autopsy case of infective endocarditis caused by multidrug-resistant Streptococcus mitis was described in a patient with a combination of factors that compromised immune status, including autoimmune hemolytic anemia, post-splenectomy state, prolonged steroid treatment, and IgA deficiency. The isolated S. mitis strain from blood culture was broadly resistant to penicillin, cephalosporins, carbapenem, macrolides, and fluoroquinolone. Recurrent episodes of bacterial infections and therapeutic use of several antibiotics may underlie the development of multidrug resistance for S. mitis. Because clinically isolated S. mitis strains from chronically immunocompromised patients have become resistant to a wide spectrum of antibiotics, appropriate antibiotic regimens should be selected when treating invasive S. mitis infections in these compromised patients.     

Infective endocarditis in the intensive care unit: clinical spectrum and prognostic factors in 228 consecutive patients

Objective To identify factors associated with in-hospital outcome of adult patients admitted to the ICU with infective endocarditis (IE). Design and setting Retrospective study performed in the two medical ICUs of a teaching hospital. Patients and participants The charts of all 228 consecutive patients aged 18 years or older admitted with infective IE between January 1993 and December 2000 were reviewed. All patients satisfied the modified Duke’s criteria for definite IE. Measurements and results There were 146 episodes of native valve endocarditis and 82 of prosthetic valve endocarditis. Staphylococcus aureus was the predominant causative micro-organism. Most complications occurred early during the course of IE. One-half of the patients underwent cardiac surgery during the same hospitalization and had a better outcome than nonoperated patients. The overall in-hospital mortality rate was 45% (102/228). Multivariate analysis revealed the following clinical factors in patients with native valve IE as independently associated with outcome: septic shock (odds ratio 4.81), cerebral emboli (3.00), immunocompromised state (2.88), and cardiac surgery (0.475); in patients with prosthetic valve IE the factors were: septic shock (4.07), neurological complications (3.1), and immunocompromised state (3.46). Conclusions IE still carries high morbidity and mortality rates for the subset of patients requiring ICU admission. Most complications occur early making the decision process for optimal medical and surgical management more difficult. Surgical treatment appears to improve in-hospital outcome. Electronic Supplementary Material Supplementary material is available for this article if you access the article at . A link in the frame on the left on that page takes you directly to the supplementary material.     

Infective endocarditis caused by Nocardia nova: A case report and literature review of nocardial endocarditis

Although a variety of microorganisms have caused infective endocarditis, Nocardia species have rarely been reported as a causative agent of the disease. We describe a case of nocardial endocarditis, occurring to a 22-year-old Japanese woman during long-term corticosteroid therapy for adult-onset Still’s disease and diagnosed after the rupture of cerebral mycotic aneurysm. Echocardiography showed that the causative organism, isolated from the blood and identified as Nocardia nova with an analysis of 16S ribosomal RNA sequences, affected the posterior papillary muscle of the left ventricle. Nocardia-like organisms were also detected in the pus around the raptured aneurysm. After treatment with imipenem/cilastatin plus amikacin for 3 months followed by oral trimethoprim/sulfamethoxazole for 1 year, no relapse of nocardiosis occurred during a follow-up for 3 years. To our knowledge, the present case is the first reported endocarditis due to N. nova.     

Sepsis in a renal transplant recipient due to Citrobacter braakii

Cellulitis is usually caused by organisms such as beta-hemolytic streptococci and Staphylococcus aureus. Citrobacter are gram-negative bacilli that can cause opportunistic infections in immunocompromised hosts. They are rarely implicated in skin or soft tissue infections. The genus Citrobacter has been respeciated according to genetic relatedness. Citrobacter braakii refers to the genomospecies 6 of the Citrobacter freundii complex. There are no detailed studies of infections caused by the newly formed specific genetic species. We report a case of C. braakii infection in a renal transplant patient receiving immunosuppressive therapy. The patient's lower extremity cellulitis did not respond to conventional antibiotic therapy. Blood cultures grew C. braakii. Sensitivity studies and treatment with appropriate antibiotics resulted in prompt recovery. Immunosuppressive therapy in renal transplant recipients predisposes to infection by unusual pathogens, and this should be suspected when lack of a clinical response to conventional antibiotics is observed. We believe this is the first reported case of C. braakii cellulitis and bacteremia in a renal transplant recipient.     

A case of infective endocarditis mimicking a large mesenteric abscess

Infective endocarditis (IE) demonstrates a broad array of clinical presentations and complications. However, IE with prominent abdominal findings is uncommon. We encountered a case of IE caused by Staphylococcus aureus that presented a large mesenteric abscess and was initially diagnosed as an intra-abdominal infection. There are few reports of IE with mesenteric abscess formation. Even if an intra-abdominal abscess is the main symptom, the possibility that it is part of a systemic infection should be considered if the causative organism is atypical or if symptoms are present in multiple organs. Physicians should always be aware of the possibility that IE may mimic other diseases, including intra-abdominal infections.     

