Early Prosthetic Valve Endocarditis with Mycobacterium Tuberculosis after Mitral Valve Replacement: A Case Report

Background: Tuberculous endocarditis is a rare but serious complication of heart valve replacement surgery. We report the case of a 24-year-old patient, who presented with tuberculous endocarditis after mechanical mitral valve replacement, with a favorable clinical course following anti-tuberculosis treatment. Case Presentation: We report a 24-year-old male patient, admitted to the cardiac surgery department of the Fann Hospital (Dakar, Senegal), for the management of severe mixed (rheumatic and endocarditic) mitral insufficiency with associated tricuspid insufficiency. He had a history of recurrent angina and polyarthralgia in childhood, was hospitalized several times for refractory global cardiac decompensation, and for a suspected infective endocarditis a month before his admission. On admission, the clinical examination revealed signs suggestive of mitral and tricuspid insufficiency. Transthoracic echocardiography revealed severe post-endocarditic mitral insufficiency with A3 amputation, highly mobile 15 mm vegetations on the free edge of the large valve, moderate tricuspid insufficiency, and severe pulmonary artery hypertension. Mechanical mitral valve replacement and tricuspid valve annuloplasty using autologous pericardial strip were performed via median sternotomy. After ten days, the patient presented with global cardiac decompensation associated with a clinico-biological infectious syndrome, and tans-oesophageal echography revealed an abscess at the sinotubular junction, communicating with the aorta. A thoraco-abdomino-pelvic CT scan was done, which revealed a bilateral alveolar-interstitial syndrome with mediastinal lymphadenopathy. Anti-tuberculosis treatment with RHZE was initiated for 06 months. The clinical course was favorable. Conclusion: Tuberculous endocarditis in prostheses is a serious complication of heart valve replacement surgery, which may evolve favorably under medical treatment.

Community-acquired multidrug-resistant pneumonia,bacteraemia,and infective endocarditis:A case report

BACKGROUND The prevalence of multidrug-resistant(MDR)bacteria has increased globally,with extensive drug-resistant(XDR)bacteria posing a threat to patients.CASE SUMMARY This case report describes a young man admitted for suspected tropical fever infections who experienced rapid deterioration in health.Despite negative results for tropical fever infections,he had neutrophilic leucocytosis,acute kidney injury,and chest imaging findings suggestive of bilateral consolidations.On day two,he was diagnosed with infective endocarditis with possible rheumatic heart disease and MDR methicillin-resistant Staphylococcus aureus bacteraemia,and communityacquired pneumonia.Despite treatment with broad-spectrum antibiotics,he did not respond and succumbed to death on day five.CONCLUSION This case highlights that clinicians/public should be aware of MDR communityacquired pneumonia,bacteraemia,and endocarditis which ultimately culminate in high rates of morbidity and mortality.Early identification of pathogenic strain and prompt antibiotic treatment are a mainstay for the management and prevention of early fatalities.Simultaneously,route cause analysis of communityacquired MDR/XDR pathogens is a global need.

Echocardiographic predictors and associated outcomes of multiple vegetations in infective endocarditis:A pilot study

BACKGROUND Infective endocarditis(IE)is a life-threatening infection with an annual mortality of 40%.Embolic events reported in up to 80%of patients.Vegetations of>10 mm size are associated with increased embolic events and poor prognosis.There is a paucity of literature on the association of multiple vegetations with outcome.AIM To study the echocardiographic(ECHO)features and outcomes associated with the presence of multiple vegetations.METHODS In this retrospective,single-center,cohort study patients diagnosed with IE were recruited from June 2017 to June 2019.A total of 84 patients were diagnosed to have IE,of whom 67 with vegetation were identified.Baseline demographic,clinical,laboratory,and ECHO parameters were reviewed.Outcomes that were studied included recurrent admission,embolic phenomenon,and mortality.RESULTS Twenty-three(34%)patients were noted to have multiple vegetations,13(56.5%)were male and 10(43.5%)were female.The mean age of these patients was 50.Eight(35%)had a prior episode of IE.ECHO features of moderate to severe valvular regurgitation[odds ratio(OR)=4],presence of pacemaker lead(OR=4.8),impaired left ventricle(LV)relaxation(OR=4),and elevated pulmonary artery systolic pressure(PASP)(OR=2.2)are associated with higher odds of multiple vegetations.Of these moderate to severe valvular regurgitation(P=0.028),pacemaker lead(P=0.039)and impaired relaxation(P=0.028)were statistically significant.These patients were noted to have an increased association of recurrent admissions(OR=3.6),recurrent bacteremia(OR=2.4),embolic phenomenon(OR=2.5),intensive care unit stay(OR=2.8),hypotension(OR=2.1),surgical intervention(OR=2.8)and device removal(OR=4.8).Of this device removal(P=0.039)and recurrent admissions(P=0.017)were statistically significant.CONCLUSION This study highlights the associations of ECHO predictors and outcomes in patients with IE having multiple vegetations.ECHO features of moderate to severe regurgitation,presence of pacemaker lead,impaired LV relaxation,and elevated PASP and outcomes including recurrent admissions and device removal were found to be associated with multiple vegetations.

