Isolation of Bartonella washoensis from a dog with mitral valve endocarditis

We report the first documented case of Bartonella washoensis bacteremia in a dog with mitral valve endocarditis. B. washoensis was isolated in 1995 from a human patient with cardiac disease. The main reservoir species appears to be ground squirrels (Spermophilus beecheyi) in the western United States. Based on echocardiographic findings, a diagnosis of infective vegetative valvular mitral endocarditis was made in a spayed 12-year-old female Doberman pinscher. A year prior to presentation, the referring veterinarian had detected a heart murmur, which led to progressive dyspnea and a diagnosis of congestive heart failure the week before examination. One month after initial presentation, symptoms worsened. An emergency therapy for congestive heart failure was unsuccessfully implemented, and necropsy evaluation of the dog was not permitted. Indirect immunofluorescence tests showed that the dog was strongly seropositive (titer of 1:4,096) for several Bartonella antigens (B. vinsonii subsp. berkhoffii, B. clarridgeiae, and B. henselae), highly suggestive of Bartonella endocarditis. Standard aerobic and aerobic-anaerobic cultures were negative. However, a specific blood culture for Bartonella isolation grew a fastidious, gram-negative organism 7 days after being plated. Phenotypic and genotypic characterizations of the isolate, including partial sequencing of the citrate synthase (gltA), groEL, and 16S rRNA genes, indicated that this organism was identical to B. washoensis. The dog was seronegative for all tick-borne pathogens tested (Anaplasma phagocytophilum, Ehrlichia canis, and Rickettsia rickettsii), but the sample was highly positive for B. washoensis (titer of 1:8,192) and, according to indirect immunofluorescent-antibody assay, weakly positive for phase II Coxiella burnetii infection.     

Aortic valve endocarditis in a dog due to Bartonella clarridgeiae

We report the first documented case of endocarditis associated with Bartonella clarridgeiae in any species. B. clarridgeiae was identified as a possible etiological agent of human cat scratch disease. Infective vegetative valvular aortic endocarditis was diagnosed in a 2.5-year-old male neutered boxer. Historically, the dog had been diagnosed with a systolic murmur at 16 months of age and underwent balloon valvuloplasty for severe valvular aortic stenosis. Six months later, the dog was brought to a veterinary hospital with an acute third-degree atrioventricular block and was diagnosed with infective endocarditis. The dog died of cardiopulmonary arrest prior to pacemaker implantation. Necropsy confirmed severe aortic vegetative endocarditis. Blood culture grew a fastidious, gram-negative organism 8 days after being plated. Phenotypic and genotypic characterization of the isolate, including partial sequencing of the citrate synthase (gltA) and 16S rRNA genes indicated that this organism was B. clarridgeiae. DNA extraction from the deformed aortic valve and the healthy pulmonic valve revealed the presence of B. clarridgeiae DNA only from the diseased valve. No Borrelia burgdorferi or Ehrlichia sp. DNA could be identified. Using indirect immunofluorescence tests, the dog was seropositive for B. clarridgeiae and had antibodies against Ehrlichia phagocytophila but not against Ehrlichia canis, Ehrlichia ewingii, B. burgdorferi, or Coxiella burnetii.     

Bivalvular Bartonella henselae prosthetic valve endocarditis

Prosthetic valve endocarditis is an uncommon manifestation of infection with Bartonella species. Herein, we report a case of Bartonella henselae endocarditis involving prosthetic mitral and aortic valves. The patient had a favorable outcome with combined medical and surgical therapy. Concomitant crescentic glomerulonephritis led to an initial mistaken diagnosis of Wegener's granulomatosis.     

Fatal case of endocarditis associated with Bartonella henselae type I infection in a domestic cat

We report the first feline case of Bartonella henselae endocarditis. Despite negative blood cultures, the cat had high Bartonella antibody titers and B. henselae type I DNA was detected in the damaged aortic valve. Microscopic examination of the valve revealed endocarditis with small silver positive coccoid structures in endothelial cells.     

