English

Abstract

The Editor, Sir, A 25-year old postpartum woman was admitted to our hospital complaining of continuous remittent fever (max 38.7 °C) and musculoskeletal symptoms including arthralgias and myalgias. Past medical history included uncomplicated normal spontaneous vaginal birth six months ago. Additionally, just before admission to hospital, she had been diagnosed with breast engorgement and mastitis with no purulant discharge. She said that she kept breastfeeding while taking antibiotics (amoxicillin 2 g/day) for mastitis. On admission, physical examination showed body temperature of 38.3 °C, blood pressure of 110/60 mmHg, pulse rate of 105 bpm, respiratory rate of 22/minute and oxygen saturation of 98.0% and 3/6 early diastolic murmur at mesocardiac focus with prominent S4. The extremities were normal. There were also no peripheral stigmata of infective endocarditis. Laboratory tests revealed haemoglobin level of 10.2 g/dL (normal range: 12–15.5 g/dL) and leukocyte count of 14 000/mm3 (normal range: 3900–11 700/mm3). Renal and liver function tests were within normal limits. In addition, erythrocyte sedimentation rate (ESR) was 42 mm/hour (normal range: 0–20 mm/h), C-reactive protein (CRP) was 87 mg/L (normal range: 0–8 mg/L) and urinalysis revealed microscopic haematuria. In view of the detection of diastolic murmur and fever, repeated blood cultures were taken and transthoracic echocardiogram (TTE) revealed left ventricular (LV) ejection fraction of 45%, LV end-diastolic diameter of 60 mm, vegetation with 1.1 × 0.7 cm largest diameter on the bicuspid aortic valve and severe aortic insufficiency (Figure). Until the precise results of blood cultures were known, the patient was diagnosed as infective endocarditis and empirical intravenous ampicillin (200 mg/kg/day) + gentamicin (3 mg/kg/day) were initiated. Although she improved clinically in a few days, sudden onset left upper flank pain developed during follow-up. Abdominal ultrasonography revealed hypoechoic regions at subcapsular regions of the spleen compatible with spleen infarct. Repeat TTE showed reduced vegetation size about 9 mm in diameter. Also Streptococcus salivarius, susceptible to ampicillin, was growing in all three blood cultures bottles. Therefore, the antibiotic therapy was restricted to only ampicillin 200 mg/kg/day. While both clinical and laboratory improvements were seen during the fourth week of antibiotic therapy, the vegetation, now 5 mm in diameter, and severe aortic regurgitation still persisted on repeat TTE. So the patient was referred for aortic valve surgery. Figure Transthoracic echocardiography on admission of the patient revealed bicuspid aortic valve (A) with severe aortic regurgitation (B) and vegetation (arrow) at left ventricular side of the aortic valve with maxiumum 11 mm diameter (C). Infective endocarditis, an uncommon disease with high morbidity and mortality, is not a uniform disease, but presents in a variety of different forms, varying according to the initial clinical manifestation, the underlying cardiac disease, the microorganism involved, the presence or absence of complications, and underlying patient characteristics. For this reason, infective endocarditis requires a collaborative approach (1). The most common organisms responsible for subacute bacterial endocarditis (SBE) are relatively avirulent/noninvasive pathogens, the Streptococci viridans (2). Streptococci viridans consisted of S sanguis, S intermedius, S militor, S sanguinis, S milleri, S salivarius, S mutans and others. Streptococci viridans are normal habitants of the oral fluora (3). In addition, Streptococci viridans may also be transiently present on the skin and may contaminate blood cultures. Because these organisms are relatively avirulent and non-invasive, virtually the only infectious disease that is associated with Streptococci viridans is SBE. The strains of Streptococci viridans causing SBE remain highly sensitive to penicillin and beta-lactam antibiotics (4). Monotherapy or combination therapy with a beta-lactam and aminoglycoside (eg gentamicin) is the most commonly used therapeutic approach (2). The infection is most probably due to transmission of S salivarius from the oral flora of the child in a breastfeeding woman during breast engorgement which resulted in bacteraemia and SBE on a previously unknown bicuspid aortic valve. Therefore, SBE should be kept in mind in a postpartum breastfeeding mother with breast engorgement in case of constitutional symptoms and cardiac murmur.