Q fever endocarditis: over 14 years of surgical experience in a referral center for rickettsioses

BACKGROUND AND AIM OF THE STUDY: Q fever endocarditis caused by Coxiella burnetii is the most important etiology of negative blood culture endocarditis. Without specific clinical findings, diagnosis is difficult and prevalence of this life-threatening disease is underestimated. METHODS: Q fever endocarditis was assessed in 19 patients (15 men, four women; age range: 36-79 years) by evaluating clinical and echocardiographic criteria and specific serology. All patients had evidence of pre-existing valvular disease, and 10 had a valvular prosthesis. Diagnosis was assessed in: the presence of unexplained fever (n = 5), heart failure with valvular dysfunction (n = 10), hemolysis (n = 1), glomerulonephritis (n = 1) and stroke (n = 2). A late diagnosis was made in eight patients, either during or after surgery. RESULTS: In all cases, usual blood cultures remained negative, despite specific serology being positive. Transthoracic and transesophageal echocardiography were conclusive in only six cases (four vegetations, two periannular abscesses). Surgery was indicated in 15 patients for heart failure or valvular dysfunction (n = 12), hemolysis (n = 1) and periannular abscess (n = 2). Intraoperative findings were suggestive of endocarditis in seven cases; valvular cultures were positive in 92% of cases. All patients were treated with combined doxycycline/ hydrochloroquine or quinolone, for a mean of 24 months (range: 6-60 months). Mean follow up was 40 months (range: 6-144 months). Two patients died from heart failure, one patient was lost to follow up, and 16 patients had no late relapses. CONCLUSION: Q fever is an underestimated cause of endocardititis, and early diagnosis is the key to good prognosis. The need for systematic serologic examination in case of valvular dysfunction, with or without endocarditis symptoms, is emphasized.     

Coxiella burnetii endocarditis: long-term clinical course in 20 patients

INTRODUCTION AND OBJECTIVES: Coxiella burnetii is a causative agent of increasingly frequent subacute infective endocarditis, and is associated with elevated morbimortality. Our aim in the present study was to assess the clinical, serological and therapeutic long-term evolution of 20 patients with Coxiella burnetii endocarditis. METHODS: Twenty patients (13 male and 7 female, age 42 +/- 10 years) admitted between 1982 and 1996 were retrospectively studied. All of them fulfilled the Duke criteria modified by Raoult for Q fever endocarditis. RESULTS: Endocarditis involved prosthetic and native valves in 14 and 6 patients, respectively. All patients except one received antibiotic treatment. Patients treated with doxycycline in monotherapy showed worse evolution than those treated with doxycycline in combination with other antibiotics. Valve replacement was performed in 15 patients, due to prosthetic dysfunction in most of them. The overall mortality was 40% (8 patients). At follow-up of 74 months (range 19-156) (mean 74 +/- 47) all patients showed persistent high levels of phase I antibodies. At follow-up of 15 to 65 months (32 +/- 30) antibiotic treatment was suspended in five patients because they were asymptomatic and without microbiologic findings of valvular endocarditis. CONCLUSIONS: Q fever endocarditis was associated with severe complications, which often required valve replacement. All patients showed persistent high serological titers of Coxiella burnetii endocarditis without other signs of active infection. This finding raises the issue of suspending antibiotic treatment in patients with negative microbiologic findings and questions the persistence of abnormal serology as a monitor of treatment efficacy.     