Paecilomyces javanicus endocarditis of native and prosthetic aortic valve

A 41-year-old diabetic woman developed endocarditis of the aortic valve caused by Paecilomyces javanicus six years after insertion of a porcine mitral valve heterograft. The patient died shortly after aortic valve replacement. Autopsy revealed vegetations of the aortic heterograft, valve ring abscess and ascending aortitis due to Paecilomyces. There was no involvement of the mitral valve heterograft. Lesions due to mycotic emboli were found in the kidneys, spleen, and brain. Cultures of the surgically removed aortic valve and of the kidney at autopsy produced rapid growth of P. javanicus. The gross and microscopic pathologic and cultural characteristics of this organism are described with a review of the literature. Previously reported cases of Paecilomyces endocarditis occurred only in prosthetic heart valves. This is the first known report of P. javanicus endocarditis of a native valve and its prosthetic heart valve heterograft.     

Cure of bartonella endocarditis of a prosthetic aortic valve without surgery: value of serologic follow-up

Bartonella species are emerging as an important cause of blood culture-negative endocarditis, but the optimal management of this disease has not been fully defined. We describe a case of subacute Bartonella henselae endocarditis of a prosthetic aortic valve in an immunocompetent woman that was cured with long-term antibiotic therapy alone. In addition, we demonstrate that follow-up of serologic titers against B. henselae was helpful in assessing definitive cure of the infection.     

Biopsy of the heart valves. 872 cases

In this study, 872 heart valves surgically excised from 810 patients during a period of 5 years (1994 through 1998) were examined pathologically. There was a predominance of aortic (506 patients) versus mitral valves (246 pts.). While aortic valves came more often from men (364) than from women (142), in mitral valves the M:F ratio is 82/164. Isolated calcific aortic stenosis appeared as the most frequent valvular disease (418 pts.), with predominance of its sclerotic-senile type (238 pts.). Mitral stenosis (185 pts.) remains the classical post-rheumatic disease. The relative frequency of a subvalvular stenosing mitral lesion is stressed. The "pure" incompetence of both aortic (70 pts.) and mitral (56 pts.) valve was usually based on valvular myxoid degeneration. An aorto-mitral disease requiring replacement of both valves (51 pts.) presented typically as a post-rheumatic lesion, however, a combination of a post-rheumatic mitral with a degenerative-sclerotic aortic valve disease may be possible. In 30 patients, the valvular replacement was performed for infective endocarditis or a post-IE lesion, mostly of the aortic valve. With the almost non-existence of acute rheumatic fever and with the increasing average age of population in this country, we may expect a long-term decline in mitral valve disease and an increase in aortic valve disease, particularly in the sclerotic type of aortic stenosis.     

Truffle's revenge: a pig-eating fungus.

A 77-year-old female initially presented with symptomatic mitral valve stenosis involving a bioprosthesis that had been implanted 8 months earlier for myxomatous mitral valve disease and severe valvular regurgitation. The patient was taken for a second mitral valve replacement due to stenosis. Intraoperatively, the bioprosthetic mitral valve was noted to have an unusual clot-like mass on the atrial side. Initial fungal smears were positive for yeast stains, and pathology revealed extensive colonization by thick filamentous fungus with apparent true hyphae, pseudohyphae, and yeast forms. The fungus was identified as Hormographiella aspergillata, the asexual form of Coprinus cinereus, a common inky cap mushroom that grows in the lawn. She was treated with 6 weeks of liposomal amphotericin B and then switched to voriconazole for long-term (lifelong) suppressive therapy in the setting of a new mechanical mitral valve. The only other reported case of infective endocarditis caused by a Coprinus species occurred in a 53-year-old man who had developed native aortic valve fungal endocarditis and died [J Med Microbiol (1971);4(3):370-4]. The valve isolate was identified as probable C. cinereus.     

Red blood cell abnormalities in cardiac valvular disease

Nineteen patients with morphological abnormalities of the red blood cells are described, and these formed approximately 3% of the total cases of cardiac valvular disease. In two patients the abnormal blood film developed after the insertion of an aortic and mitral valve prosthesis respectively, but in another two patients the abnormal blood film was corrected by aortic valve surgery. Anisopoikilocytosis may have been associated with microangiopathic haemolytic anaemia in one patient, but in the others the cardiac valvular disease was severe and other mechanical factors were not present. The mitral valve was involved in 16 patients and the aortic valve in eight.Elliptocytosis was the only abnormality in 11 blood films, schistocytes and burr cells were present in seven, and in three there were a few microspherocytes. Family studies in seven patients produced evidence of hereditary elliptocytosis in three.Anaemia was present in only two patients. One of these had infective endocarditis, and the other developed overt haemolytic anaemia following the replacement of a diseased mitral valve by a Starr-Edwards prosthesis. In this latter case there was a transiently positive direct antiglobulin test, and the anaemia and abnormal blood picture were corrected without further surgical treatment. Haemolytic anaemia did not develop in 23 patients after the insertion of an aortic valve prosthesis or homograft.Indirect evidence of haemolysis was obtained in some patients who were not anaemic. There was a reticulocytosis in one third and serum haptoglobins were decreased or absent in over half of the patients tested.     