A Rare Case of Aortic Valve Endocarditis and Acute Meningitis Due to Haemophilus influenzae

HACEK organisms represent a rare but important group of causative pathogens in endocarditis. These bacteria have historically been associated with culture-negative endocarditis;however, modern laboratory techniques have made this less common. In this case, we present a 74-year-old man who presented with acute onset altered mentation, fever, and sepsis. He was ultimately found to have Haemophilus influenzae meningitis, cerebral empyema, aortic valve endocarditis, psoas myositis, and L2 - L3 diskitis with osteomyelitis. Although HACEK organisms are commonly found in the oropharynx and upper respiratory tract in humans, our patient did not report recent preceding dental or ENT procedures. H. influenzae is responsible for approximately 0.16% of all cases of bacterial endocarditis, representing a very limited subset. Although generally considered low virulent pathogens, this case demonstrates the unusual extent of infection from a HACEK organism, H. influenzae, causing aortic valve endocarditis as well as atypical non-cardiac sequelae, including acute meningitis.

Infective Endocarditis in Chronic Hemodialysis Patients: Specificities and Therapeutic Management

Infective endocarditis (IE) is a frequent complication in chronic hemodialysis patients (CHD). The repeated placement and manipulation of central venous catheters, underlying valvulopathies, and immunosuppression are the main predisposing factors for these patients to develop IE. We aimed to highlight the clinical and microbiological specificities of IE in CHD patients, detail the therapeutic management in these patients and identify the risk factors for in-hospital mortality. We included 28 CHD patients in whom the diagnosis of IE was established according to modified Duke criteria. The mean age was 47 ± 17 years. Among them, 57% were hypertensive and 39% were diabetic. The average duration of hemodialysis was 3.5 ± 7 years. The vascular access was a tunnelled jugular catheter, arteriovenous fistula, and temporary catheter in 54%, 28%, and 18% of patients, respectively. Half of the patients presented with heart failure at admission. Methicillin-sensitive Staphylococcus is the most commonly implicated pathogen. Transthoracic echocardiography revealed vegetation in all patients. In 60% of cases, the lesion is located on the mitral valve, and in 35% it is on the tricuspid valve. Patients initially received empirical antibiotic therapy, which was adjusted according to bacteriological results. Valve surgery was indicated in 12 patients, with aortic valve replacement being the most performed procedure followed by tricuspid annuloplasty. The in-hospital mortality rate was 32%. Factors associated with mortality were severe mitral insufficiency (p = 0.036), heart failure (p = 0.043), and the presence of Methicillin-resistant Staphylococcus in blood cultures (p = 0.047). IE is a complication with high morbidity and mortality. Its increasing incidence, specificities in chronic CHD patients, and the complexity of its management require a rigorous preventive strategy. A multidisciplinary collaboration between nephrologists, infectious disease specialists, cardiologists, and surgeons is crucial to optimize therapeutic management.

Candida endocarditis: Update on management considerations

The rise in incidence rates of invasive candidiasis warrants an increase in atten-tion and efforts toward preventing and treating this virulent infection.Cardiac involvement is one of the most feared sequelae and has a poor prognosis.Despite the introduction of several novel antifungal agents over the past quarter century,complications and mortality rates due to Candida endocarditis have remained high.Although fungal endocarditis has a mechanism similar to bacterial endocar-ditis,no specific diagnostic criteria or algorithm exists to help guide its manage-ment.Furthermore,recent data has questioned the current guidelines recommen-ding a combined approach of antifungal agents with surgical valve or indwelling prostheses removal.With the emergence of multidrug-resistant Candida auris,a focus on improved prophylactic measures and management strategies is nece-ssary.

