Endocarditis In Patients Research Articles

Aortic root abscess – a deadly complication of UTI-induced infective endocarditis

Aortic root abscess and endocarditis should be suspected in patients with bradycardia and sepsis. We present a case of a 76 year old male who presented with urinary tract infection and sepsis and developed bradycardia and ventricular stand still during hospital admission. Transthoracic echocardiogram was unrevealing; transesophageal echocardiogram showed prosthetic valve dehiscence and aortic root abscess, intracardiac fistula, and tricuspid valve endocarditis. This case highlights the importance of suspecting endocarditis in patients with sepsis and known source of infection, especially if blood cultures do not clear or conduction abnormalities develop.

Risk of infective endocarditis in patients with Staphylococcus aureus blood stream infection and declining kidney function

Abstract Background Worldwide, Staphylococcus aureus (S.aureus) is one the most common causes of infective endocarditis (IE), particularly in dialysis patients. However, the association between mildly and moderately decreased kidney function and IE in patients with S.aureus blood stream infection (SAB) has not been examined. Purpose In a retrospective nation-wide study, to evaluate the association between IE and declining kidney function in SAB patients. Methods All patients with first-time SAB between January 1st, 1996 to December 31st, 2018 were identified from a national database including >90% of all patients with SAB. By cross-linking with other nationwide databases, co-morbidities were recorded. The population was divided into 4 groups according to eGFR: group 1 (eGFR ≥90), group 2 (eGFR 30–89), group 3 (eGFR <30) and group 4 (Renal Replacement Therapy dependent). Patients were followed until the outcome of IE. Changes in co-morbidities across the eGFR groups were tested with the Cochran-Armitage test. In a multivariable logistic regression analysis, the odds ratio (OR) of IE was calculated for each eGFR group while adjusting for age, sex, hypertension, diabetes, native valve disease (NVD), prosthetic valve, and cardiac implantable electronic device (CIED). Results Among 17,759 SAB patients, 1,098 were diagnosed with IE. The male population accounted for 60–70% of the IE patients in each eGFR group (Table 1). The overall median age of S.aureus IE patients was 61.5 [48–72] with the highest median age in group 2 (67 [57–76]). Across the eGFR groups, there was a significant increase in the prevalence of diabetes (12.6% in group 1 to 47.0% in group 4), hypertension (18.9% in group 1 to 80% in group 4) and native valve disease (18.7% in group 1 to 36.4% in group 4), p<0.0001. In a multivariate analysis with group 1 as reference, the adjusted OR of S.aureus IE increased significantly with OR 1.16 [95% CI 1.01–1.34] in group 2 to OR 1.42 [95% CI 1.07–1.87] in group 3. The increase was not significant in group 4, OR 1.63 [95% CI 0.95–2.53]. The OR of S.aureus IE decreased with increasing age groups and OR was 0.55 [95% CI 0.43–0.71] among patients >80 years as compared to the reference age group, 18–39 years. A significantly increased OR of S.aureus IE was found among patients with NVD (OR 3.25 [95% CI 2.22–4.76]), prosthetic valve (OR 6.31 [95% CI 5.10–7.79] and CIED (OR 2.88 [95% CI 2.35–3.53]). The overall in-hospital mortality was 16.4% (n=181), with the highest mortality in group 3 (n=11, 22.3%). Overall, the one-year mortality was 26.6% (n=292), and the highest mortality was found in group 4 (n=29, 34.1%). When adjusting for age and sex, mortality did not differ significantly with declining eGFR. Conclusion In this study, we found a significant increase in the odds ratio of IE in patients with SAB when kidney function decreased. Both in-hospital and one-year mortality were high, but did not differ significantly across the eGFR groups. Funding Acknowledgement Type of funding sources: None.

Clinical and echocardiographic characteristics associated with the development of infective endocarditis in patients with significant mitral stenosis

Abstract Background Infective endocarditis (IE) confers significant mortality and morbidity in patients with underlying mitral stenosis (MS), with both diseased native valves and after valvular procedures. Purpose We examined the clinical and echocardiographic parameters in association with the development of IE on patients with significant MS. Methods A total of 478 consecutive patients with index echocardiographic diagnosis of significant mitral stenosis (mitral valve area<1.5cm2) were included. Patients were divided into those with or without IE on at least 3 years of follow-up. Baseline clinical, echocardiographic profile and clinical outcomes were compared. Results IE was observed in 4.4% (n=21) of the cohort. These patients were younger (45.3±14.6 vs 53.2±15.5 years, p=0.022) at time of MS. NT-proBNP was higher in patients who developed IE (13529±12230 vs 4381±5875 pg/ml, p<0.001), with larger left atrial diameter (54.4±10.1 vs 49.9±9.5 mm, p=0.040) and elevated pulmonary artery systolic pressure (PASP, 62.3±17.2 vs 47.2±16.5 mmHg, p=0.026). There was no significant difference in terms of mitral stenosis severity, other concomitant valvulopathies, or aetiology (rheumatic or degenerative) of MS. Patients who smoked had higher incidence of IE (33.3% vs 14.2%, log-rank 7.27, p=0.007). After adjusting for age, valve procedure and PASP, patients who smoked remained at elevated risk of IE (adjusted hazards ratio 2.99, 95% confidence interval 1.18 – 7.56, p=0.021). Conclusion IE occurs in a proportion of patients with MS. Smoking, younger age of diagnosis of MS as well as dilated left atria with elevated PASP may be associated with an elevated risk of this complication. Funding Acknowledgement Type of funding sources: None. Kaplan-Meier CurveMultivariable Cox Regression