Q fever bioprosthetic aortic valve endocarditis (PVE) successfully treated with doxycycline monotherapy

Q fever is a zoonotic infection caused by Coxiella burnetii. The most common clinical manifestation of acute Q fever infection is as an atypical community-acquired pneumonia. The pulmonary findings are accompanied by extrapulmonary findings, most typically an increase in serum transaminases and splenomegaly. Because C. burnetii is difficult to culture, the diagnosis of Q fever is usually made serologically. The diagnosis of acute Q fever atypical community-acquired pneumonia is made by demonstrating a fourfold or greater increase in titer between acute and convalescent specimens or by demonstrating elevated immunoglobulin (IgM) (phase II) titers. Chronic Q fever is manifested as granulomatous hepatitis or more commonly as culture-negative endocarditis (CNE). Chronic Q fever (CNE) is a difficult diagnosis because of difficulty in culturing the organism from the blood and the vegetations with Q fever CNE are small or absent. The diagnosis of chronic Q fever CNE is based on serology. Such patients commonly have highly elevated IgM and IgG titers (phase I/II) titers. Chronic Q fever CNE may involve native or prosthetic heart valves. Q fever prosthetic valve endocarditis is rare compared with native valve Q fever endocarditis. Q fever prosthetic valve endocarditis usually requires valve replacement for cure. We present a case of chronic Q fever bioprosthetic aortic valve endocarditis that was successfully treated with doxycycline monotherapy that did not require aortic valve replacement.     

Doxycycline and chloroquine as treatment for chronic Q fever endocarditis

Endocarditis is a rare but severe complication of Q fever, an infectious disease caused by the intracellular pathogen Coxiella burnetii. Heart involvement is the most common clinical presentation of chronic Q fever, and it occurs almost invariably in patients with previous valvular disease or artificial valves, and in the immunocompromised host. The optimal treatment of Q fever endocarditis is still today debated, and recommended duration of treatment varies from one year to one's lifespan. A case of chronic Q fever endocarditis is described in a patient with biological prosthetic aortic valve and aortic homograft, successfully treated with doxycycline and chloroquine for 2 years.     

Endocarditis caused by Coxiella burnetii in aortic prosthesis. Presentation of a case with a fatal course

A case of endocarditis caused by Coxiella burnetii in a patient with an aortic Starr-Edwards prosthesis is described. The diagnosis was made by detecting high titres of antibody against Coxiella burnetii phase I antigens. After 15 weeks of chemotherapy with tetracycline and cotrimoxazole, aortic prosthetic valve replacement was carried out because of haemodynamic deterioration and he died 4 days later. The histologic picture of the excised valve was consistent with endocarditis. Coxiella burnetii should be considered in the differential diagnosis of culture-negative endocarditis in our country, especially when the patient has not receiving antibiotic treatment in the last 2 weeks.     

Q fever endocarditis

Despite a worldwide distribution of Coxiella burnetii, only single cases of Q fever endocarditis have been reported outside Great Britain and Australia. We present 10 patients; five were female, only four had a history of environmental exposure, and the mitral valve was involved as commonly as the aortic valve. One patient had congenital aortic stenosis, and three patients had a prosthetic valve. We confirm the importance of hepatic involvement, thrombocytopenia and hypergammaglobulinemia as diagnostic features. Diagnosis was established by finding an elevated complement-fixing antibody to Phase I C. burnetii antigen. Tetracycline, with or without lincomycin or cotrimoxazole, was used in nine patients, and one patient received cotrimoxazole as the sole antibiotic agent. Optimal duration of therapy is unknown. In one patient, relapse followed when treatment was stopped after 18 months. Valve replacement was necessary in five patients, because of hemodynamic problems. Five patients died, and the mean survival is 36 months with a range of five to 66 months. We suggest that Q fever endocarditis is frequently missed, and we recommend clinicians to consider the diagnosis in all cases of culture-negative endocarditis.     