Long-term survival of a patient with prosthetic valve endocarditis due toTrichosporon beigelii

A case is described of a 49-year-old man with rheumatic aortic valve disease who developed endocarditis seven years after valvular replacement.Trichosporon beigelii was isolated from the blood, a peripheral thrombus, and the removed prothesis. After two valve prosthesis replacements and prolonged antifungal therapy, the patient survived for four years, but eventually died as a consequence of multiple septic complications due to the same organism. To the authors' knowledge, this is the longest survival time of any reported case ofTrichosporon prosthetic valve endocarditis.     

Freestyle stentless bioprosthesis for active aortic infectious endocarditis with undetermined causative organism

A 52-year-old woman developed congestive heart failure and was diagnosed with aortic regurgitation with approximately 20 mm of vegetation located on the noncoronary cusp of the aortic valve. The patient had undergone tooth extraction 3 months earlier, and various antibiotics had been given in the treatment of refractory high fever for 1 month. The damage to the aortic valve extended to the fibrous trigone near the mitral valve, and aggressive debridement of necrotic and infected tissue was done. The excised defect was repaired and reinforced with a pericardial patch, and the Freestyle stentless bioprosthesis was implanted using the full-root technique. Although the causative organism was never isolated, recurrent endocarditis has not occurred during 3 years of follow-up. The Freestyle stentless bioprosthesis was useful in the management of active aortic infectious endocarditis with undetermined causative organism for the prevention of recurrent endocarditis in the early postoperative period.     

First isolation of Bartonella alsatica from a valve of a patient with endocarditis

We report the first documented case of endocarditis in a man infected with Bartonella alsatica, which causes bacteremia in healthy wild rabbits. B. alsatica was identified by serology and culture and by PCR of an aortic valve specimen. B. alsatica should be added to the list of zoonotic agents of blood culture-negative endocarditis.     

Ten years of infective endocarditis: a clinicopathologic study

The records of 46 patients with infective endocarditis diagnosed either clinically or post-mortem were analyzed. Twenty-six patients were over 60 years of age. S. aureus was the predominant organism, almost exclusively found in patients with acute endocarditis. Thirty-six patients had pre-existing heart disease, the most common being non-rheumatic valvular calcification and congenital defects. Two thirds of the patients, especially those with aortic valve regurgitation, developed new or progressive heart failure. A correct clinical diagnosis was established in only 30 patients. Twenty-three patients died, the mortality being 71% in acute and 32% in subacute disease. Only one of eight patients with prosthetic valve infection died. Four patients required urgent valve replacement. Early surgical intervention should be considered in patients with uncontrolled heart failure.     

Culture-Positive Bartonella quintana Endocarditis

 A 50-year-old alcoholic man with a 1-year history of pyrexia of unknown origin was admitted with symptoms of endocarditis. Large vegetations on his mitral and aortic valve were found on echocardiography. Using the Bactec 9240 system, Bartonella quintana could be grown from two culture sets of blood collected before the start of antimicrobial therapy. This is the first case report of culture-proven bartonella infection in the UK, and is noteworthy because Bartonella quintana was detected in conventional blood culture systems after prolonged incubation.     

Severe valvular and aortic arch calcification in a patient with Gaucher's disease homozygous for the D409H mutation

Gaucher's disease is an autosomal recessive inherited defect of the lysosomal enzyme glucocerebrosidase, which leads to glucocerebroside accumulation in the reticuloendothelial system. Homozygosity for the D409H mutation has been associated with cardiovascular valvular disease. We present a case of a 17-year-old Palestinian patient who presented with severe aortic and mitral valvular calcification, as well as calcification of the ascending aorta, the aortic arch and the ostia of his coronary arteries. The patient was confirmed to be homozygous for the D409H mutation in the glucocerebrosidase gene. The patient's enzyme assay for glucocerebrosidase activity was 5 nm/h/mg protein (normal 13-22 nm/h/mg). The patient presented with symptoms of dyspnea and chest pain. He had a 6-year history of documented aortic valve calcification by echocardiogram after two of his older brothers died of congestive heart failure and severe valvular calcification. Cardiac catheterization showed a severely calcified aorta with almost no motion of the aortic valve leaflets and severe calcification of the mitral valve and the mitral valvular apparatus. The patient underwent extensive cardiac surgery with aortic and mitral valve replacements and intraoperative findings confirmed calcification of the entire aortic root. Electron microscopy of the valves confirmed the presence of Gaucher's cells. Enzyme therapy with imiglucerase was initiated. The patient is in stable condition, 20 months post-operatively.     

