Spondylodiscitis and infective endocarditis: case studies and review of the literature

STUDY DESIGN: This study evaluated the association between infective endocarditis and infective spondylodiscitis and its clinical features. OBJECTIVES: To report case studies of patients with spondylodiscitis complicating infective endocarditis. SUMMARY OF BACKGROUND DATA: Early diagnosis of infective endocarditis as the source of the spondylodiscitis is often difficult because clinical and radiologic patterns are similar to those present in spondylodiscitis alone. METHODS: The case records of the patients with infective endocarditis admitted to our Department from 1991-1998 were reviewed. The diagnosis of spondylodiscitis was made on the basis of clinical features and of typical radiologic signs. RESULTS: Among 30 patients affected by infective endocarditis, three also were affected by spondylodiscitis. All patients fully recovered after appropriate antibiotic therapy. CONCLUSIONS: In all patients with spondylodiscitis, infective endocarditis should be excluded, particularly in patients with a history of heart valve disease.     

Limited reliability of the "negative" two-dimensional echocardiogram in the evaluation of infectious vegetative endocarditis: diagnostic and surgical implications

Three patients with vegetative endocarditis involving a native valve, a mechanical prosthesis and a bioprosthetic valve respectively are presented. Each underwent emergency surgical exploration and prosthetic valve replacement based on clinical evidence of vegetative endocarditis after an initial delay following a report of a negative two-dimensional echocardiographic study. These cases emphasize the fact that within the clinical setting in which vegetative endocarditis is strongly suspected a negative two-dimensional echocardiographic study must be interpreted with caution. This is particularly true in patients with fungal, embolic or prosthetic valvular endocarditis. A decision to delay surgical consultation and therapy based upon a negative two-dimensional echocardiographic study in these patients is ill advised and may result in serious thromboembolic complications or even death.     

Recurrent embolism in the course of marantic endocarditis

Marantic or nonbacterial thrombotic endocarditis (NBTE) associated with systemic embolism is usually a complication of advanced or terminal malignancies. We report on the case of a 46-year-old woman in whom nonbacterial thrombotic endocarditis (NBTE)-related cerebral embolism was the first clinical sign of ovarian neoplasm, which was diagnosed after cardiac surgery. Marantic endocarditis should alert the physician to make every effort to diagnose the possible background of this clinical phenomenon. Early identification of NBTE, treatment of the underlying disease, and the associated coagulopathy could possibly prevent cardiac surgery.     

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.     

Outcome after mitral valve repair for acute and healed infective endocarditis.

OBJECTIVE: To evaluate the long-term clinical and echocardiographic outcomes after mitral valve surgery for acute and healed infective endocarditis. METHODS: Of 37 consecutive patients presenting with native mitral valve endocarditis, mitral valve repair (MVRep) was feasible in 34 (92%) patients. In 17 (50%) patients, surgery was indicated during antibiotic therapy (acute endocarditis), whereas 17 (50%) underwent surgery after antibiotic therapy was completed (healed endocarditis). Patients were evaluated for early and long-term clinical and echocardiographic outcome. RESULTS: In-hospital death occurred in two (6%) patients and two (6%) died during follow-up, with a 2-year survival of 100% in healed endocarditis as compared to 76% (p=0.03) in patients undergoing surgery in acute endocarditis. No patient with acute endocarditis needed repeat mitral valve surgery. Three (9%) patients underwent re-operation because of early mitral regurgitation (n=1) or late recurrent endocarditis (n=2). The average grade of mitral regurgitation was 3.8+/-0.4 (all grades 3 to 4+) before surgery and 0.6+/-0.8 during follow-up (p<0.001). Significant reductions in left atrial (from 52+/-8mm to 46+/-8mm, p=0.004), left ventricular end-diastolic (from 61+/-8mm to 54+/-8mm, p=0.001), and end-systolic dimensions (from 41+/-8mm to 36+/-9 mm, p=0.02) were observed during follow-up, compared to preoperative dimensions. Of note, significant reverse remodeling was only observed in patients undergoing surgery in healed endocarditis. CONCLUSION: MVRep for mitral valve endocarditis is feasible with good clinical results, maintained valve competency with significant reductions in left atrial and left ventricular dimensions after surgery.     