Valve repair after infective endocarditis secondary to perforation caused by Streptococcus gordonii:A case report

BACKGROUND We report a case of infective endocarditis(IE)in a patient with congenital heart valve lesions accompanied by IE,which was diagnosed based on blood culture analysis that revealed the presence of a gram-negative bacterium,Streptococcus gordonii.CASE SUMMARY The patient had a history of precordial valve disease diagnosed by cardiac ultrasound,as well as a 4-mo history of fever.He was subjected to comprehensive anti-infection and anti-heart failure treatment in the internal medicine department.Further examination revealed sudden dislodgement from and perforation through the aortic valve by the superfluous organisms,as well as occurrence of bacterial emboli dislodgement,which caused bacteremia and infectious shock.He recovered and was discharged from the hospital after surgical and postoperative anti-infection treatments.CONCLUSION We review the treatment process and highlight inspirations and reflections from this case;suggest possible future changes in treatment modalities.

Eosinophilic granulomatosis with polyangiitis,asthma as the first symptom,and subsequent Loeffler endocarditis:A case report

BACKGROUND Eosinophilic granulomatosis with polyangiitis(EGPA),formerly known as Churg-Strauss syndrome,is a rare form of anti-neutrophil cytoplasmic antibodyassociated vasculitis characterized by asthma,vasculitis,and eosinophilia.CASE SUMMARY We report an atypical case of EGPA in a 20-year-old female patient.Unlike previously reported cases of EGPA,this patient’s initial symptom was asthma associated with a respiratory infection.This was followed by Loeffler endocarditis and cardiac insufficiency.She received treatment with methylprednisolone sodium succinate,low molecular weight heparin,recombinant human brain natriuretic peptide,furosemide,cefoperazone sodium/sulbactam sodium,and acyclovir.Despite prophylactic anticoagulation,she developed a large right ventricular thrombus.EGPA diagnosis was confirmed based on ancillary test results and specialty consultations.Subsequent treatment included mycophenolate mofetil.Her overall condition improved significantly after treatment,as evidenced by decreased peripheral blood eosinophils and cardiac markers.She was discharged after 17 d.Her most recent follow-up showed normal peripheral blood eosinophil levels,restored cardiac function,and a reduced cardiac mural thrombus size.CONCLUSION This case illustrates the swift progression of EGPA and underscores the significance of early detection and immediate intervention to ensure a favorable prognosis.

A CASE OF TRICUSPID ENDOCARDITIS WITH SUBSEQUENT LUNG ABSCESS

THE incidence of isolated right heart infective endocarditis （IE） is far less common than that of left heart. Clinical presentation is often associated with pulmonary manifestations. The main symptoms include high fever, chest pain, and dyspnea due to septic pulmonary emboli. Degenerative valvular disease, congenital heart diseases, prosthetic valves, long-term hemodialysis, diabetes mellitus predispose patients at increased risk of IE.1 In young persons, IE may be associated with intravenous drug abuse.2 This report dealt with a young patient who had none of the risk factors mentioned above. He was diagnosed and treated for lung abscess and septemia for one and a half months. Further investigation unveiled infective vegetation on tricuspid valve. Following surgical resection of the vegetation, fever and respiratory symptoms completely remitted. The mechanism of the IE occurred on the normal native tricuspid valve is proposed.

Endocarditis after transcatheter aortic valve implantation： a current assessment

1 Introduction Transcatheter aortic valve implantation （TAVI） constitutes an established treatment in inoperable or high perioperative risk patients with severe aortic stenosis, demonstrating similar mortality rates （at 30 days and 1 year） with surgical aortic valve replacement （SAVR）. Various complications have been reported during TAVI, weeks or months post procedure. The most frequent causes of transcatheter heart valve （THV） failure are paravalvular regurgitation, infective endocarditis （IE）, thrombosis and late valve Migration.

Clinical outcomes in patients with native valve infective endocarditis and diabetes mellitus

