AN UNUSUAL CULPRIT FOR ENDOCARDITIS

Abstract

SESSION TITLE: Cardiothoracic Surgery SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Serratia endocarditis is extremely rare, with no reported cases in Louisiana so far with the first described case in 1951 with only 19 case reports since 1980. Interestingly, Serratia marcescens causes left-sided endocarditis reason for which remains unexplained CASE PRESENTATION: A 69-year-old female with a history of cryptogenic liver cirrhosis with portal hypertension, diabetes, and Alzheimer’s disease but no history of intravenous drug use presented with fever, generalized weakness, right foot abscess for 4 days. Vitals were BP 80/35 mm Hg, HR 100 bpm , temperature 36.1 C. Patient was alert, oriented but lethargic. Physical exam was significant for 2/6 holosystolic murmur over the mitral area, 3cm abscess on right leg wound medial aspect without erythema or drainage. Labs revealed lactic acid 6.2 mmol/liter, WBC 28,000/μl. Chest X-ray showed interstitial edema with small pleural effusions. Transthoracic echocardiogram showed ejection fraction >55% with small highly mobile echodensity on mitral valve and mild mitral regurgitation (MR). Blood and wound cultures grew Serratia marcescens. The patient was placed on Meropenem. Due to worsening respiratory failure, the patient had to be intubated and mechanically ventilated. Trans-esophageal echocardiogram revealed very large vegetation 2.1cm x 1.4cm attached to the atrial aspect of the anterior mitral leaflet with evidence of internal necrosis, moderate MR with a central and a peripheral jet, and possible perforation of the anterior mitral leaflet. Cardiothoracic surgery was consulted for mitral valve replacement. During the hospital course, the patient went into severe septic shock and family chose do not resuscitate status, and she died on 4th hospitalization day. DISCUSSION: S. marcescens is a rare pathogen causing endocarditis with the majority of reported amongst intravenous drug users. Chronic debilitating conditions, intravenous lines or catheters, liver cirrhosis and immunocompromised conditions increase the risk of Serratia infections. The mortality rate of Serratia endocarditis patients undergoing medical therapy alone is 85%, valve replacement surgery is generally recommended. In our case, the patient had a history of cryptogenic liver cirrhosis and foot abscess which may have increased her risk of obtaining Serratia marcescens infection. It is important to consider AmpC Beta-lactamase resistance along with ESBL since failure to treat appropriately may result in increased mortality for the patient. Carbepenems have thus become the drug of choice against AmpC/ESBL. CONCLUSIONS: S. marcescens endocarditis is a highly fatal condition as it can lead to valve destruction. Hence, early evaluation for valve replacement should be considered to prevent poor outcomes. Reference #1: Phadke VK, Jacob JT. Marvelous but Morbid: Infective endocarditis due to Serratia marcescens. Infectious diseases in clinical practice (Baltimore, Md). 2016;24(3):143-150. Reference #2: Hadano Y, Kamiya T, Uenishi N. A fatal case of infective endocarditis caused by an unusual suspect: Serratia marcescens. Internal medicine. 2012; 51:1425–1428. Reference #3: Choi SH, Lee JE, Park SJ, et al. Emergence of antibiotic resistance during therapy for infections caused by Enterobacteriaceae producing AmpC beta-lactamase: implications for antibiotic use. Antimicrobial agents and chemotherapy. 2008; 52:995–1000. DISCLOSURES: No relevant relationships by Dwayne Brown, source=Web Response No relevant relationships by Ronak Patel, source=Web Response No relevant relationships by JAY PATEL, source=Web Response No relevant relationships by Rushil Randive, source=Web Response No relevant relationships by Naga Sai Shravan Turaga, source=Web Response