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Identification and properties of Aerococcus viridans isolated from the blood of a patient with infectious endocarditis are described. The role of this agent in the pathogenesis of this disease was demonstrated by repeated cultivations as well as by high titres of specific antibodies in the patient's serum. Pathogenicity of this strain for experimental animals was not demonstrated.
AIM: To check practical feasibility of recommendations of prevention of infectious endocarditis (IE) and to provide more accurate figures on the occurrence of valvular lesions in working population. MATERIALS AND METHODS: Subacute IE manifestations have been analysed in 10 patients of a general outpatient clinic. Echocardiograms of 6209 patients under 60 years of age were studied retrospectively. RESULTS: In one-third of the patients IE developed in the presence of streptococcal and staphylococcal infection. In all the cases cardiac valve involvement was stated. In 4 cases changes in the valve were not accompanied my impairment of the valvular function. By echocardiography, valvular structure changes without valvular disease were detected 2.3 times more frequently that valvular disease. Difficulties presenting in outpatient IE prophylaxis are outlined. CONCLUSION: Advances in IE prevention will be achieved if echo-CG becomes a mandatory examination in the program of working population check-up, if early diagnosis of streptococcal ENT infection is made, if physicians of different specialties work as a team.
Allograft valve replacement is the preferred treatment for infectious endocarditis With severe annular destruction. Explantation of the valve in patients with cerebral death requires preliminary cardiac investigations and strict surgical procedures. The authors report two cases of right atrial endocarditis discovered at the time of explantation of the valvular allografts. In view of the infectious nature of the lesions, no tissues were resected. In both cases, transthoracic echocardiography had not diagnosed these lesions. The sensitivity of transoesophageal echocardiography in the diagnosis of these lesions should lead to systematic referral for this investigation. The infectious nature of these endocarditic lesions should raise suspicion about the presence of a central venous catheter. In addition, careful inspection of the chambers, septa and cardiac valves should be performed at surgery. The detection of potentially infectious endocarditic lesions should, in accordance with present recommendations, lead to renouncing the explantation of valvular allografts.
The diagnosis of infective endocarditis remains a challenge to physicians providing primary care. On one hand this type of infection will be rarely encountered in primary care, but on the other hand this disease carries an enormous detrimental potential. Furthermore infective endocarditis, particularly in its initial phase, often has an uncharacteristic presentation with findings and symptoms shared with many much more frequent and often harmless diseases. To confront these difficulties, which are responsible for the often delayed diagnosis of infective endocarditis, strict rules must be applied. In patients at risk for infectious endocarditis no antibiotic therapy should be instituted without prior cultures. Also, in all other patients aimless, "blind" antibiotic therapy without diagnosis of a bacterial infection should be avoided. In patients with uncharacteristic symptoms and findings compatible with the diagnosis of infective endocarditis that persist for more than 5 days, blood cultures prior to any antibiotic therapy are warranted in addition to other clinical exams and tests. The sensitivity of echocardiography in detecting infective endocarditis is frequently overestimated. Furthermore, transesophageal echocardiography in endocarditis high-risk patients requires antibiotic prophylaxis which would obscure bacteriological diagnosis. For these reasons echocardiography should not be used as first test method when considering the diagnosis of infective endocarditis.
We report a case of ventricular septal defect with acquired rupture of sinus Valsalva induced by infectious endocarditis. After irrigati on of all infectious tissues, the defect was closed twice using two different patches. One was an autologous pericardial patch from the right ventricle and the other was a composite patch made of an autologous pericardium and axenologous pericardium from the left ventricle. As a result, the xenologous pericardium was sandwiched between autologous pericardiums. We thought that this "sandwiched patch" would compensate for the shortcomings of each type of pericardium and resist left ventricular pressure and infection. Despite the development of antibiotic therapy, infectious endocardit is (IE) is still one of the most difficult disease to cure. In the case of a rupture of sinus Valsalva, because of the rapid spread of infection into any of the cardiac chambers, surgical intervention is necessary. In this report, we describe a case treated successfully.