BACKGROUND There is a lack of data on the clinical outcomes in patients with native valve infective endocarditis(NVIE)and diabetes mellitus(DM).AIM To investigate(1)trends in the prevalence of DM among patients with NVIE;and(2)the impact of DM on NVIE outcomes.METHODS We identified 76385 with NVIE from the 2004 to 2014 National Inpatient Sample,of which 22284(28%)had DM.We assessed trends in DM from 2004 to 2014 using the Cochrane Armitage test.We compared baseline comorbidities,microorganisms,and in-patients procedures between those with vs without DM.Propensity match analysis and multivariate logistic regression were used to investigate study outcomes in in-hospital mortality,stroke,acute heart failure,cardiogenic shock,septic shock,and atrioventricular block.RESULTS Crude rates of DM increased from in 22%in 2004 to 30%in 2014.There were significant differences in demographics,comorbidities and NVIE risk factors between the two groups.Staphylococcus aureus was the most common organism identified with higher rates in patients with DM(33.1%vs 35.6%;P<0.0001).After propensity matching,in-hospital mortality(11.1%vs 11.9%;P<0.0001),stroke(2.3%vs 3.0%;P<0.0001),acute heart failure(4.6%vs 6.5%;P=0.001),cardiogenic shock(1.5%vs 1.9%;P<0.0001),septic shock(7.2%vs 9.6%;P<0.0001),and atrioventricular block(1.5%vs 2.4%;P<0.0001),were significantly higher in patients with DM.Independent predictors of mortality in NVIE patients with DM include hemodialysis,congestive heart failure,atrial fibrillation,staphylococcus aureus,and older age.CONCLUSION There is an increasing prevalence of DM in NVIE and it is associated with poorer outcomes.Further studies are crucial to identify the clinical,and sociodemographic contributors to this trend and develop strategies to mitigate its attendant risk.

The Infectious Tricuspid Endocarditis in ICU： Clinical Features, Management and Outcome

Objectives： Infectious tricuspid endocarditis is known to simply require antibiotherapy and to have good prognosis in most cases. Few studies focused on severe episodes managed in ICU. We aimed to describe clinical and microbiological features, and fmal outcome of infectious tricuspid endocarditis managed in ICU. Methods： From 1 January 2009 to 31 August 2017, all patients hospitalized in intensive care unit with infectious tricuspid endocarditis were enrolled. Key findings： We collected 15 episodes of infectious tricuspid endocarditis. Median age was of 39 years. Risk factors were： intravenous drug users （n = 10）, pace maker （n = 1）, vascular device （n = 2）, none （n = 2）. Median SAPS II, APACHE II and SOFA on admission were 21, 10 and 2 respectively. Organ failures on admission were： acute respiratory failure （n = 10）, sepsis （n = 7）, coma （n = 1） and acute kidney injury （n = 8）. The most frequent causative pathogen was Staphylococcus Aureus. Antibiotherapy failure happened in 10 patients from whom 8 underwent cardiac surgery （53.3%）. Most frequent complications were acute kidney injury （n = 14） and withdrawal syndrom. Infectious tricuspid endocarditis relapse on bioprosthesis occurred within 2 intravenous drug users after hospital discharge. Overall in-hospital mortality was 40%. Conclusions： Infectious tricuspid endocarditis in ICU is fitted with poor prognosis and high need to cardiac surgery. Special care should be provided to intravenous drug users to prevent relapse.

Infective Endocarditis with Negative Cultures:A Defiant Diagnosis

The diagnosis and management of blood culture-negative endocarditis constitute a real clinical challenge and a systemic approach is necessary for a successful outcome. The authors report a case of a female patient aged 26, with previous clinical history of valve disease and heart failure NYHA class II, with decompensation of co-morbidities associated with fever, productive cough, nonselective anorexia and unquantified weight loss with one month of evolution with negative blood cultures. Transesophageal echocardiography revealed the presence of severe pulmonary hypertension and mitral valve vegetations in the context of positive serology for Q fever. Herein, the authors report a case of blood culture-negative endocarditis and present a brief review on the management of this medical condition. We highlighted the diagnostic difficulties of blood culture-negative endocarditis and subacute clinical presentation, which sometimes present with fever of unknown origin and complaints of deterioration of cardiac function, thus creating a challenging differential diagnosis.

Obstructive shock secondary to fungal prosthetic aortic valve endocarditis

Dear editor,Fungal endocarditis is a rare disease with a poor prognosis,suboptimal diagnostic tools responsible for long diagnostic delays in most cases,and poorly defined activity of most antifungal agents in endocarditis.^([1])The burden of diagnosis still lies with clinicians:they need a

Infective endocarditis and thoracic aortic disease: A review on forgotten psychological aspects

AIM To summarize the current evidence on psychological issues in thoracic aortic disease(TAD) and infective endocarditis(IE) setting. METHODS We performed a narrative review about psychological issues in adults with IE and TAD. Through the electronic databases, Pub Med and Psyc INFO, we searched full manuscripts in English and published until September 1, 2014. RESULTS We found sixteen studies exploring psychological issues in patients with IE(six studies) and in TAD(ten papers). Psychological issues assessed were quality of life, depression, anxiety and posttraumatic stress disorder. Quality of life was explored in IE(four papers) and in TAD(eight papers). Depression and anxiety were analyzed in TAD only(five papers). Post-traumatic stress disorder was assessed in IE(one study). Quality of life was found impaired in three of four studies about IE and in three of eight studies about TAD. Posttraumatic stress disorder was present in 11% and was associated with lower levels of quality of life in IE patients. In TAD patients, anxiety and depression levels after different invasive interventions did not differ. CONCLUSION Sixteen studies report about psychological issues in IE and TAD. Most of them explore quality of life and to a less extent anxiety and depression.

