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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 12  |  Issue : 1  |  Page : 31-33

Multiple systemic cardio-embolism in native aortic valve endocarditis


Department of Cardiology, Elias Emergency University Hospital, Carol Davila University of Medicine and Pharmacy; Department of Cardiology, Elias Emergency University Hospital, Bucharest, Romania

Date of Submission17-Jan-2021
Date of Decision17-Jan-2021
Date of Acceptance16-Feb-2021
Date of Web Publication08-Feb-2022

Correspondence Address:
Dr. Livia F Trasca
Elias Emergency University Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest; Department of Cardiology, Elias Emergency University Hospital, 17 Marasti Boulverad, Sector 1, Bucharest
Romania
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jicc.jicc_5_21

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  Abstract 


We present a challenging case of native aortic valve endocarditis with Enterococcus faecalis in a patient with a history of multiple urinary tract infections and urethral strictures treated by local dilations. The case was complicated by Clostridium difficile colitis and multiple septic embolization. Despite intensive antibacterial therapy, guided by the antibiogram, the vegetations grew in size and the infection became uncontrolled causing recurrent embolism.

Keywords: Embolism, infective endocarditis, transesophageal echocardiography


How to cite this article:
Paraschiv C, Trasca LF, Popescu AC, Balanescu SM. Multiple systemic cardio-embolism in native aortic valve endocarditis. J Indian coll cardiol 2022;12:31-3

How to cite this URL:
Paraschiv C, Trasca LF, Popescu AC, Balanescu SM. Multiple systemic cardio-embolism in native aortic valve endocarditis. J Indian coll cardiol [serial online] 2022 [cited 2022 May 27];12:31-3. Available from: https://www.joicc.org/text.asp?2022/12/1/31/337351




  Introduction Top


Enterococcus spp is the third most frequent cause of infective endocarditis (IE) in both native valve and prosthetic valve endocarditis.[1] Due to its expanding drug resistance, enterococcal IE is known as a diagnostic and therapy challenge. Echocardiography has a major role in the diagnosis and the follow-up of IE. It is the fundamental imaging method used to diagnose the condition and it is included as a major criterion in the Modified Duke IE Criteria. It is also of undeniable importance in predicting the risk of embolization and assessing the course of treatment.


  Case Report Top


A 68-year-old male patient is admitted to the Cardiology Department for a thorough the evaluation of 1 month history of a fever, accompanied by fatigue and shortness of breath occurring on minimum exertion The febrile syndrome, lasting for over 30 days has been empirically treated with a few antibiotic courses, changed every week, including aminoglycosides, cephalosporins, and quinolones. The patient's medical history revealed urethral strictures which have been dilated and recurrent urinary tract infections with Enterococcus faecalis. The last positive urine culture has been documented 5 months before the presentation.

On hospital admission, the patient presented altered mental status, fever, elevated heart rate and arterial hypotension. A diastolic heart murmur was present in the aortic area. The electrocardiogram showed sinus tachycardia.

Blood tests revealed systemic inflammation. Transthoracic echocardiography showed an intracardiac mass of 10 mm, attached to the aortic valve (AV), highly mobile. Transesophageal echocardiography (TEE) confirmed a 10/3 mm vegetation attached to the right coronary cusp (RCC) of the AV, with complete rupture of the RCC, perforation of the noncoronary cusp and secondary severe regurgitation [Figure 1]a and [Figure 1]b. Three blood cultures resulted positive for Enterococcus faecalis.
Figure 1: (a) Transesophageal echocardiography mid esophageal long axis view of the aortic valve shows a 10/3 mm long vegetation attached to the right coronary cusp; (b) Transesophageal echocardiography long axis Color Doppler of the aortic valve shows a perforation of the noncoronary cusp severe regurgitation; (c) Transesophageal echocardiography mid esophageal long axis view of the aortic valve shows a 13/7 mm long vegetation attached to the right coronary cusp, 4 weeks after 1a; (d) Transesophageal echocardiography long axis color Doppler of the aortic valve shows a perforation of the noncoronary cusp and severe regurgitation, 4 weeks after 1b

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  Results Top


As two major Duke criteria have been fulfilled, a diagnosis was formulated: Native valve IE with severe aortic regurgitation. Intravenous (IV) antibiotic treatment was initiated, first empirically, then according to the antibiogram: Second generation cephalosporin and aminoglycoside. As the patient presented mild symptoms of heart failure with dyspnea on exercise, he was treated with beta blockers and diuretics. He needed transfusions for severe anemia. Moreover, the patient developed Clostridium difficile colitis thus the antibiotic scheme was changed, by IV aminopenicillin (ampicillin 200 mg/kg/day IV), aminoglycoside (gentamicin 3 mg/kg/day IV) and glycopeptide (vancomycin 30 mg/kg/day IV) associated with oral glycopeptide (vancomycin 1 g oral administration). The colitis was successfully treated.

At this point, the heart team's decision, according to the current guidelines, was to treat the patient with antibiotics to obtain negative blood cultures thus lowering the surgical and infectious risk for AV replacement.