Infective endocarditis and osteomyelitis caused by Cellulomonas: a case report and review of the literature

Cellulomonas spp. are often believed to be of low virulence and have never been reported as a pathogen causing human disease before. We report the first case of endocarditis caused by Cellulomonas and complicated with osteomyelitis of the lumbar spine in a 78-year-old woman. General weakness and aggravated lower back pain followed by sudden-onset of fever and chills were the major presentation. The diagnosis of infective endocarditis in this case was definitely using the Duke criteria. The magnetic resonance imaging of the lumbar spine revealed infective spondylodisciitis at an early stage. After a full course of antibiotics treatment, the patient's fever subsided but her lower back pain persisted. A slow clinical response to appropriate antimicrobial agents was characteristic of Gram-positive bacillary endocarditis.     

A case of transient global amnesia with hippocampal infarction due to infective endocarditis

Transient global amnesia (TGA) is an uncommon disease characterized by sudden onset anterograde amnesia that typically improves within 24 hours. A 35-year-old woman presented with complete disruption of memory that had started on the previous day. She had fever and heart murmur and was diagnosed as having infective endocarditis with Staphylococcus lugdunensis, a coagulase-negative staphylococcus. Septic embolizations were found in the spleen and kidney on CT scan. The patient underwent aortic valve replacement. MRI susceptibility-weighted imaging showed a dotted low intensity area in the right hippocampus. Recently, etiology of TGA is reported to be related to hippocampal disorder. We report a rare case of TGA with hippocampal infarction due to septic embolism from infective endocarditis.     

Antibiotic prevention of infective endocarditis due to oral procedures: myth,magic, or science?

Infective endocarditis (IE) can be induced by bacteremia attributable to dental procedures. To prevent this disease, prophylactic administration of antimicrobials prior to dental procedures has been recommended in several countries. However, no prospective study has proved its efficacy in a clinical setting. Recent recommendations from the American Heart Association (AHA) strongly suggested that dental work is not an important cause of IE; therefore, prophylactic use of antibiotics is of no use in most cases. Prevention of IE may be essential but its pathology and epidemiology remain unclear in various aspects. This article reviews the theoretical background of IE prophylaxis, and discusses how we should proceed when patients with a known cardiac disorder visit the dental clinic. The discussion includes antibiotics usage, daily maintenance procedures, and a possible new strategy with the use of antibacterial substances.     

超声心动图对感染性心内膜炎患者的赘生物及其他常见并发症的研究

目的总结和探讨感染性心内膜炎患者的赘生物及其他常见并发症的超声心动图详细特征及其不足之处。方法选取2003～2008年在我院住院且确诊为感染性心内膜炎患者118例,所有患者均进行了手术和病理检查确诊。并将患者经胸超声心动图与手术、病理结果进行比较研究。结果在符合入选条件的118例感染性心内膜炎患者中,病理发现赘生物或菌落者78例,慢性瓣膜炎71例,黏液样变性13例。本组病例中,超声检查出赘生物大小2～26mm,1至多个,活动度主要为好,以强或中强回声,首先以左心房面受累;超声心动图对赘生物检出率为83.8%;并且经胸超声心动图的检出率随着赘生物增大和数量逐渐增加。超声对于赘生物形态描述主要为团块状、不均质样回声,而手术中常描述为菜花状、结节状。超声对损伤瓣膜的检出率达89.1%,对单纯主动脉瓣损伤的检出率最高;对于其他并发症的检出率如人工瓣瓣周漏、瓣膜脱垂、脓肿、假性动脉瘤、瓣叶穿孔分别为100%、95.0%、66.7%、66.7%及33.3%,虽然超声对瓣叶穿孔检出率最低,但其特异度高达99.1%,而敏感度仅为22.2%。结论超声心动图能够对大部分感染性心内膜炎患者的赘生物大小、数量及附着位置、损伤瓣叶及其常见并发症进行准确判断,但对瓣叶穿孔判断能力有待提高,对赘生物形态的描述有待与手术统一。     

Fatal visceral disseminated varicella-zoster virus infection in a renal transplant recipient: A case report

BACKGROUNDVisceral disseminated varicella-zoster virus (VZV) infection is a rare but life-threatening disease. In transplant recipients with VZV infection, visceral dissemination may develop without skin eruptions, which leads to the failure of early diagnosis.CASE SUMMARYThe patient was a 33-year-old male renal recipient who was referred to our hospital with severe upper abdominal pain of 3-d duration. On admission, the patient rapidly developed septic shock and multiple organ dysfunction syndrome with liver dysfunction and acute kidney injury. Next-generation sequencing of peripheral blood yielded 39224 sequence reads of VZV, and real-time polymerase chain reaction for VZV was positive, with 1.2 × 10⁷ copies/mL. The final diagnosis was visceral disseminated VZV infection. Acyclovir and supportive therapy were started, but the patient died of severe visceral organ damage 16 h after admission.CONCLUSIONVisceral disseminated VZV infection is possible in renal transplant recipients presenting abdominal pain and rapidly-evolving organ damage without skin involvement.     

