Membranoproliferative Glomerulonephritis due to Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, Kingella Endocarditis in a Patient with Cirrhosis: A Case Report

Infective endocarditis: Perioperative management and surgical principles

Aggregatibacter aphrophilus infective endocarditis confirmed by broad-range PCR diagnosis: A case report

79-Year-Old Man With Shortness of Breath and Fevers

Uh-Jin Kim, M.D., Eun Jeong Won, M.D., Ji-Eun Kim, M.D., Mi-Ok Jang, M.D., Seung-Ji Kang, M.D.,<br> Hee-Chang Jang, M.D., Kyung-Hwa Park, M.D., Sook-In Jung, M.D., and Jong-Hee Shin, M.D.. Ann Lab Med 2014;34:317-20. https://doi.org/10.3343/alm.2014.34.4.317

P47 FEATURES OF INFECTIVE ENDOCARDITIS CAUSED BY AEROCOCCI

BackgroundInfective endocarditis caused by Actinomyces spp. is extremely rare. However, cases by new species of Actinomyces have been increasingly reported due to advances in laboratory techniques, and many of these species do not cause classic presentations of actinomycosis. Actinomyces neuii is reported to have a tendency to cause endovascular infection. The course of infective endocarditis caused by Actinomyces spp. is usually indolent.Case presentationA 61-year-old man with history of infective endocarditis, end stage renal disease, and monoclonal gammopathy was admitted for an abrupt fever, confusion, dysarthria, and facial droop after hemodialysis. Echocardiogram showed vegetations on both the aortic and mitral valves. Two sets of blood culture grew A. neuii. Brain MRI showed multiple bilateral cerebral infarcts consistent with septic emboli. The patient recovered after valvular surgery and prolonged intravenous and oral antibiotic therapy.ConclusionsThis case illustrates an unusually acute presentation of A. neuii infective endocarditis. As with other Gram-positive bacilli, Actinomyces spp. isolates are often regarded as a result of contamination. One should keep it in mind as a cause of infective endocarditis in vulnerable patient populations.

Aortic Valve Vegetation Without Endocarditis

AN UNUSUAL CASE OF SUBACUTE BACTERIAL ENDOCARDITIS PRESENTING WITH CATASTROPHIC SUBARACHNOID HEMORRHAGE

The co-occurrence of infective endocarditis (IE) and primary spinal infections (PSI) like spondylodiscitis (SD) and isolated spinal epidural empyema (ISEE) has been reported in up to 30% of cases and represents a life-threatening infection that requires multidisciplinary management to be successful. Therefore, we aimed to characterize the clinical phenotypes of PSI patients with concomitant IE and furthermore to assess the accuracy of the modified Duke criteria in this specific population. We conducted a retrospective cohort study in consecutive SD and ISEE patients treated surgically at our University Spine Center between 2002 and 2022 who have undergone detailed phenotyping comprising demographic, clinical, imaging, laboratory, and microbiologic assessment. Comparisons were performed between PSI patients with IE (PSICIE) and without IE (PSIWIE) to identify essential differences. Methicillin-susceptible Staphylococcus aureus (MSSA) was the most common causative pathogen in PSICIE group (13 patients, 54.2%) and aortic valve IE was the most common type of IE (12 patients, 50%), followed by mitral valve IE (5 patients, 20.8%). Hepatic cirrhosis (p < 0.011; OR: 4.383; 95% CI: 1.405-13.671), septic embolism (p < 0.005; OR: 4.387; 95% CI: 1.555-12.380), and infection with Streptococcus spp. and Enterococcus spp. (p < 0.003; OR: 13.830; 95% CI: 2.454-77.929) were identified as significant independent risk factors for the co-occurrence of IE and PSI in our cohort. The modified Duke criteria demonstrated a sensitivity of 100% and a specificity of 66.7% for the detection of IE in PSI patients. Pathogens were detected more frequently via blood cultures in the PSICIE group than in the PSIWIE group (PSICIE: 23, 95.8% vs. PSIWIE: 88, 62.4%, p < 0.001). Hepatic cirrhosis (PSICIE: 10, 41.7% vs. PSIWIE: 33, 21.6%, p = 0.042), pleural abscess (PSICIE: 9, 37.5% vs. PSIWIE: 25, 16.3%, p = 0.024), sepsis (PSICIE: 20, 83.3% vs. PSIWIE: 67, 43.8%, p < 0.001), septic embolism (PSICIE: 16/23, 69.6% vs. PSIWIE: 37/134, 27. 6%, p < 0.001) and meningism (PSICIE: 8/23, 34.8% vs. PSIWIE: 21/152, 13.8%, p = 0.030) occurred more frequently in PSICIE than in PSIWIE patients. PSICIE patients received longer intravenous antibiotic therapy (PSICIE: 6 [4-7] w vs. PSIWIE: 4 [2.5-6] w, p < 0.001) and prolonged total antibiotic therapy overall (PSICIE: 11 [7.75-12] w vs. PSIWIE: 8 [6-12] w, p = 0.014). PSICIE patients spent more time in the hospital than PSIWIE (PSICIE: 43.5 [33.5-53.5] days vs. PSIWIE: 31 [22-44] days, p = 0.003). We report distinct clinical, radiological, and microbiological phenotypes in PSICIE and PSIWIE patients and further demonstrate the diagnostic accuracy of the modified Duke criteria in patients with PSI and concomitant IE. In the high-risk population of PSI patients, the modified Duke criteria might benefit from amending pleural abscess, meningism, and sepsis as minor criteria and hepatic cirrhosis as major criterion.