Prosthetic valve endocarditis caused by Corynebacterium afermentans subsp. lipophilum (CDC coryneform group ANF-1).

Corynebacteria are important causes of endocarditis in individuals with valvular prostheses. We report the first published case of prosthetic valve endocarditis caused by the newly defined species Corynebacterium afermentans subsp. lipophilum (former CDC coryneform group ANF-1). The isolate was recovered from a perivalvular abscess specimen and 5 of 15 Bactec blood cultures after 7 to 15 days of incubation. The isolation, identification, and susceptibility testing of Corynebacterium species are discussed.     

Late prosthetic valve endocarditis due to Cardiobacterium hominis, an unusual complication

We report a case of prosthetic valve endocarditis caused by Cardiobacterium hominis in a patient who had undergone atrial septal defect closure and mitral valve replacement of the heart in 1978. He presented with pyrexia of unknown origin and congestive cardiac failure. Investigations revealed infective endocarditis of prosthetic valve in mitral portion. Blood culture samples grew C. hominis. The patient was empirically started on vancomycin and gentamicin intravenously and ceftriaxone was added after isolation of the organism. Though subsequent blood cultures were negative, patient remained in congestive cardiac failure and died due to complications.     

Pathology of the cardiovascular system--new findings

Presented is a review of important new informations in the field of cardiovascular pathology. The particular items discussed are hypertension (new definition and classification), etiopathogenesis of atherosclerosis, ischemic heart disease (unstable plaque; acute coronary syndrome; advances in therapy), valvular diseases (changing spectrum; calcific aortic stenosis; mitral valve prolapse), cardiomyopathies (new definition; etiology), infective endocarditis (changing pattern), senile heart diseases, and endomyocardial biopsy.     

Right-sided infective endocarditis combined with mitral involvement in a patient with ventricular septal defect

An autopsy case of right-sided infective endocarditis combined with mitral valvular involvement in a 20-year-old male Japanese with ventricular septal defect (VSD) was reported. The vegetations were found on the endocardium bordering VSD, tricuspid valve, mural endocardium of the right ventricular outflow tract, and even the pulmonic valve, resulting in forming infective aneurysm of the pulmonary trunk. Streptococcus was morphologically identified in the vegetations obtained at autopsy. On the other hand, smaller vegetations were also noted on the mitral valve. The mechanisms of the mitral extending were discussed when right-sided infective endocarditis associated with VSD preceded that on the mitral valve. The authors think that mitral regurgitation in relation to VSD and right to left shunt through VSD which occur even temporarily may be the most important mechanism responsible for the mitral valvular involvement. Several differences between right-sided and left-sided infective endocarditis were also reviewed.     

Infective endocarditis at a Hospital of the University of Kiel, 1958–1987

Summary The clinical courses of 214 patients with infective endocarditis treated between 1958 and 1987 at the First Medical Hospital of the University of Kiel (FRG) were analyzed retrospectively. A decrease in the incidence of endocarditis occurred during the 30-year observation period. The mean age of patients was 48 years, and men were more frequently affected than women. In the course of the investigation, a rise in isolated aortic valve disease was noted, whereas the number of patients with isolated involvement of the mitral valve and combined mitral-aortic valvular defects declined. Streptococci (57%) were the most frequent pathogens isolated; as opposed to their increase, the percentages ofStaphylococcus aureus and enterococci decreased. Otolaryngological, dentogenic and urogenital diseases were most frequently held to be responsible for the development of infective endocarditis. Prior cardiosurgical interventions became increasingly significant as a cause of the disease. In this connection, a rising percentage of endocarditis cases was linked with prosthetically replaced heart valves. Complications and concomitant symptoms of endocarditis included the development of heart failure, cerebral embolism and encephalitis, splenomegaly, and renal inflammation. Finally, the marked decrease in mortality contrasted with a simultaneous rise in the number of endocarditis cases achieving full recovery.