We report a series of 40 cases of infectious endocarditis, diagnosed on a 10-year period in a department of Internal Medicine. Initial clinical features were not suggestive of endocarditis and led to delayed hospitalization and diagnosis.
BACKGROUND: Valve replacement has been the treatment of choice for patients with valvular complications of infectious endocarditis (IE). However, excellent results with valve repair allowed it to become a new therapeutic alternative for these patients. AIM: To evaluate the results of valve repair in patients with valvular complications of IE. PATIENTS AND METHODS: From January 1991 to December 2000, 14 patients with valvular complications of IE underwent valve repair. Mean age was 37.9 +/- 14.9. RESULTS: New York Heart Association (NYHA) class was 2.8 +/- 0.9. IE was located in the aortic in 6 (42%), in the mitral valve in 4 (29%) and in both valves in 4 cases (29%). Surgical indication was hemodynamic in 50% of the cases, echocardiographic in 29% and septic in 21%. Five aortic valves were bicuspid, 3 mitral valves were myxomatous and the rest were normal. The most common septic lesions were vegetations and leaflet perforations. A total of 23 aortic and 21 mitral valve repair procedures were performed. There were no deaths. Only 1 patient had a surgical complication (renal failure and prolonged mechanical ventilation). Follow-up was 100% complete. There was not late mortality. One patient with bone marrow aplasia required reoperation for a new episode of IE 19 months later. At the end of the follow-up NYHA class was 1.3 +/- 0.6 and echocardiography showed a mild or absence of valve regurgitation in most patients. CONCLUSIONS: Valve repair surgery in IE has good results, with advantages over valve replacement.
Transthoracic and transesophagal echocardiography (TT EChG and TE EChG) were performed in 43 patients with infectious endocarditis (IE). Sensitivity and specificity of TE EChG in detection of vegetations were higher (92 and 75%, 81 and 50% for TE EChG and TT EChG, respectively). Vegetations and thromboembolism were unrelated. With TE EChG, morphologically verified perforations of valvular cusps were revealed 3 times more frequently than with TT EChG. Along with detection of vegetations and dysfunction of the prosthetic valve, an essential diagnostic marker of IE of the artificial valve is visualization of paraprosthetic fistulas in 2 of 5 patients. Indications for TT and TE EChG and techniques of their performance are described. TT EChG is used in screening for IE. TE EChG is conducted in complications of IE.
AIM: To compare clinical laboratory data in systemic lupus erythematosus (SLE) and infectious endocarditis (IE) for analysis of similar and different features. MATERIAL AND METHODS: Clinical and laboratory findings were compared for 72 IE and 71 SLE patients examined for a decade. RESULTS: SLE and IE have the following common features: fever, pleurisy, pericarditis, hemorrhagic vasculitis, articular syndrome, renal disorders, anemia, rheumatoid factor (RF), cryoproteins (CP), elevated ESR, concentrations of circulating immune complexes (CIC), IgM. Characteristic of SLE were skin erythema, alopecia, Raynaud's syndrome, cerebrovasculitis, lymphadenopathy, pneumonitis, frequent articular lesions, leucopenia, high IgG levels, CP and antibodies to DNA. IE was characterized by thromboembolic complications, splenomegaly, pneumonia, high CIC and medium mass molecules concentration, high incidence rate of RF, positive hemoculture. CONCLUSION: In spite of known differences between IE and SLE, in some cases differential diagnosis is not easy to make. This leads to late etiopathogenetic therapy.