Acquired aortocameral fistula occurring late after infective endocarditis: An emblematic case and review of 38 reported cases

AIM To delineate the features and current therapeutic option of congenital and acquired aortocameral fistulas(ACF) secondary to iatrogenic or infectious disorders.METHODS From a Pub Med search using the term "aortocameral fistula", 30 suitable papers for the current review were retrieved. Reviews, case series and case reports published in English were considered. Abstracts and reports from scientific meetings were not included. A total of 38 reviewed subjects were collected and analyzed. In addition, another case- an adult male who presented with ACF between commissures of the right and noncoronary sinuses and right atrium as a late complication of Staphylococcus aureus infective endocarditis of the AV- is added, the world literature is briefly reviewed.RESULTS A total of thirty-eight subjects producing 39 fistulas were reviewed, analyzed and stratified into either congenital(47%) or acquired(53%) according to their etiology. Of all subjects, 11% were asymptomatic and 89% were symptomatic with dyspnea(21 ×) as the most common presentation. Diagnosis was established by a multidiagnostic approach in 23(60%), single method in 14(37%)(echocardiography in 12 and catheterization in 2), and at autopsy in 2(3%) of the subjects. Treatment options included percutaneous transcatheter closure in 12(30%) with the deployment of the Amplatzer duct or septal occluder and Gianturco coil and surgical correction in 24(63%). CONCLUSION Acquired ACF is an infrequent entity which may occur late after an episode of endocarditis of the native AV. The management of ACF is generally by surgical correction but non-surgical device intervention has recently been introduced as a safe alternative.

Candida tropicalis infection in a term neonate with gall bladder masses and infective endocarditis

Candida endocarditis is extremely rare in term neonates,and gall bladder involvement due to candidemia has never been reported amongst neonates and infants.A term,appropriate for gestational age neonate developed Candida tropicalis blood stream infection in second week of life.He was started on conventional amphotericin B.However,he failed to show any clinical improvement,and candidemia keep on persisting.Repeat sanctuary sites screening revealed multiple echogenic masses in heart(vegetations) and gall bladder.On changing the treatment to liposomal amphotericin B and fluconazole,he recovered clinically,echogenic masses in gall bladder disappeared,and intracardiac vegetations decreased in size.

Late endocarditis of Amplatzer atrial septal occluder device in a child

Bacterial endocarditis following atrial septal defect closure using Amplatzer device in a child is extremely rare. We report a 10-year-old girl who developed late bacterial endocarditis, 6 years after placement of an Amplatzer atrial septal occluder device. Successful explantation of the device and repair of the resultant septal defect was carried out using a homograft patch. The rare occurrence of this entity prompted us to highlight the importance of a closed long-term follow up, review the management and explore preventive strategies for similar patients who have multiple co-morbidities and a cardiac device. A high index of suspicion is warranted particularly in pediatric patients.

More to the picture of the psychological impact of endocarditis and thoracic aortic pathology

Over the years there has been substantial advanced in the diagnosis and surgical management of complex thoracic aortic disease and complex endocarditis.As these therapies are being offered to a growing segment of patients-and more and more patients are felt to potentially benefit from such therapies,the longterm consequences of these interventions is sometimes poorly understood.While traditional medical complications,such as stroke,renal failure,respiratory failure,and even death are often the focus of outcomes studies,little is known on the impact of these diseases and therapies on mental health.This commentary emphasizes the importance of better understanding the psychologic impact of endocarditis and thoracic aortic pathology as reviewed by Dr.Bagnasco.

Implantable cardioverter defibrillator lead-related methicillin resistant Staphylococcus aureus endocarditis:Importance of heightened awareness

Methicillin resistant Staphylococcus aureus(MRSA) septicemia is associated with high morbidity and mortality especially in patients with immunosuppression,diabetes,renal disease and endocarditis.There has been an increase in implantation of cardiac implantable electronic devices(CIED) with more cases of devicelead associated endocarditis been seen.A high index of suspicion is required to ensure patient outcomes are optimized.The excimer laser has been very efficient in helping to ensure successful lead extractions in patients with CIED infections.We present an unusual case report and literature review of MRSA septicemia from device-lead endocarditis and the importance of early recognition and prompt treatment.