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A 4-month old baby, who developed infective endocarditis of the aortic valve following purulent arthritis of the hip joint, is presented. The baby developed signs of myocardial infarction and died suddenly at the age of 6 months. Autopsy revealed a localized healed coronary arteritis, almost certainly due to an infected embolus, as the underlying cause.
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A case of acute enterococcal aortic valve endocarditis is presented in which the complication of a septal myocardial abscess was diagnosed clinically and successfully treated surgically. This represents the first instant, to our knowledge, in which the preoperative diagnosis of a myocardial abscess served as the indication for emergency cardiac surgical intervention in active endocarditis with successful outcome. The diagnostic parameters permitting clinical recognition of a myocardial abscess include the development of advancing degrees of atrioventricular and bundle branch block, and the finding of pericarditis or pericardial effusion in aortic valvular infections. Two additional findings were noted in the present case: echocardiographic evidence of septal thickening, and loss of septal Q waves on the electrocardiogram. Since myocardial abscesses do not respond to medical therapy, continuous electrocardiographic monitoring and frequent echocardiographic determinations are recommended in cases of active aortic valve endocarditis to permit early diagnosis and surgical management of this complication.
Sixteen documented cases of Actinobacillus actinomycetemcomitans endocarditis have been reported in the past 15 years. The characteristic granular growth and the fastidious nature and slow-growing character of this organism decrease the yield of positive blood cultures. Two recently observed cases of subacute endocarditis due to Actinobacillus are reported, one in a patient who required surgical intervention for complications of his disease and the other case associated with an aortic prosthetic valve. The first patient had late embolic complications which are commonly seen with Actinobacillus endocarditis. A review of the literature; including a synoptic table with clinical failures, treatment, and outcome is presented. Unless special care is taken to isolate these slow growing organisms, these cases will be misclassified as culture negative endocarditis.
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A total of 239 surgically treated patients with primary endocarditis were reviewed both from the literature and from our own experience. The age range was 10 to 74 years with a male to female ratio of 3:1. A wide variety of organisms was found. However, as a group, gram positive organisms predominate. The onset of congestive failure was the major indication for surgery. The aortic valve was predominantly involved with the mitral valve running a distant second. The hospital mortality rate was 20% and the late mortality rate was 6.7% with an overall mortality of 26.7%. The prognosis in infective endocarditis when congestive failure develops, even in the presence of antibiotic therapy, is poor (79-89% mortality). In view of this poor prognosis, an aggressive attitude with regard to early surgical intervention can greatly improve the outcome of valvular endocarditis.
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The clinical features of an infective embolic choroidopathy are described, from its early onset to late complications in a 45-year-old man with acute Staphylococcus aureus endocarditis of the aortic valve. Initial fundus examination revealed, in addition to fresh choroidal lesions, stigmata of a previous embolic episode secondary to endocarditis from Actinobacillus actinomycetemcomitans. The choroidal lesions were extremely asymmetrical, with a clear preference for localization in the left eye. Similar ocular findings were seen in a 78-year-old female with mitral valve prolapse and acute S. aureus endocarditis. In this case, however, choroidal involvement from septic emboli spread was bilateral and roughly symmetrical. Choroidal neovascular membranes arising in scars from choroidal septic emboli occurred in the macular area of the left eye of both patients, 10 months and 5 years after embolization, respectively.
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Enterococcal endocarditis occurred in a young man with tetralogy of Fallot who had just completed therapy for staphylococcal endocarditis. The patient had a transient reversal of flow through the ventricular septal defect during staphylococcal endocarditis with lung abscesses and had persistently elevated teichoic acid antibody titers during the second episode caused by enterococcus. Our review of the literature on recurrent infective endocarditis indicates that our case represents one of the shortest intervals of recurrence with a second organism.
BACKGROUND: Endocarditis-induced crescentic glomerulonephritis is a well-described complication in nontransplant patients. Its occurrence in transplant patients has not been reported to date. METHODS: A 50-year-old man who had received a renal allograft 13 years before and been treated with prednisone, 10 mg/day, was admitted for progressive renal failure, purpura, edema of the lower limbs, and fever. RESULTS: Blood cultures isolated Streptococcus bovis and cardiac ultrasound examination revealed a 23-mm-large vegetation on the mitral valve. His plasma creatinine level was 478 micromol/L and his proteinuria was 5.5 g/day. A renal biopsy showed diffuse crescentic glomerulonephritis. Long-term antibiotic treatment and three methylprednisolone pulses were effective in treating the endocarditis and glomerulonephritis. CONCLUSION: Endocarditis-induced glomerulonephritis is an immune-mediated disease that can also occur on a renal allograft. It is likely that a low daily dose of immunosuppressive treatment may have been a facilitating factor.