Prognostic significance of valvular regurgitation in patients with infective endocarditis

PURPOSE: Doppler ultrasound is a sensitive modality for detecting and quantitating valvular regurgitation in patients with infective endocarditis. Because valvular regurgitation leads to heart failure, we evaluated the prognostic significance of Doppler-detected valvular regurgitation in patients with endocarditis who had not yet developed clinical heart failure. PATIENTS AND METHODS: We reviewed the medical records of 65 patients with a clinical diagnosis of infective endocarditis from May 1985 to March 1990. A total of 49 patients were included in the study: 33 patients with native valve endocarditis and 16 patients with prosthetic valve endocarditis. The initial Doppler echocardiogram was examined in these patients to determine the presence and degree of valvular regurgitation. RESULTS: Significant (moderate to severe) valvular regurgitation was detected in 23 (47%) patients. The presence or absence of significant valvular regurgitation did not predict the development of congestive heart failure, the need for surgery, or death (p = NS). The development of congestive heart failure was significantly associated with the need for surgery (p less than 0.0001) and death (p less than 0.05). CONCLUSION: We conclude that the detection of significant valvular regurgitation in patients with infective endocarditis who have not yet developed heart failure is not predictive of future complications nor does the absence of significant valvular regurgitation identify a group of patients with a more favorable prognosis. In our series, patients who developed congestive heart failure had a significantly higher incidence of surgery and death. Therefore, decisions regarding clinical management in patients with infective endocarditis should not be made solely on the presence or absence of echocardiographically detected valvular regurgitation.     

Echocardiographic and clinical correlations in infectious endocarditis of the left heart

The echocardiographic features were correlated with the clinical findings and outcome in 35 patients with aortic and/or mitral valve endocarditis. There were 26 males and 9 females with a mean age of 38 years. The infection involved native valves in 27 patients and prosthetic valves in 8 patients. Echocardiographically, fourteen patients had involvement of native aortic valve. All patients in this group required surgical intervention, nine patients during antimicrobial therapy. Congestive heart failure was the clinical indication for valvular replacement. A patient died immediately after surgery from low cardiac output syndrome. Six patients had echocardiographic evidence of aortic and mitral valves involvement. A patient in this group expired before surgery, five underwent surgery because of progressive heart failure (aortic or aortic and mitral valves replacement). Seven patients showed lesions on native mitral valve (6 in this group had prolapse syndrome). A patient died from cerebrovascular embolus, two underwent surgery because of persistent infection and embolic events, four were successfully treated with medical therapy. Among patients with prosthetic valve endocarditis, four showed signs of valvular dehiscence and required surgical intervention, during antimicrobial therapy, from congestive heart failure; one patient expired from recurrent infection. The pathological findings correlated well with echocardiographic findings. Conclusions: in IE the localization of lesions by echo has prognostic significance: most patients with aortic valve or aortic and mitral valves endocarditis require early surgical intervention because of congestive heart failure. On the contrary, mitral valve involvement carries a better prognosis, requiring less frequently valvular replacement; the patients with echocardiographic signs of prosthetic valve dehiscence require urgent intervention.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cardiac valves in patients with Q fever endocarditis: microbiological,molecular, and histologic studies

The pathologic features of Q fever endocarditis, which is caused by Coxiella burnetii, were histologically evaluated in cardiac valves from 28 patients. We used quantitative image analysis to compare valvular fibrosis, calcifications, vegetations, inflammation, and vascularization due to Q fever endocarditis with that due to non-Q fever endocarditis and valvular degeneration. We also studied the presence of C. burnetii in valves by immunohistochemical analysis, culture, and polymerase chain reaction (PCR). Histologically, Q fever endocarditis was characterized by significant fibrosis and calcifications, slight inflammation and vascularization, and small or absent vegetations. Despite antibiotic treatment, non-statistically significant variations at the histologic level were observed. These pathologic features could be confused with noninfectious valvular degenerative damage. We found that the detection of C. burnetii in cardiac valves by immunohistochemical analysis, culture, and PCR decreased significantly only after 1 year of antibiotic treatment, which emphasizes the long persistence of this organism in valve tissues. Pathologic and immunohistochemical analyses may contribute to the diagnosis of Q fever endocarditis.     

Risks factors and prevention of Q fever endocarditis.