This paper shows our experience concerning the study of Streptococcus bovis infectious endocarditis (EI): 47 patients, with no prior history of IV drug abuse (NTD), who suffered EI caused by Streptococcus bovis were excerpted from a case record of 1053 cases with diagnosis of EI defined in accordance with Duke's Hospital criteria. For each patient we considered age, sex, complications, echocardiographic findings, antibiotic therapy, eventual heart-surgery and final outcome of the disease. We then compared the parameters of our patients, with the ones of 216 NTD patients suffering non Streptococcus bovis EI, selected according to age correspondence and concomitant onset of the disease. The characteristics of Streptococcus bovis EI are analogous to the ones of EIs caused by other micro-organisms in NTD patients, except for a non statistically significant trend of higher frequency in old age and in males. Concerning possible predisposing conditions, we considered the association extensively described in the literature between Streptococcus bovis EI and gastroenteric pathology (above all colon neoplasms): this association was not frequently observed in our study because appropriate instrumental investigations of the digestive tract were carried out only in a minority of patients.
Ultrasound research methods were applied in 32 children with the clinical signs of infectious endocarditis (IE). The patients' age varied from 3 to 16 years. In 5 patients, IE turned out primary in the intact valves whereas in 27 patients, it superadded on different congenital heart disease. In 10 patients, IE had developed before surgical correction of the diseases and in 17, within different times after operation. The direct and indirect echo-signs of IE were delineated. The direct echo-signs included vegetations which were discovered in 22 out of the 32 patients. The indirect echo-signs included the signs of regurgitation in the externally unchanged or minimally changed cusps of the valves and blood drop at the level of the ventricles in connection with the defect reshunting in the interventricular septum. The data obtained are in good agreement with the clinical picture, surgical and morbid anatomy data.
Prognostic significance of various clinical and laboratory indices for predicting the course and outcome of infectious endocarditis (IE) has been analyzed for 139 IE patients aged 15-68 (77 males and 62 females). The unfavourable prognosis was associated with uncontrollable sepsis, persistence of circulating immune complexes and developing glomerulonephritis. The latter had also prognostic signs unfavourable for IE: moderate or severe proteinuria and/or cylindruria, reduced renal function, diffuse proliferation, pronounced extracapillary and/or tubulointerstitial components.
We present the case of a 62-year-old man with infectious endocarditis in a Chiari network. Chiari networks are present in 1.5% to 3% of the population. Although Chiari networks are usually clinically insignificant, they are associated with a number of conditions, including patent foramen ovale, thromboembolism, atrial aneurysm, and cardiac arrhythmias. Although there are rare reports of patients with a Chiari network who had endocarditis develop, this is the first report of a patient who had endocarditis develop solely within a Chiari network.
OBJECTIVE: Many changes have occurred in the natural history and the management of active infectious endocarditis (AIE) in recent years. Therefore, the records of patients admitted in a tertiary care specialized hospital presenting with the Duke criteria were reviewed. METHODS: Adults operated on to treat AIE were included during a 3-year period. Patients presenting with AIE associated with a pacemaker were not included. Bacteriologic investigations included blood cultures, intraoperative samplings (including polymerase chain reaction), and serologies. Clinical and bacteriologic factors associated with hospital mortality were studied by univariate regression analysis (p < 0.05). RESULTS: Ninety-eight of 164 patients (60%) admitted with the diagnosis of AIE underwent valvular surgery. The duration between the beginning of AIE and surgery was 23 +/- 16 (mean +/- standard deviation) days. Only 45 patients had a previous history of valvular disease. Seventy-two patients presented with aortic and 41 with mitral valve AIE. Fifty suffered from embolic events. Streptococcus species were responsible in 64 cases (23 were Streptococcus bovis) and Staphylococcus species in 24 cases. Death occurred postoperatively in 19 patients. The factors associated with fatal outcome were preoperative hemodynamic instability, age, Parsonnet and Simplified Acute Physiology Score II scores, diabetes mellitus, preexisting valvulopathy, antiarrhythmic treatment, hypoalbuminemia, renal dysfunction, duration of extracorporeal circulation, and red cell allogeneic transfusions. The type of bacteria did not influence mortality. The mean intensive care unit and hospital stays were 10 and 39 days, respectively. Eleven patients suffered from neurologic sequelae; 2 years later, 2 of them presented with severe deficit and 1 had died. CONCLUSIONS: AIE necessitating cardiac surgery should be considered as a severe and resource-consuming disease.