Abiotrophia defectiva, also known as nutritionally variant streptococcus, is part of the normal flora of the oral cavity and urogenital and intestinal tracts and is a rare cause of infective endocarditis. It is fastidious or difficult to culture and associated with high rates of septic embolization, treatment failure and mortality. We describe an unusual presentation of infective endocarditis with severe mitral valve regurgitation due to Abiotrophia defectiva in an immunocompetent patient. After a complicated hospital course, surgical replacement of both the mitral and aortic valves was performed. We suggest that this patient likely had subacute infective endocarditis before diagnosis and treatment of her urinary tract infection, and following treatment failure, she developed life-threatening infective endocarditis. This case report highlights that patients with Abiotrophia defectiva infections are at high risk for infective endocarditis and that the clinical progression from this infection can be slow, with difficulty isolating the pathogen, which can significantly impact patient outcome.

Background The HACEK group of organisms are one of the infrequent causes of infective endocarditis (IE)(5% of cases in adults).Cultures require long incubation time and clinical presentation may be insidious,delaying final diagnosis.We report a case of subacute atypical presentation of native mitral valve Haemophilus parainfluenzae IE A 33 yo female with no history of cardiac disease was presented in our hospital with malaise,weakness &amp;high fever till 39oC for at about two weeks.The patient was treated with levofloxacin and discharged. The 1st blood culture was negative.After 25 days the patient was presented with prolonged fever,neurological signs of TIA(motor aphasia and septic embolic episode of 2nd level on the right hand&amp;foot).Physical exam normal,no cardiac murmurs. ECG:normal. Echo:TTE-mitral valve with thickened leaflet, presence of structures suggestive for vegetations (15x19 mm) at the posterior leaflet, perforation of the posterior leaflet causing an IM mild-moderate.TEE-mitral valve with small posterior leaflet, big anterior leaflet with mobile vegetations of coral-forms with diameter maximum 20x10 mm,located at A3 scallop of mitral valve at posteromedial commissural,with a perforation at this level causing moderate IM.No other pathological findings.Cranial CT scan-no data of any acute intracranial abnormality.Body CT scan-a low uptake area of the renal parenchyma related to acute pyelonephritis/infarction.Blood tests-elevated CRP &amp; thrombocytopenia.Blood culture(2nd one): Haemophilus parainfluenzae.Treatment-The patient went on ceftriaxone and underwent a surgical mitral valve repair with mitral annuloplasty and patch placement because of the size of the vegetation and the embolic risk.We also respect the desire of the patient to be pregnant.The patient improved, no fever. Follow-up:CRP normal.TTE echo showed no evidence of the previously detected vegetation with a residual mild MR.The patient was discharged home followed up after 6 weeks with full recovery. Discussion We present the case of a young healthy woman without any diseases,admitted with the symptoms of a simple flu-like syndrome with a negative blood culture, but complicated later in one of the rarest forms of IE with Haemophilus parainfluenzae. HACEK organisms are most often associated with IE, although rare, can be extremely serious because of the tendency of big size vegetation and embolic episodes,but outcomes generally are successful if the organism is identified early and treated appropriately.The treatment of a HACEK infection is based on the location of the infection,clinical severity and available susceptibility data.According to the ESC recommendations Ceftriaxone or ampicillin/sulbactam is the therapy of choice for patients with HACEK endocarditis in both native and prosthetic-valve endocarditis.Fluoroquinolones may be considered as alternative therapy.Regardless of the agent chosen,treatment should last 4– 6 weeks,depending upon the type of valve involved Abstract P1459 Figure.