Coxiella burnetii causes acute and chronic Q fever. To evaluate the risk factors of development of chronic endocarditis following Q fever and to assess the best preventive therapy, a retrospective study of patients diagnosed as having Q fever during 1985-2000 was conducted. Twelve patients with acute Q fever who developed endocarditis and 102 patients with Q fever endocarditis were included in the study. When compared to 200 control patients with acute Q fever, preexisting valvular disease (P<10(-7)), especially a prosthetic valve (P=.01), were encountered more often among patients with endocarditis. Among patients with valvular defects, we estimate the risk of developing endocarditis to be 39%. A combination of doxycycline plus hydroxychloroquine was better at preventing the development of endocarditis than doxycycline alone (P=.009). Our results should encourage physicians to detect valvular lesions in patients with acute Q fever and to search for acute Q fever in patients with a valvulopathy and unexplained fever. A proper treatment for such patients and a scheduled follow-up should reduce the risk of developing endocarditis.     

Short and long-term prognosis of prosthetic valve endocarditis in non-drug addicts

INTRODUCTION AND OBJECTIVES: Prosthetic valve infective endocarditis is a complication of valvular replacement surgery with a high morbimortality during the in-hospital phase and an important risk of complications during follow-up. The objective of the present study is to assess the clinical features and the short and long-term prognosis of this disease. PATIENTS AND METHODS: A prospective study of 43 consecutive cases of prosthetic valve endocarditis in non-addict patients from January 1987 to March 1997. RESULTS: The mean age was 51 +/-16 years. Eight patients (19%) had early prosthetic valve endocarditis (two months following heart surgery), fourteen patients (32%) had intermediate (between 2 and 12 months post surgery) and twenty-one (49%) had late prosthetic valve endocarditis (more than one year after heart surgery). Transesophageal echocardiography was performed in 32 patients with a sensibility of 81%. Complications occurred in 86% of patients and 53% of patients underwent surgery during the active phase (25% was emergency surgery). Inpatient mortality was 23% (50% in early prosthetic valve endocarditis). After a mean follow-up of 56 months there were 5 cases of recurrence, four patients required late surgery and 5 patients died. Survival (excluding early mortality) was 82% at 5 years with no significant differences among patients who received only medical treatment and those who underwent surgery in the active phase. CONCLUSIONS: Early mortality of prosthetic valve endocarditis is, according to our experience of 20%. The prognosis of survivors to the active phase is favourable in the majority. Early prosthetic valve endocarditis still causes a high mortality rate despite the use of combined medical surgical treatment in most cases.     

Q Fever Presenting As Recurrent, Culture-negative Endocarditis with Aortic Prosthetic Valve Failure: A Case Report and Review of the Literature.

The present report describes a case of recurrent, culture-negative endocarditis presenting with aortic prosthetic valve dysfunction in a 62-year-old man who required four valve replacement surgeries. On each occasion, he presented with valve failure. Fever was only documented during his first presentation. Furthermore, no vegetations were detectable on his aortic valve at transesophageal echocardiography. On the occasion of his most recent presentation, a detailed history of animal exposure - including hunting and skinning deer, moose and other large animals with his bare hands - was the only clue to his diagnosis. Serum antibodies against Coxiella burnetii were strongly positive, and C burnetii DNA was detected by polymerase chain reaction from his resected aortic valve tissue. Q fever is a worldwide zoonotic infection with diverse reservoirs. This diagnosis should be considered when evaluating unexplained prosthetic valve dysfunction, particularly in the setting of animal exposure.     