Pulmonary valve neocuspidization and tricuspid valve replacement in intravenous drug abusers with infective endocarditis: Report of two cases

Right-sided infective endocarditis accounts for 5–10% of endocarditis cases. It occurs predominantly among intravenous drug abusers. The pulmonary valve is involved in fewer than 2% of patients with endocarditis. Literature data are limited and optimal medical strategy, including surgical technique, remains non-standardized in this clinical situation. We present 2 patients treated surgically for tricuspid and pulmonary valve endocarditis and discuss a method of pulmonary valve neocuspidization based on the Ozaki technique.     

Endocarditis in burn patients: clinical and diagnostic considerations

BACKGROUND: Burned patients are at high risk for invasive procedures, bacteremia, and other infectious complications. Previous publications describe high incidence, delayed diagnosis, and high mortality for endocarditis in burned patients, but do not address use of contemporary diagnostic criteria. Further analysis of the clinical presentation and diagnosis may aid in the earlier recognition and decreased mortality of endocarditis in burned patients. METHODS: At a 40 bed burn center, during the period from 1 January 2003 to 1 August 2006, blood culture, electronic inpatient, echocardiographic, and autopsy records were reviewed for cases of endocarditis and persistent bacteremia (blood culture positivity for the same organism separated by 24h). In addition, we reviewed cases of burn-related bacterial endocarditis published in the English language. We compared the clinical and diagnostic aspects of our identified cases with those in the published literature. RESULTS: There were 90 episodes of persistent bacteremia or fungemia in 56 of 1250 patients admitted during the study period. Echocardiography was performed on 19, identifying 4 cases of endocarditis. One additional case of endocarditis was identified post-mortem. Time until echocardiography ranged from 6 to 176 days after onset of bacteremia. Case patient age ranged from 31 to 64 years, and total burn surface area ranged from 34 to 80%. Endocarditis occurred in 0.4% of burn unit admissions and in 8.9% of these patients with persistent bacteremia. Sites involved included the mitral valve (3), tricuspid valve (2), aortic valve (1), and pulmonic valve (1). Pathogens included Staphylococcus aureus, Pseudomonas aeruginosa, and one case of Enterococcus faecium. Diagnostic clues were minimal. Case mortality was 100%. A literature review revealed 17 publications describing confirmed bacterial endocarditis in burned patients. These cases revealed a predilection for infection by S. aureus and P. aeruginosa, a relative paucity of diagnostic clues prior to death, and a trend towards ante-mortem diagnosis and increased survival with use of diagnostic echocardiography. CONCLUSIONS: The incidence and mortality of endocarditis in burned patients remain high. Clinical clues for endocarditis in this cohort are minimal and diagnosis may be delayed. For burned patients with persistent bacteremia, especially S. aureus or P. aeruginosa of unknown source, the diagnosis of endocarditis should be entertained and early echocardiography considered.     

Treatment of destructive aortic valve endocarditis with the Freestyle Aortic Root Bioprosthesis

BACKGROUND: Successful treatment of destructive aortic valve endocarditis with annular abscess formation requires extensive surgical debridement and reconstruction of the left ventricular outflow tract and aortic root. Homograft aortic roots are the conduits of choice, but because they are not available in all cases, alternative conduits are needed. METHODS: Owing to its features, which are comparable to those of homografts, the Freestyle aortic root xenograft was used in 10 consecutive patients aged between 32 and 77 years. All patients had extensive abscess formation, 5 presented with prosthetic valve endocarditis, 2 had additional mitral valve endocarditis requiring partial leaflet resection and reconstruction, 1 patient had an additional fistula into the right atrium, and 1 required coronary bypass. One patient developed a septic ventricular septal defect and fistula into the right atrium with tricuspid valve endocarditis. RESULTS: None of the patients required reoperation for bleeding. Two (20%) patients died in the postoperative period, 1 due to multiorgan failure, and 1 due to preexisting invasive pulmonary aspergillosis. At autopsy, neither had evidence of intrapericardial hematoma or suture dehiscence. One patient died 13 months postoperatively without clinical signs of valve dysfunction or recurrent endocarditis. All other patients are well at 12 to 42 months after surgery. Clinical examination and echocardiography at the most recent follow-up showed no signs of valve dysfunction, recurrent fistulation, or endocarditis. CONCLUSIONS: The Freestyle aortic root appears to be an acceptable alternative to homografts in the treatment of severe endocarditis. Long-term valve durability in younger patients, however, remains to be determined.     