BackgroundAggregatibacter aphrophilus (A. aphrophilus) is a rare cause of infective endocarditis (IE), but is a recognized cause of culture-negative IE. The risk of developing IE is increased in patients with valvular disease or prosthetic valves. To our knowledge, A. aphrophilus has never previously been reported to cause lumbar facet joint arthritis in combination with IE.Case presentationWe present the first case where facet joint arthritis was the presenting symptom for culture-negative A. aphrophilus native valve IE in a patient with no prior cardiac disease. A 58-year-old Japanese male without known cardiac disease, presented with high fever, chills, and lower back pain. Initial laboratory evaluation showed leukocytosis and transaminitis. Transthoracic echocardiography revealed an aortic valve vegetation with moderate aortic regurgitation. Magnetic resonance imaging (MRI) showed high-intensity areas in the right iliopsoas muscle and L4/L5 facet joint, indicative of fluid accumulation and disseminated lesions. Multiple sets of blood cultures showed no bacterial growth. Broad-range polymerase chain reaction (br-PCR) for 16S ribosomal RNA on both blood and hepatocytes (due to the patient’s acute liver damage) also failed to identify the causative organism. The patient developed heart failure, and transesophageal echocardiography showed severe aortic regurgitation and an aneurysm at the noncoronary cusp of the aortic valve with perforation. He underwent aortic valve replacement and his symptoms were promptly improved. Although cultures from the excised valve were negative, br-PCR on the valve tissue eventually confirmed the presence of A. aphrophilus.ConclusionThis is the first reported case of culture-negative native valve IE caused by A. aphrophilus presenting with facet joint arthritis in a patient without known cardiac disease. Our case emphasizes the importance of considering IE in patients with fever and unexplained musculoskeletal pain, even without known cardiac disease. When conventional diagnostic tests are inconclusive, br-PCR on excised valve tissue is indispensable. Further improvements in non-invasive diagnostic methods are needed to facilitate early diagnosis and treatment.

