TWO CASES OF FATAL BACTERIAL ENDOCARDITIS IN ADULTS WITH CORRECTED CHD

Abstract

SESSION TITLE: Critical Care 1 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Over the last 40 years advances in the treatment of pediatric congenital heart disease (CHD) have resulted in increasing numbers of adults with repaired CHD. Bacterial Endocarditis is a known complication of CHD; however, subacute bacterial endocarditis (SBE) has variable symptoms and can be difficult to diagnose. We present two cases of fatal SBE in adults with corrected CHD. CASE PRESENTATION: Patient A was a 34-year-old male with a bicuspid aortic valve and aortic stenosis who had a Ross procedure 20 years prior. One month prior to presentation he developed progressive renal failure and pancytopenia. He underwent a renal and bone marrow biopsy and was treated with steroids for presumed vasculitis. Three days prior to transfer he presented with abdominal pain, vomiting, and jaundice. He developed progressive renal failure and was transferred with consideration for plasmapheresis for presumed TTP. Blood cultures prior to transfer grew MRSA. Upon arrival, he was normotensive and afebrile with a saturation of 91% and heart rate 116. His exam was notable for an early systolic murmur at the RUSB. Laboratory tests showed WBC 19.1 k/ul, hemoglobin 7.9 g/dL, platelets 44 k/ul, creatinine 7.5 mg/dl, and BUN 151. A blood smear showed no schistocytes. He was started on antibiotics for MRSA bacteremia and arrangements were made for hemodialysis. However, he abruptly developed chest pain, ST elevations, and respiratory distress followed by cardiac arrest. Resuscitation efforts were unsuccessful. At autopsy, he was noted to have MRSA pulmonic valve endocarditis and evidence of DIC. Patient B was a 35-year-old female with aortic coarctation post-surgical repair who presented with two months of arthralgia, dyspnea, and chest pain. She was initially treated for pneumonia with levofloxacin but developed acute liver injury with ALT 2008 and AST 3444. She was transferred for liver transplant evaluation. Her blood pressure was 91/47, pulse 94, respiratory rate 49, and saturation of 95%. Laboratory studies were notable for a WBC 14.29 k/uL, hemoglobin 9.3 g/dL, platelets 99 k/uL, INR 2.5, lactic acid 12.5 mmol/L, AST 4921, ALT 2373, and normal renal function. She developed progressive multi-organ failure and shock, resulting in a family decision to focus on palliative measures. At autopsy, she was noted to have infective tricuspid valve endocarditis. DISCUSSION: Corrected CHD is a known risk factor for SBE but the absolute risk is low. As patients can be decades removed from their surgeries, a careful review of history is paramount. Patients with corrected CHD are more likely to have right-sided IE which is more likely to have atypical presentations. CONCLUSIONS: These two cases highlight the need for a keen understanding of adult corrected CHD, its myriad presentations, and the need for early recognition, prompt antimicrobial therapy, and appropriate surgical referral. Reference #1: Knirsch W, Nadal D. Infective endocarditis in congenital heart disease. Eur J Pediatr. 2011;170(9):1111-27. Reference #2: Baddour LM, Wilson WR, Bayer AS, et al. Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation. 2015;132(15):1435-86. Reference #3: Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2007;116(15):1736-54. DISCLOSURES: No relevant relationships by Andrew Barros, source=Web Response No relevant relationships by Michael Bergman, source=Web Response no disclosure on file for Max Weder