Even so, the heart failure symptoms worsened and the patient started experiencing paroxysmal nocturnal dyspnea. Unilateral pleural effusion subsequently developed. Thoracocentesis was performed. Furthermore, embolic events started occurring, first in the spleen, then in the kidneys. The first computer tomography (CT) was requested 12 days after admission, as the patient developed abdominal pain. The CT revealed splenic nodular lesions consistent with embolic events [Figure 2]a. On the 30th days of hospitalization, the second CT shows renal lesions consistent with septic emboli consistent with elevated creatinine and blood urea nitrogen levels, in addition to the splenic ones [Figure 2]a and [Figure 2]b. After 4 weeks of hospitalization, a second TEE was performed. This revealed that not only the mass grew in size, from 10/3 mm to 13/7 mm but also new small masses appeared attached to the AV [Figure 1]c and [Figure 1]d. As the antibiotic treatment alone did not prevent the complications and was unable to cure the patient, we decided in favor of surgical treatment. The calculated Society of Thoracic Surgeons Score showed a risk of mortality of 3.008%.
Figure 2: (a) Computed tomography coronal view shows splenic lesions and left renal lesions consistent with septic emboli (arrows); (b) Computed tomography coronal view shows right renal lesions consistent with septic emboli (arrows)

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On the 32nd day of hospitalization, the patient was transferred to the Cardiovascular Surgery Department. AV replacement with a metallic prosthesis and mitral valve annuloplasty were performed.

On the 2-day after the procedure, the patient developed hemiplegia and was diagnosed with stroke, the evolution was severe with no recovery of the motor deficit. The patient died 10 days after the surgery


  Discussions Top


Enterococcus spp. is the third most common cause of IE, after Streptococcus spp. and Staphylococcus spp.[1] In cohorts, enterococcal endocarditis amounted to 6%–10% of total case burden.[2],[3] Although frequently described, enterococcal endocarditis is still a medical challenge nowadays and the mortality remains high.[1] Enterococcus spp. has growing drug resistance and its complete remission requires a prolonged antibiotic treatment.[4] Enterococcus faecalis is the most common of the Enterococcus spp. involved in the etiology of IE.[4] It is usually associated with previous IE, prosthetic valves or intracardiac devices.[4] In this case, the patient had none of the aforementioned risk factors. Even though our patient had no immunodeficiency disorder, no high risk condition, either congenital or acquired (prosthetic valve, previous IE) and underwent no high risk procedure, he still developed IE. Antibiotic prophylaxis for urogenital procedures is not recommended in guidelines, unless there is already an established and documented infection.[4] All of his documented urinary tract infections have been treated with antibiotics. The patient developed septic emboli even though antibiotic therapy has been initiated promptly. The splenic embolization occurred within the first 2 weeks after the beginning of antibiotics, which is the most frequently described scenario.[5] In our case, renal embolization occurred after 3–4 weeks. Furthermore, because of the high risk of early IE and postoperative valve dysfunction, the current guidelines recommend antibiotic treatment until blood cultures become negative. In addition, the patient presented no high risk features at first, therefore our patient was initially medically treated and surgical treatment was postponed.[4],[6] The patients who had valve replacement surgery within the 1st week of antibiotic therapy had lower mortality risk but presented a high risk of relapse endocarditis or postoperative dysfunction of the valve.[7] Even though valve surgery in patients with complicated left sided IE was associated with a lower mortality, compared to those medically treated,[8] the optimal timing of the surgery is still debatable.[6],[7] Despite proper antibiotic therapy, followed by surgery, the infection could not be controlled, ultimately leading to the patient's death.


  Conclusions Top


Enterococcal IE of a structurally normal AV in a patient with no high risk conditions could have an unpredictable, severe evolution despite proper medical treatment. Maybe deciding for an earlier surgical intervention, septic embolization could have been avoided and the outcome could have been better. Further research is needed to establish the right timing for surgery, and to define high risk features, as to improve the outcome of IE patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chirouze C, Athan E, Alla F, Chu VH, Ralph Corey G, Selton-Suty C, et al. Enterococcal endocarditis in the beginning of the 21st century: Analysis from the International Collaboration on Endocarditis-Prospective Cohort Study. Clin Microbiol Infect 2013;19:1140-7.  Back to cited text no. 1
    
2.
Murdoch DR, Ralph Corey G, Hoen B, Miro JM, Fowler VG Jr., Bayer AS, et al. Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century. Arch Intern Med 2009;169:463.  Back to cited text no. 2
    
3.
Tleyjeh IM, Steckelberg JM, Murad HS, Anavekar NS, Ghomrawi HM, Mirzoyev Z, et al. Temporal trends in infective endocarditis: A population-based study in Olmsted County, Minnesota. JAMA 2005;293:3022-8.  Back to cited text no. 3
    
4.
Habib G, Lancellotti P, Antunes MJ, Bongiorni MG, Casalta JP, Del Zotti F, et al. 2015 ESC guidelines for the management of infective endocarditis. Eur Heart J 2015;36:3075-123.  Back to cited text no. 4
    
5.
Vilacosta I, Graupner C, San Roman JA, Sarria C, Ronderos R, Fernandez C, et al. Risk of embolization after institution of antibiotic therapy for infective endocarditis. J Am Coll Cardiol 2002;39:1489-95.  Back to cited text no. 5
    
6.
Habib G, Avierinos JF, Thuny F. Aortic valve endocarditis: Is there an optimal surgical timing? Curr Opin Cardiol 2007;22:77-83.  Back to cited text no. 6
    
7.
Thuny F, Beurtheret S, Mancini J, Gariboldi V, Casalta JP, Riberi A, et al. The timing of surgery influences mortality and morbidity in adults with severe complicated infective endocarditis: A propensity analysis. Eur Heart J 2011;32:2027-33.  Back to cited text no. 7
    
8.
Vikram HR, Buenconsejo J, Hasbun R, Quagliarello VJ. Impact of valve surgery on 6-month mortality in adults with complicated, left-sided native valve endocarditis: A propensity analysis. JAMA 2003;290:3207-14.  Back to cited text no. 8
    


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  [Figure 1], [Figure 2]



 

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