Mitral valve surgery for mitral regurgitation caused by Libman-Sacks endocarditis: a report of four cases and a systematic review of the literature

Libman-Sacks endocarditis of the mitral valve was first described by Libman and Sacks in 1924. Currently, the sterile verrucous vegetative lesions seen in Libman-Sacks endocarditis are regarded as a cardiac manifestation of both systemic lupus erythematosus (SLE) and the antiphospholipid syndrome (APS). Although typically mild and asymptomatic, complications of Libman-Sacks endocarditis may include superimposed bacterial endocarditis, thromboembolic events, and severe valvular regurgitation and/or stenosis requiring surgery. In this study we report two cases of mitral valve repair and two cases of mitral valve replacement for mitral regurgitation (MR) caused by Libman-Sacks endocarditis. In addition, we provide a systematic review of the English literature on mitral valve surgery for MR caused by Libman-Sacks endocarditis. This report shows that mitral valve repair is feasible and effective in young patients with relatively stable SLE and/or APS and only localized mitral valve abnormalities caused by Libman-Sacks endocarditis. Both clinical and echocardiographic follow-up after repair show excellent mid- and long-term results.     

Fungal endocarditis after open-heart surgery. Report of 4 cases]

Four patients with fungal endocarditis after open-heart surgery were confirmed microbiologically. Two of them died, and the other 2 were treated with intravenous administration of miconazole. Clinical symptoms of the disease were similar to those of bacterial endocarditis, but headache and sweating were more predominant. This complication was likely to be found and treated with effective anti-fungi drugs. We suggest that reoperation is the only possible way to cure those with residual shunt or vegetation, and that prevention of postoperative fungal endocarditis is of great importance because of its refractoriness. Measures of preventing fungal endocarditis after open-heart surgery are discussed.     

Recurrent endocarditis of a bicuspid aortic valve due to Q fever

A 46-year-old man was referred to our institution for a recurrent endocarditis with negative blood culture. Clinical examination and complementary investigations confirmed the diagnosis of aortic valve endocarditis with left ventricular fistula. Blood culture was negative but serological tests were positive for Coxiella burnetti. Aortic valve replacement and fistula repair were done. A combination of Doxycycline and Chloroquine antibiotics was given postoperatively with a clinical improvement. Coxiella burnetti should be systemically searched for in all cases of endocarditis even with negative blood cultures. This case is interesting because of its rarity, diagnosis, therapeutic problems and its severe complication.     

Successful treatment of left sided native valve MRSA endocarditis in immunocompromised host treated with daptomycin and surgery: a case report

Infections of the left side of the heart, involving the aortic or mitral valves, have greater therapeutic failure rates than those of the right side. The emergence of antimicrobial resistance amongst gram-positive pathogens, particularly Methicillin- Resistant S Aureus (MRSA) has made treatment more difficult. Daptomycin is a newer option for treatment of bacteraemia and endocarditis due to MRSA. Infective endocarditis is an important clinical mimic of vasculitis. We report here a case of left sided native valve endocarditis due to MRSA in an immunosuppressed host successfully treated with surgery and daptomycin.     

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。     

A case of abdominal aortic pseudoaneurysm associated with right heart mass

We present a patient with right-sided endocarditis associated with abdominal aortic pseudo-aneurysm presenting only with high fever and pulsating abdominal mass. A higher clinical awareness of aortic pseudoaneurysms associated with intracardiac lesions disease, leading to early computed tomography evaluation and prompt surgical intervention appears to offer the best chance of survival. In this aspect, single-stage surgical treatment of both endocarditis and the aortic pathology is necessary.     

Staged laparoscopic splenectomy and valve replacement in splenic abscess and infective endocarditis

Splenic abscess is a rare clinical entity that is most commonly associated with infective endocarditis. Valve replacement in the setting of an unaddressed splenic abscess is associated with a high incidence of prosthetic valve infection and death. We describe 2 patients with infective endocarditis and splenic abscess treated by laparoscopic splenectomy followed by valve replacement.     

Latent infective endocarditis: epidemiology and clinical characteristics of patients with unsuspected endocarditis detected after elective valve replacement

Background

The diagnosis of infective endocarditis is usually made on the basis of clinical and laboratory criteria and may be confirmed by histologic examination or culture of excised valves. We tried to determine the incidence and significance of inflammatory changes in valves excised during operations for reasons other than infective endocarditis.