Prosthetic valve endocarditis: an overview

Infection of an intracardiac prosthesis, the incidence of which is about 2.5% among patients having undergone valve replacement, is a serious complication with considerable morbidity and mortality. Early prosthetic valve endocarditis (PVE), with an onset within 60 days of valve replacement, accounts for approximately one-third of all cases, while the remaining two-thirds, occur more than two months postoperatively (late prosthetic valve endocarditis). Prosthetic valve endocarditis is most commonly caused by Staphylococcus epidermidis, less frequently by viridans streptococci, Staphylococcus aureus, and gram-negative bacilli. The most likely pathogenetic mechanisms in prosthetic valve endocarditis are intraoperative contamination and postoperative infections at extracardiac sites. Prominent clinical features include fever, new or changing heart murmurs, leukocytosis, anemia and hematuria. The etiologic microorganism can be isolated in more than 90% of all cases. Patients with proven prosthetic valve endocarditis should be examined daily to detect signs of congestive heart failure and changes in murmurs; electrocardiographic monitoring is essential for documentation of arrhythmias. With limitations, echocardiography, especially two-dimensional, may help to demonstrate vegetations or valvular dehiscence. Cinefluoroscopy may reveal loosening or dehiscence of the sewing ring or impaired motion of a radio-opaque poppet due to thrombus or vegetation. Cardiac catheterization, not always necessary even when surgical intervention is anticipated, may provide valuable information on the degree of dysfunction, multiple valve involvement, left ventricular function and extent of concomitant coronary artery disease. In patients with mechanical valves, prosthetic valve endocarditis may be associated with a high incidence of valve ring and myocardial abscesses; the reported frequency of valve ring abscesses is lower with porcine heterografts. Infections on mechanical valves characteristically localize to the sewing ring with subsequent detachment of the prosthesis and valvular incompetence; infections on porcine heterografts tend to localize to the cusps, leading to valvular incompetence because of leaflet destruction. Large vegetations may result in functional stenosis. Over the last ten years the overall mortality of prosthetic valve endocarditis was 53.8%; 73.6% in early and 43% in late prosthetic valve endocarditis. More recently, however, the survival rate appears to be improving. In general, the mortality associated with prosthetic valve endocarditis caused by fungi and Staphylococcus aureus is highest and that of streptococci lowest.(ABSTRACT TRUNCATED AT 400 WORDS)     

Stenotrophomonas maltophilia endocarditis: a systematic review

The disease characteristics, management, and outcome of Stenotrophomonas maltophilia endocarditis were evaluated by examining the reports on the subject identified through a comprehensive literature search. Twenty-three (17 male) cases of S.. maltophilia endocarditis were identified. Mean age was 41 +/- 15 years. All patients presented with fever. Prosthetic valves were involved in 12 (52%) cases. Among native valves, the aortic valve was most frequently involved (50%), followed by the tricuspid valve (36%). Twenty (87%) patients had underlying risk factors for the development of endocarditis, including prior valvular or congenital heart disease surgery (60%), intravenous drug abuse (32%), and infected intravascular lines (18%). The endocarditis was postoperative in 14 patients. Seventeen (74%) patients experienced complications including septic embolism (23%), cardiac abscesses (23%), and congestive heart failure (18%). A combination of two or more antibiotics was used in all cases except one. The frequently used antibiotics were aminoglycosides (59%), trimethoprim-sulfamethoxazole (48%), and penicillins (48%). One half of the patients required cardiac surgery, but the proportion of surgically treated cases was higher among prosthetic valve endocarditis (62%). Mortality was 39% and was equally distributed between patients with prosthetic and native valve endocarditis. The S. maltophilia endocarditis carries high complication and mortality rates. The antibiotic regimen should consist of a combination of multiple antibiotics guided by the sensitivity panel. Early surgery may be considered in patients not responding to antibiotic treatment and in those with prosthetic valve endocarditis.     

