Endocarditis, bacterial

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Tricky Diagnosis: An Aberrant Mitral Valve Chord

Marina Santos et al. Mariana Paiva Joana Ferreira Sara Guerreiro

Case

We present the case of a 52-year-old man with hepatitis C and a history of intravenous drug abuse, admitted to the infectology department with spondylodiscitis and psoas muscle abscess. Staphylococcus aureus was isolated from blood, urine, and spinal fluid cultures, and the transthoracic echocardiogram was negative for vegetation, abscess, or fistula. The transesophageal echocardiogram (TEE) showed a filamentous and mobile structure attached to the atrial surface of the mitral valve (MV), and a diagnosis of infective endocarditis was presumed. Seven days later, the patient was referred to our tertiary institution for a detailed TEE. In 2D images, we found a thin, well-delineated strand connecting the interatrial septum (IAS) to the tip of the anterior mitral leaflet without significant regurgitation ( , supplementary video 1). 3D imaging confirmed the presence of an anomalous chord connecting the A2 scallop of MV to the middle of the interatrial septum ( , supplementary video 2). There was no evidence of infective endocarditis, and this strand was found to be compatible with an anomalous left atrial MV chord.

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Research Letter

Mitral Valve Perforated Aneurysm: An Issue of Inflammation or Pressure Gradients?

Inês Oliveira et al. Isabel Cruz Ana Neto Bruno Bragança … Glória Abreu João Azevedo Aurora Andrade

Case Report

Mitral valve aneurysms (MVA) are uncommon and usually develop acutely in the setting of infective endocarditis (IE). MVA as a late complication of IE in a patient with obstructive hypertrophic cardiomyopathy (HCM) is rather unusual, raising considerations regarding the role of the infectious process and the hemodynamic conditions inherent to the cardiomyopathy.^, We present a case report of a patient with HCM and a ruptured aneurysm of the mitral valve (MV) leaflet, secondary to previously treated IE.

A 68-year-old male patient with type 2 diabetes mellitus and dyslipidemia was admitted to a hospital with a 3-week history of malaise, fever, and recent left-sided abdominal pain. His physical examination revealed a grade II/VI systolic heart murmur at the cardiac apex, fever, abdominal tenderness in the left upper quadrant, and purpuric lesions in the inferior limbs. Blood analyses showed neutrophilia and C-Reactive Protein of 211mg/L. Positive blood cultures indicated Staphylococcus aureus methicillin-sensitive. Abdominal Computed Tomography revealed spleen embolization, with no abscess. Transthoracic (TTE) and transesophageal echocardiography (TEE) disclosed a highly mobile polypoid mass in the atrial side of the anterior MV leaflet, suggestive of a vegetation, with mild mitral regurgitation and no evidence of abscess, aneurysm, or valve perforation; asymmetrical left ventricular (LV) hypertrophy with the presence of an increased intraventricular systolic gradient (IVSG) and systolic anterior motion (SAM) of the MV ( ). The diagnosis of IE in HCM was established and treated accordingly with flucloxacillin, presenting a favorable clinical evolution. After three months of follow-up, cardiac magnetic resonance was performed, confirming the diagnosis of HCM: an increased LV mass (96g/m ) with asymmetrical left ventricular hypertrophy (maximal thickness of 20mm in the inferoseptal wall), with no perfusion defects but with evidence of intramural late gadolinium enhancement in the inferoseptal wall,and SAM of the MV ( ). Echocardiography was repeated and, in addition to evidence of obstructive HCM with a rest IVSG of 44 mmHg, an aneurysm of the anterior leaflet of the MV was identified. Two mitral regurgitant jets were observed, one due to incomplete coaptation of the leaflets and another through the perforated aneurysm, quantifying global mitral regurgitation (MR) in a moderate (grade II/IV) ( ). The beta-blocker dose was increased, and a strategy of close follow-up was adopted. Maintenance of the characteristics of the aneurysm was verified in outpatient follow-up after 2 years.

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IJCS

Case Report

Oral Antibiotic Therapy for Infective Endocarditis Due to Enterococcus Spp. After Hemorrhagic Stroke and Heart Surgery

Guilherme Augusto Reissig Pereira et al. Graziela Regina Kist Tiago Santini Machado Christiano da Silveira de Barcellos

Introduction

Infectious endocarditis (IE) is a severe infectious disease with an annual incidence of 3 – 7 cases per 100 000 people, and is considered the 3rd most life-threatening infection after pneumonia and intra-abdominal abscess. Intra-hospital mortality ranges from 15 to 30% and patients affected today are older and have more comorbidities than in the past.

In IE the treatment is traditionally performed in hospitalized patients, due to the need for intravenous antibiotics. Patients with IE on the left side of the heart are typically treated for 2 – 6 weeks, according to the American and European Guidelines. ^– Enterococcus spp. is the third cause of IE, representing 10% of cases in non-users of intravenous drugs, and is considered to be a bacterium that is difficult to eradicate, requiring 6 weeks and the combination of antibiotics.