Impact of adherence to surgical and non-surgical components of infective endocarditis guidelines and recommendations

BackgroundInfective endocarditis (IE) is associated with significant morbidity and mortality. Non-adherence to IE guidelines and recommendations is frequent, and may adversely impact patient outcomes.AimTo assess the impact of non-adherence to components of existing IE guidelines and recommendations on a composite outcome consisting of any of the following: mortality, unplanned cardiac surgery, embolic event or relapse of positive blood culture within six months of diagnosis.MethodsA single centre, retrospective cohort study.ResultsAmongst 157 patients, there was inconsistent adherence to: initial diagnosis of an infective condition (87%), timely administration of antimicrobial therapy (82%), appropriateness of predominant antimicrobial regime (94%), appropriate management of the portal of entry (86%), multidisciplinary input (75%), end of antimicrobial therapy repeat echocardiography (60%) and adherence to indications for surgery (76%). Inpatient mortality was 12.1% (n = 19) and the composite adverse outcome occurred in 36 (22.9%) patients. In multivariate logistic regression analysis, infection of prosthetic device (adjusted odds ratio [95% confidence interval]; 2.43 [1.07–5.50]) and non-adherence to surgical guidelines (aOR 3.67 [1.60–8.47]) were significantly associated with an adverse outcome.ConclusionsOur data suggests that adherence to differing components of IE management guidelines and recommendations varies and that non-adherence to surgical aspects of guidelines has the biggest impact in determining outcomes.     

Infective bicuspid aortic valve endocarditis causing acute severe regurgitation and heart failure: A case report

BACKGROUNDInfective endocarditis (IE) is an uncommon but potentially life-threatening infection, which occasionally develops into acute severe valve insufficiency leading to the onset of heart failure, and necessitates timely intervention. However, the variable and atypical clinical manifestations always make the early detection of IE difficult and challenging.CASE SUMMARYA 45-year-old female who was previously healthy presented with exertional shortness of breath and paroxysmal nocturnal dyspnea. She also suffered from a significant decrease in exercise capacity, whereas her body temperature was normal. She had severe hypoxemia and hypotension along with a marked aortic valve murmur. Diffuse pulmonary edema and bilateral pleural effusion were observed on both chest X-ray and computed tomography scan. Transthoracic echocardiography was performed immediately and revealed severe regurgitation of the bicuspid aortic valve. Transesophageal echocardiography was further performed and vegetations were detected. In addition to adequate medical therapy and ventilation support, the patient underwent urgent and successful aortic valve replacement. Her symptoms were significantly relieved and the postoperative chest X-ray showed that pulmonary edema was significantly reduced. Histopathology of the resected valve and positive microorganism culture of the surgical specimen provided evidence of definite IE.CONCLUSIONIE should be considered in critical patients with refractory heart failure caused by severe bicuspid aortic valve regurgitation.     

Obstructive uropathy and acute renal failure due to ureteral calculus in renal graft: a case report

Introduction

Obstructive uropathy caused by kidney stones is quite rare in transplant kidneys.

Clinical case

The authors report the case of a patient, previously gastrectomized for gastric carcinoma. He underwent renal transplantation using uretero-ureterostomy, and presented an episode of acute renal failure 7 years after surgery. Ultrasound (US) examination showed no sign of rejection but allowed detection of moderate hydronephrosis in the transplant kidney. Subsequent computed tomography (CT) revealed a kidney stone in the middle ureter at the crossing of the iliac vessels. The patient therefore urgently underwent percutaneous nephrostomy of the graft and recovered diuresis and renal function. The patient was transferred to the Transplant Center where he underwent ureterotomy with removal of the stone and subsequent ureteropyelostomy. Also transureteral resection of the prostate (TURP) was performed due to urinary retention of prostatic origin. Histological examination showed prostate carcinoma, Gleason stage 3, which was treated conservatively using radiotherapy without suspension of the administered low dose of immunotherapy.

Discussion

Calculosis is one of the least common causes of obstructive uropathy in transplant kidneys. In the described case, US examination performed after onset of renal insufficiency led to subsequent radiological investigation and resulting interventional procedures (nephrostomy and surgical removal of the stone) with complete recovery of pre-existing renal function.