The Quattro valve and active infective endocarditis of the mitral valve

BACKGROUND AND AIM OF THE STUDY: Even today, infective endocarditis remains a therapeutic challenge. Active endocarditis at the time of valve implantation is an important risk factor for the development of prosthetic valve infection. This study reports results following implantation of the Quattro valve, a stentless chordally supported quadrileaflet mitral valve made from bovine pericardium. METHODS: The Quattro valve was implanted in seven patients (four females, three males; mean age 34 years) requiring isolated mitral valve replacement for active bacterial endocarditis. All had congestive heart failure; two were in cardiogenic shock. The diagnosis of active endocarditis was based on clinical and echocardiographic findings, together with macroscopic evidence of acute infection at surgery, blood culture or histopathological evidence of valve infection. Postoperatively, all patients received at least four weeks of parenteral antibiotic therapy. RESULTS: Congestive heart failure (and large pedunculated vegetations and mobile septic left atrial thrombi in two patients) prompted early surgical intervention. Patients underwent surgery at a mean of 7 days (range: 1-16 days) after admission. Endocarditis was caused by Gram-positive cocci in all patients except one. At a mean follow up of 15 months (range: 6-24 months) all patients were alive and symptomatically improved. To date, all remain free of prosthetic valve endocarditis, reoperation and thromboembolism. CONCLUSION: The Quattro valve can be implanted safely in patients with acute bacterial endocarditis. The results also reflect the benefit of early surgical intervention in patients with infective endocarditis complicated by congestive heart failure, with or without large vegetations.     

Infectious endocarditis in the University Hospital Center of Brazzaville. A study of 32 cases

Thirty-eight cases of infective endocarditis (IE) were observed between 1976 and 1989 (1.3% of all cardiac disease). Thirty two cases were retained for study based on Von Reyn's criteria: 28 native valve endocarditis (27 left and 1 right heart valves) of which 18 occurred on previously undiseased valves (56.3%); 4 cases of left heart prosthetic valve endocarditis. The average age of the patients was 27.5 +/- 14 years and the group comprised 24 women and 8 men (p less than 0.001). Blood cultures were negative in 13 cases, revealed a Gram negative pathogen in 8 cases, a streptoccocus in 3 cases. Blood cultures were not performed in 2 cases. The IE was acute in 18 cases (56.7%) and subacute in 14 cases (43.7%). The dominant clinical signs were of massive and sometimes acute valvular regurgitation (mitral: 21 cases; aortic: 10 cases; mitral and aortic: 3 cases; tricuspid: 1 case). Twenty-six patients had cardiac failure (81.2%): LVF: 15 cases, congestive cardiac failure: 10 cases, RVF: 1 case. The other complications were embolic: cerebral (3 cases), mesenteric (1 case), pulmonary (4 cases). Antibiotic therapy was prescribed in all patients; surgery was required in 9 cases. There were 12 fatalities (37.5%), 10 in the medically treated group and 2 in the surgical group (p less than 0.05). The results show that the prognosis of IE in underdeveloped regions remains poor. Effective strategies of early diagnosis and treatment are urgently required to reduce the high mortality. Prophylaxis of IE should commence with measures to counter the portals of entry of the pathogens and the valvular sequellae of acute rhumatic fever.     

Reoperations in valve surgery. Apropos of 194 cases

Between 1970 and 1985, 194 patients underwent one or several reoperations after conservative valvular surgery (Group A) or valvular replacement surgery (Group B). Group A: comprised 141 patients with a previous history of closed heart mitral commissurotomy (114 cases), open heart mitral commissurotomy (20 cases), mitral valvuloplasty (5 cases) or aortic commissurotomy (2 cases) reoperated after an average period of 153 +/- 44 months. At reoperation, prosthetic valve replacement of the previously operated valve was systematic and another valvular procedure was also performed in 66 cases. Hospital mortality was 7.8 p. 100. Mortality was high in patients reoperated in functional Class IV of the NYHA classification, after closed heart mitral commissurotomy performed over 10 years before hand. The global mortality rate was 17 p. 100 (average postoperative follow-up of 70 +/- 44 months). The actuarial 5 year survival rate was 85 +/- 6 p. 100 and the 10 year survival was 70 +/- 13 p. 100; NYHA Class IV cardiac failure was a significant poor prognostic factor (p less than 0.05). The prognosis of reoperation after commissurotomy depended mainly on the interval between the relapse of symptoms and reoperation. Group B: comprised 53 patients with valvular prostheses reoperated after an average period of 58 +/- 41 months. The indications of reoperation were prosthetic valve dysfunction (31 cases), perivalvular leak (5 cases), prosthetic valve thrombosis (6 cases), infective endocarditis (7 cases), haemolysis (1 case) and associated valvular disease (10 cases). Reoperation concerned mechanical prostheses in 26 cases and bioprostheses in 24 cases. It consisted in valvular replacement (51 cases) or reinsertion (2 cases). Eight patients underwent second reoperation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Echocardiographic identification of an aortic valve ring abscess