Hemorrhagic stroke is a complication of infectious endocarditis (IE), and severe hemorrhage accompanies Staphylococcus aureus IE during early uncontrolled infection. However, subarachnoid hemorrhage (SAH) or subdural hematoma is rare. A case of S. aureus IE associated with SAH and subdural hematoma in the early stage is reported. A 54-year-old man with a history of mitral valve prolapse presented with fever. Two days after the onset, he fell into a confused state with convulsion and left hemiparesis. He became comatose and brain CT and MRI demonstrated SAH and subdural hematoma with severe right hemisphere swelling. Multiple brain abscesses were also observed. No septic aneurysm was detected by cerebral angiography.
The aim of the study was to compare survival of patients with infectious endocarditis (IE) by abuse of intravenous narcotic substances in conservative and combined treatment in acute IE phase. A total of 195 IE patients were examined. 121 of them was treated conservatively, 74 patients received a combined treatment including surgical one. A long-term prognosis was studied by the Kaplan-Meier method. Among drug addicts with IE, the number of survivors in the observation period in early operation in the active IE phase was significantly higher than in the conservative therapy. Long-term survival of drug addicts with IE in combined treatment was also higher: 1-2- and 3-year survival was 85.8, 76.3 and 61.0% against 64.8, 49.0 and 34.2% in conservative treatment, respectively. In non-addicts the differences were weaker: long-term survival in combined treatment was higher than in conservative one only in 5-year survival (74.1 and 41.6%, respectively).
From 1972 to 1984, 104 cases of aortic valve infectious endocarditis were treated surgically. The average age of the patients was 40 years and the majority were men (69/104). Forty patients had no previous cardiac disease; 44 patients had documented valvular heart disease, which was unlikely in the remaining 20 patients. There were 16 mitral valve, 55 aortic valve, 1 tricuspid, 30 mitro-aortic, 1 mitro-tricuspid and 1 mitro-aorto-tricuspid valve infections. Aerococcus viridans was isolated in only 4 out of 71 positive cultures: the prevalence of the infecting organisms was otherwise normal (30 staphylococcus, 30 streptococcus, 7 rare organisms). Forty one patients were operated because of haemodynamic deterioration, 13 for resistant infection and 13 for an association of both indications; 37 patients were operated for embolism or threatening vegetations. Eight patients were in functional Class I, 26 in Class II, 52 in Class III and 17 in Class IV. The patients were divided into 4 groups according to the degree of surgical emergency (26 extremely urgent, 26 semi urgent, 32 controlled endocarditis and 20 chronic endocarditis). The actuarial survival rate was 70% at 5 years. Poor prognostic factors were the presence of previous valve disease, the isolation of a staphylococcus and an aortic valve localisation. The degree of emergency and the precise surgical indication did not seem to be important. Most patients at long term were in functional Classes I or II. There was no preferential indication for bioprosthetic or mechanical valve replacement in endocarditis.(ABSTRACT TRUNCATED AT 250 WORDS)
To enhance the echocardiographic identification of high risk lesions in patients with infectious endocarditis, the medical records and two-dimensional echocardiograms of 204 patients with this condition were analyzed. The occurrence of specific clinical complications was recorded and vegetations were assessed with respect to predetermined morphologic characteristics. The overall complication rates were roughly equivalent for patients with mitral (53%), aortic (62%), tricuspid (77%) and prosthetic valve (61%) vegetations, as well as for those with nonspecific valvular changes but no discrete vegetations (57%), although the distribution of specific complications varied considerably among these groups. There were significantly fewer complications in patients without discernible valvular abnormalities (27%). In native left-sided valve endocarditis, vegetation size, extent, mobility and consistency were all found to be significant univariate predictors of complications. In multivariate analysis, vegetation size, extent and mobility emerged as optimal predictors and an echocardiographic score based on these factors predicted the occurrence of complications with 70% sensitivity and 92% specificity in mitral valve endocarditis and with 76% sensitivity and 62% specificity in aortic valve endocarditis.