Methods

The charts and histopathology of all patients undergoing valve replacement during a 10-year period (1993-2002) were reviewed. A total of 868 patients underwent a total of 970 valve replacements during this period, of whom 11 patients (1.3%) were for endocarditis, with the remaining 857 (98.7%) for other indications. All excised valves were cultured and examined histologically for the presence of inflammatory infiltrates, vegetations, and microorganisms.

Results

In 8 of 857 patients (0.9%), the histologic examination unexpectedly demonstrated an infiltrate suggestive of endocarditis. Blood and valve cultures, and serologic tests for Mycoplasma, Chlamydia, Legionella, Q fever, Brucella, Rickettsiae, VDRL, and Bartonella were negative in all but 1 patient, who was found to have Q fever. All received a prolonged course of antibiotics. Six patients had an uneventful recovery; 1 had intramyocardial abscesses and expired during cardiac reoperation; and 1 had recurrent fever and dehiscence of the aortic and mitral valve prostheses and after two cardiac reoperations remains in severe heart failure.

Conclusions

The presence of an unexpected inflammatory infiltrate in heart valves excised for reasons other than endocarditis may occur in 0.9% of such operations; these infiltrates could indicate presence of endocarditis. A microbial origin should be sought, and patients should receive empiric antibiotic treatment for endocarditis.     

Staphylococcus lugdunensis pulmonary valve endocarditis in a patient on chronic hemodialysis

We describe a case of Staphylococcus lugdunensis pulmonary valve endocarditis in a 65-year-old woman on chronic hemodialysis and provide a review of previously reported cases. The patient presented with fever and altered mental status, but had no other localizing symptoms or signs; coagulase-negative staphylococcus (subsequently identified as S. lugdunensis) was isolated from two sets of blood cultures. Transthoracic and transesophageal echocardiograms showed a large (2.3 x 3.1 cm) vegetation on the pulmonary valve with moderate valvular insufficiency. The patient was treated with 6 weeks of antibiotic therapy and is stable 4 months following the completion of therapy; no surgical intervention was performed. Of the 28 previously reported cases of S. lugdunensis endocarditis, only 1 had previously survived with medical therapy alone. This is the 3rd case report of S. lugdunensis endocarditis in a patient on hemodialysis; the presumed portal of entry in this and previously reported cases was the vascular access device. Endocarditis due to this organism is characterized by a high mortality, rapid tissue destruction, and a predilection for native valves. Because the clinical outcome is much more favorable with valvular replacement, speciation of the organism assumes great importance in defining the therapeutic approach. Copyright Copyright 1999 S. Karger AG, Basel     

Surgical Treatment of Prosthetic Valve Endocarditis with Homograft Aortic Valve Replacement

This article presents the University of Alabama experience with homograft aortic valve replacement for prosthetic valve endocarditis. Of 117 patients who have undergone homograft aortic valve replacement since 1981, there has been a total of 22 patients who underwent operation for endocarditis. Sixteen were isolated valve replacements, three combined with other procedures, and three were aortic root replacements. When placed in a setting of active endocarditis, there have been no reoperations for endocarditis of the homograft valve. Surgical techniques are presented for the freehand sewn homograft as well as aortic root replacement. Prosthetic valve endocarditis is a highly lethal event and when aortic valve replacement is advised in this setting, we believe a homograft aortic valve should be implanted whenever possible.     

Double-chambered right ventricle associated with infective endocarditis complication of the pulmonary valve: surgical management

Double-chambered right ventricle (DCRV) is a rare congenital heart disease characterized by the presence of anomalous muscle bundles, which divide the right ventricle into two chambers: a high-pressure proximal chamber and a low-pressure distal chamber. Most DCRV patients are diagnosed and treated during childhood, and presentation in adulthood is not common. Many congenital heart diseases are often associated with other complications such as infective endocarditis (IE). Right-side endocarditis, which usually involves infection of the tricuspid valve, is uncommon, and endocarditis of the pulmonary valve is extremely rare. We report a 51-year-old woman with undiagnosed DCRV and ventricular septal defect associated with pulmonary valve endocarditis. The diagnostic evaluation and the surgical management are discussed.