A valve ring abscess was diagnosed in four patients with a prosthetic aortic valve by identifying an echo-free space on two-dimensional echocardiography. Three of the patients presented with severe aortic regurgitation and congestive heart failure after an episode of endocarditis, but two of them did not have evidence of active endocarditis. The fourth patient had endocarditis, but no evidence of aortic regurgitation or heart failure. All four patients required valve replacement. Similar findings in all 11 previously reported cases suggest that a valve ring abscess can be diagnosed by two-dimensional echocardiography. It may be found without clinical evidence of endocarditis, in the absence of aortic regurgitation, without echocardiographically identifiable vegetations or during resolution of endocarditis.     

Prosthetic valve endocarditis. A survey.

Fifty eight patients (aged 8-59 years, mean 27) treated for prosthetic valve endocarditis from January 1966 to January 1985 were studied retrospectively by review of case notes. There were 12 cases of early and 46 cases of late prosthetic valve endocarditis. These developed in 28 patients with an isolated aortic valve, in 26 with an isolated mitral valve, and in four with both aortic and mitral prosthetic valves. Streptococci were the most commonly isolated microorganisms, followed by staphylococci, Gram negative bacteria, and fungi. A surgical (34 cases) or a necropsy specimen (10 cases) from 44 cases was examined. Eighty two per cent of the patients had congestive heart failure. Twenty four of the 58 patients were medically treated and 17 died (70% mortality). Combined medical and surgical treatment was used in 34 patients; the main indication for surgery was congestive heart failure. Fourteen patients on combined treatment died (40% mortality). Persistent sepsis and prosthetic valve dehiscence were the most common early and late operative complications. The most important influences on outcome were congestive heart failure, the type of micro-organism, the severity and extent of anatomical lesions, the time of onset of prosthetic valve endocarditis, and the type of treatment. This survey indicates that only patients without congestive heart failure or embolic complications and with sensitive micro-organism should be treated medically. In view of the poor prognosis patients with prosthetic valve endocarditis associated with congestive heart failure, persistent sepsis, and repeat arterial emboli should be treated by early surgical intervention.     

Propionibacterium endocarditis: a case series from the International Collaboration on Endocarditis Merged Database and Prospective Cohort Study

Propionibacterium species are occasionally associated with serious systemic infections such as infective endocarditis. In this study, we examined the clinical features, complications and outcome of 15 patients with Propionibacterium endocarditis using the International Collaboration on Endocarditis Merged Database (ICE-MD) and Prospective Cohort Study (ICE-PCS), and compared the results to 28 cases previously reported in the literature. In the ICE database, 11 of 15 patients were male with a mean age of 52 y. Prosthetic valve endocarditis occurred in 13 of 15 cases and 3 patients had a history of congenital heart disease. Clinical findings included valvular vegetations (9 patients), cardiac abscesses (3 patients), congestive heart failure (2 patients), and central nervous system emboli (2 patients). Most patients were treated with beta-lactam antibiotics alone or in combination for 4 to 6 weeks. 10 of the 15 patients underwent valve replacement surgery and 2 patients died. Similar findings were noted on review of the literature. The results of this paper suggest that risk factors for Propionibacterium endocarditis include male gender, presence of prosthetic valves and congenital heart disease. The clinical course is characterized by complications such as valvular dehiscence, cardiac abscesses and congestive heart failure. Treatment may require a combination of medical and surgical therapy.