Leclercia adecarboxylata infective endocarditis in a man with mitral stenosis:A case report and review of the literature

BACKGROUND Infective endocarditis(IE) is a rare disease with a high mortality rate.Leclercia adecarboxylata(L.adecarboxylata) is a movable Gram-negative bacillus of enterobacteriaceae,and it can rarely be a pathogen which often affects immunodeficient patients.There are about three cases of immunocompetent patients with monomicrobial L.adecarboxylata infection.There are only three reported cases of IE caused by L.adecarboxylata in the world.The mitral valve is often affected in IE,and the prognosis for IE with mitral valve lesions is often poor.CASE SUMMARY A 51-year-old man was found to have moderate to severe mitral stenosis on echocardiography.He came to our Cardiothoracic Surgery Department for surgical management.A diastolic murmur was heard on auscultation of the heart in the mitral region.On the second day of hospitalisation,he presented with slurred speech,reduced muscle strength in the left limb,and acute cerebral infarction on cranial computed tomography.Surgical treatment was decided to postpone.On the ninth day of admission,the patient developed a sudden high fever and shock and was transferred to the Cardiac Intensive Care Unit,where echocardiogram revealed an anterior mitral valve leaflet vegetation.After empirical anti-infective treatment with vancomycin(1g q12h),an emergency valve replacement was performed.Bacterial culture identified L.adecarboxylata.Antiinfective treatment with piperacillin-tazobactam(4.5g q8h) was added for 4 wk.Follow-up echocardiography showed normal bioprosthetic valve function after mitral valve replacement.CONCLUSION We report the first case of L.adecarboxylata IE in China,and clinicians should pay attention to this pathogen.

Predictive accuracy of Sepsis-3 definitions for mortality among adult critically ill patients with suspected infection

Background: Sepsis-3 definitions have been published recently;however, their diagnostic value remains controversial. This study was to assess the accuracy of Sepsis-3 definitions compared to Sepsis-1 definitions by stratifying mortality among adult critically ill patients with suspected infection. Methods: A multicenter, prospective cohort study was conducted from November 10, 2017 to October 10, 2018, in five Intensive Care Units (ICUs) at four teaching hospitals. Thirty-day mortality was compared across categories for both Sepsis-3 definitions and Sepsis-1 definitions, which were evaluated by logistic regression analysis followed by measurement of the area under the receiver operating characteristic curve (AUROC) for predicting 30-day mortality rates. Results: Of the 749 enrolled patients, 644 (85.9%) were diagnosed with sepsis according to the Sepsis-1 definitions. Among those patients, 362 were diagnosed with septic shock (362/749, 48.3%). However, according to the Sepsis-3 definitions, there were 483 patients with a diagnosis of sepsis (483/749, 64.5%), among whom 299 patients were diagnosed with septic shock (299/749, 39.9%). According to the Sepsis-3 definitions, sepsis (sepsis and septic shock) patients had higher 30-day mortality (41.8%) than sepsis patients according to the Sepsis-1 definitions (31.8%,χ^2 = 5.552, P = 0.020). The AUROC of systemic inflammatory response syndrome (SIRS) and quick sequential organ failure assessment (qSOFA) scores with regard to 30-day mortality rates were 0.609 (0.566-0.652) and 0.694 (0.654-0.733), respectively. However, the AUROC of SOFA scores (0.828 [0.795-0.862]) were significantly higher than that of SIRS or qSOFA scores (P < 0.001). Conclusion: In adult critically ill patients with suspected infection, the Sepsis-3 definitions were relatively accurate in stratifying mortality and were superior to the Sepsis-1 definitions.

A Case of Cerebral Fat Embolism

To the Editor： The symptoms of cerebral fat embolism （CFE） are often a triad of acute respiratory failure, unconsciousness, and petechial rash after a symptom-free interval of 12-24 h following trauma. Although cases of CFE have been reported since the 1960s, to our knowledge, a few reports have discussed the beneficial effects of corticosteroids for CFE treatment though corticosteroids are generally believed to have preventative effects. Here, we report a case of CFE in a 63-year-old woman who had fractures of the right tibia and fibula without cranial trauma. We gave her intravenous injections of dexamethasone lbr 11 days starting from the 1th day of trauma, and the patient experienced good recovery.

Extracorporeal Membrane Oxygenation as Salvage Therapy for Acute Massive Pulmonary Embolism after Surgery for Tibiofibular Fractures

To the Editor： Surgery for fractures is a major risk factor for pulmonary embolism （PE）. Massive PE （MPE） remains an important clinical challenge with a high mortality rate. The potential for sudden and fatal hemodynamic deterioration highlights the need for prompt and appropriate interventions.