Many bacterial infections can cause multisystem or metastatic infection, commonly through haematogenous spread, with preferred sites or tropism depending upon specific organism. For example, Staphylococcus aureus is a well-recognized cause of infective endocarditis, joint infection, and vertebral osteomyelitis. Klebsiella pneumoniae can cause endogenous endophthalmitis in association with a pyogenic liver abscess, a syndrome well described in East Asia. Streptococcus pneumoniae typically causes lower respiratory tract infections or bacterial meningitis. The combination of meningitis, pneumonia, and endocarditis is called ‘Austrian syndrome’ and is strongly associated with hyposplenism or alcohol abuse. Other examples of bacteria that disseminate and cause multisystem infection are covered elsewhere. C. albicans or non-albicans species in the blood can metastasize to the eye (causing chorioretinitis or endophthalmitis) or to the heart (causing infective endocarditis). The primary sites of infection are commonly the GI tract or intravascular catheters, and high-risk groups include patients who have recently undergone abdominal surgery, received multiple courses of intravenous antibiotics, and are receiving total parenteral nutrition. Empirical treatment is with either IV liposomal amphotericin or an echinocandin before stepping down to an oral azole, commonly fluconazole at a dose of 400mg od. Because of the risk of metastatic spread, minimum duration is normally two weeks after the first negative blood culture. Cryptococcosis is caused by one of two species: Cryptococcus neoformans or Cryptococcus gattii. Unlike C. neoformans, C. gattii can cause infection in immunocompetent people. The clinical syndrome, Cryptococcosis, is an opportunistic infection for AIDS, but other conditions that predispose to infection are lymphoma, sarcoidosis, liver cirrhosis, and corticosteroids. Following inhalation, cryptococci can disseminate to the cerebrospinal fluid (CSF) and cause meningitis. Occasionally, Cryptococcoma—umbilicated papules on the skin— can occur. Symptoms are often subacute and include fever and dry cough. Following dissemination to the CSF, headache and confusion can occur. Diagnosis is based upon detection of capsular antigen by latex particle agglutination or culture, typically from blood or CSF. For meningitis, treatment consists of three phases. The induction phase is two weeks of IV liposomal amphotericin and flucytosine, followed by consolidation with eight weeks of oral fluconazole 800mg once daily, then finally secondary prophylaxis, 200mg orally once daily.

IntroductionAbiotrophia defectiva (A. defectiva) is a rare species leading to infective endocarditis (IE) with a poor prognosis. We describe a previously healthy patient with mitral valve infective endocarditis caused by A. defectiva.Case reportA young man was admitted with intermittent fever. Echocardiography confirmed vegetation on the mitral valve with evidence of valve perforation and severe mitral regurgitation. Three sets of blood cultures became positive for A. defectiva. As he presented with manifestations of mesenteric arterial branch pseudoaneurysm, splenic and renal infarction, mitral valve replacement, and embolization of superior mesenteric aneurysm were operated during 8 weeks' targeted antibiotic therapy.ConclusionThis case study emphasizes the importance of considering A. defectiva as a rare but important cause of IE and of performing blood culture to make its accurate diagnosis and timely anti-infective treatment. Early surgical management and active prevention of complications have been associated with a favorable prognosis.

Early-onset sepsis (EOS) is a rare but profoundly serious bacterial infection. Neonates at risk of EOS are often treated with antibiotics. The start of empiric antibiotic therapy can successfully be reduced by the implementation of the EOS calculator. However, once started, antibiotic therapy is often continued despite a negative blood culture. To decrease the burden of antibiotic therapy, it is necessary to know whether the clinician's reasons are based on objective factors. Therefore, we performed a retrospective single-centre cohort study to identify the factors associated with prolongation of antibiotic therapy in neonates with suspected EOS but a negative blood culture. Maternal, clinical, and laboratory data of neonates with a gestational age of ≥32 weeks, admitted between January 2019 and June 2021, were collected. Among neonates with a negative blood culture, we compared neonates with prolonged (≥3 days) to neonates with discontinued (<3 days) antibiotic therapy. The clinician's reported reasons for prolonging therapy were explored. Blood cultures were positive in 4/146 (2.7%), negative in 131/146 (89.7%), and not obtained in 11/146 (7.5%) of the neonates. The incidence of EOS was 0.7 per 1000 neonates. Of the 131 neonates with a negative blood culture, 47 neonates (35.9%) received prolonged antibiotic therapy. In the prolonged group, the mean gestational age was higher (38.9 versus 36.8 weeks), and spontaneous preterm birth was less prevalent (21.3% versus 53.6%). Prolonged treatment was associated with late onset of respiratory distress, respiratory rate, hypoxia, apnoea and bradycardia, pale appearance, behavioural change, and elevated CRP levels. The most reported reasons were clinical appearance (38.3%), elevated CRP levels (36.2%), and skin colour (10.6%). Prolonging empiric antibiotic therapy despite a negative blood culture is common in suspected EOS. Clinical signs associated with prolongation are uncommon and the reported reasons for prolongation contain subjective assessments and arbitrary interpretations that are not supported by the guideline recommendations as arguments for prolonged therapy.