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Original Article

Association between Insulin use and Infective Endocarditis: An Observational Study

Renato Lott Bezerra et al. Thales Figueiredo de Carvalho Ricardo dos Santos Batista Yago Machado da Silva … Bruno Fiuza Campos João Henrique Máximo de Castro Matheus de Carvalho Alves Pedro Ivo Palhares Monteiro Raimundo Matos Bezerra Filho Eduardo Luis Guimarães Machado

Abstract

Background:

The association between Diabetes Mellitus (DM) and Infective Endocarditis (IE) is controversial in the literature, since many controversial results have been published. However, when evaluating specifically the evidence on IE and individuals with DM using insulin, we found only two observational studies that considered this variable, with discordant results regarding the prognosis and prevalence of Staphylococcus sp in insulin users compared to non-users. Despite the lack of evidence, in clinical practice the insulin use could be interpreted as minor criteria “injection drug use”, using the modified Duke criteria for IE diagnosis.

Objectives:

To compare the microbiological and valvar profile, as well as the outcome of non-diabetic and diabetic patients with IE who were insulin users or not.

Methods:

This was an observational, analytical and retrospective study of patients diagnosed with IE between 2003 and 2015 in three tertiary care centers. A total of 211 patients were included, of which 17 were diabetics and 9 were insulin users. Patients were compared using the Shapiro-Wilk normality test and Fisher’s exact test, with a significance level of 5%.

Results:

The mortality from IE in diabetic individuals was higher than that of non-diabetic patients, but with no statistical significance (35.29% vs. 21.1%; p = 0.221), even when the groups were divided into insulin-user diabetic, non-insulin user diabetic and non-diabetic patients (33.3% vs. 37.5% vs. 21.1%, p = 0.229). There was a difference regarding the prevalence of IE caused by S. aureus (57.1% vs. 14.3% vs. 17.4%, p = 0.029) and the involvement of the tricuspid valve (33.3% vs. 0.00% vs. 10.0%, p = 0.034) among insulin users.

Conclusion:

In our sample, insulin use or the presence of DM did not mean higher in-hospital mortality from IE. It is not possible to generalize the microbiological and valvar findings due to the lack of studies evaluating insulin users in IE; however, particularities have been previously reported and may indicate a different behavior of IE in these patients. New studies considering the insulin use variable are required to elucidate the association between DM and IE.

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Case Report

Case Report: Catheter-Related Interatrial Septum Endocarditis Caused by Candida Parapsilosis

Gustavo Neves de Araújo et al. Felipe H. Valle Douglas M. Freitas Felipe Martins Lampa … Miguel Gus Luis E. Rohde

Introduction

Patients with end-stage chronic kidney disease without mature arteriovenous fistula frequently require central venous access for dialytic therapy. More than 15 percent of patients who receive these catheters have complications such as infection, arterial puncture, thrombosis and pneumothorax. Infective endocarditis (IE) is a rare and serious complication with high morbidity and mortality. Right-sided endocarditis is uncommon due to low hemodynamic pressure, but patients using central venous catheters have an increased risk. The correct therapeutic approach whenever there is no valvar involvement is not well defined. We report a case of interatrial septum endocarditis caused by candida sp., associated to the prolonged use of catheter.

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Left Ventricular Pseudoaneurysm Secondary to Mitral Valve Endocarditis

Bruno Bochard-Villanueva et al. Jordi Estornell-Erill

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Case Report

Lactococcus garvieae endocarditis: first case report in Latin America

Tatiana Franco Hirakawa et al. Fernando Augusto Alves da Costa Marcos Cairo Vilela Micheli Rigon … Henry Abensur Maria Rita Elmor de Araújo

Lactococcus garvieae, an emerging zoonotic pathogen, is responsible for mastitis in rodents and sepsis in fish. Although deemed opportunistic and hardly ever causing infections in humans, its incidence is probably underestimated due to the difficulty in diagnosis. There are very few reports of osteomyelitis, liver abscess, and peritonitis, and only nine cases of endocarditis described in worldwide literature. We describe the first case of Lactococcus garvieae endocarditis in Latin America, in a female patient with metallic prosthetic heart valve who presented with daily fever, chills, Osler nodes and six positive blood cultures for Lactococcus garvieae, which met Duke’s criteria for the diagnosis of “definitive infective endocarditis”

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Case Report

Ambulatory treatment of streptococcal bacterial endocarditis

Sirio Hassem Sobrinho et al. Carlos Henrique de Marchi Ulisses Alexandre Croti Cristiane Girotto de Souza … Érico Vinícius Campos Moreira da Silva Moacir Fernandes de Godoy

Bacterial endocarditis is a severe infectious disease. of which treatment is traditionally carried out in hospitalized patients through intravenous medication. The possibility of at-home or ambulatory treatment. for stringently selected cases. is attractive from the social as well as from the economic point of view. We report 6 patients with a diagnosis of bacterial endocarditis caused by Streptococcus. treated partially or completely on an outpatient basis. All of them evolved without complications and presented complete resolution of the infection.

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