18F-FDG PET/TC en infección e inflamación cardiovascular

In Nuclear Cardiology, the diagnosis of cardiovascular infection and inflammation by [18F]FDG PET/CT is of growing interest, because this technique has improved the certainty in the diagnosis of infective endocarditis in patients with prosthetic valves respect to echocardiography, in patients with cardiac implantable devices, with increasing frequency of implantation because of the progressive ageing of the population, as well as in patients with suspected large vessel vasculitis. They are serious clinical situations, where it is necessary to establish as soon as possible the correct diagnosis and appropriate treatment, because they can cause severe complications, high mortality and also increased health care costs.We review the use of [18F]FDG PET/CT in cardiovascular infection and inflammation, including the clinical point of view and the contribution of other image modalities, focusing on the conditions for the appropriate methodology of this exploration, patient preparation, images acquisition, their correct interpretation and the quantification possibilities, defining the specific characteristics of the diagnosis in patients with prosthetic valves, cardiac implantable devices and large vessel vasculitis, in initial diagnosis as well as in the follow-up, to assess the treatment response. We analyze the possible causes of false positive and false negative results and we emphasize the special value in these cases of a multidisciplinary team for optimal management of patients.

Prognostic Value of Cardiac Troponin I In Infective Endocarditis

Abstract Aim The aim of this study is to assess the prognostic value of cardiac troponin I as a predictor of in-hospital morbidity and mortality in patients with infective endocarditis. Methods This study included 48 patients with definite and possible IE according to modified Duke’s criteria for diagnosis of IE. This prospective longitudinal study was conducted on patients admitted to the cardiovascular department of Cairo University hospitals. All patients were subjected to full history taking and clinical examination, all laboratory and radiological investigations which included chest radiography, echocardiogram and other diagnostic procedures as needed for diagnosis and follow-up of IE were done with emphasis on cardiac troponin I level on admission. Results Troponin I was found to be statistically significant predictor for heart failure (NYHA III/IV), septic pulmonary embolism and in-hospital mortality in infective endocarditis patients by univariate and multivariate regression analysis with P values 0.023, 0.037and 0.002 respectively. Tricuspid valve vegetations had showed significant relation to troponin I levels with p value 0.033. Also it was found that SOFA score on first day of admission showed significant relation to troponin I level with P value 0.045 and 0.004 for prediction of hospital stay duration. Shock and intracranial hemorrhage showed borderline significance with P values 0.097, 0.069. On other hand, troponin I as predictor of pulmonary edema, mechanical complications, systemic embolization, acute kidney injury and presence of aortic root abscess had no statistical significance in our studied patients. Conclusions This study showed that there is as significant predictive value of elevated cardiac troponin I with heart failure, septic pulmonary embolism and all cause in-hospital mortality. In addition, it was significant predictor of the length of hospital stay, lymphocytosis and SOFA score. These results are emphasizing that cTn I level may predict higher risk patients who would need early and aggressive control of infection medically alone or combined with surgery in IE patients.

Aspirin or Ticagrelor in Staphylococcus aureus Infective Endocarditis: Where Do We Stand?

Infective endocarditis is a challenging disease with a high mortality and morbidity rate. Antibiotic prophylaxis is currently recommended in high-risk infective endocarditis patients. However, the use of antibiotics faces the challenge of a low efficacy and contributes further to the emerging infection rate by antibiotic-resistant strains, emphasizing the need for new therapeutic strategies. Platelets are essential in the initial phase of infective endocarditis, acting as first-line immune responders. During the first phase of disease, bacteria can interact with platelets and counteract platelet antimicrobial activities. Mechanistic in vitro and animal studies on the effect of aspirin on bacteria-platelet interactions and the prevention of vegetation development showed promising results. However, data from clinical studies on the outcome of infective endocarditis patients who were receiving medically indicated aspirin therapy remain controversial. Therefore, the benefit of antiplatelet agents in infective endocarditis prevention has been questioned. Besides aspirin, it has been discovered that the platelet P2Y12 receptor antagonist ticagrelor has antibacterial properties in addition to its potent antiplatelet activity. Furthermore, a recent study in mice and a case report remarkably indicated the ability of this drug to eradicate Staphylococcus aureus bacteremia. This review will focus on current knowledge on antibacterial activity of ticagrelor, compared to aspirin, pointing out main unanswered questions. The goal is to provide food for thought as to whether a prior ticagrelor therapy might be beneficial for the prevention of infective endocarditis.

18F-FDG PET/CT in cardiovascular infection and inflammation

The diagnosis of cardiovascular infection and inflammation by [18F]FDG PET/CT in Nuclear Cardiology is of growing interest, because with respect to echocardiography this technique has improved the certainty in the diagnosis of infective endocarditis in patients with prosthetic valves, the increasing number of patients with implantable cardiac devices because of the progressive ageing of the population, as well as in patients with suspected large vessel vasculitis. All are serious clinical situations which require correct diagnosis and appropriate treatment as soon as possible, because they can cause severe complications, high mortality and also increased health care costs.We review the use of [18F]FDG PET/CT in cardiovascular infection and inflammation, including the clinical point of view and the contribution of other image modalities. We focus on the appropriate methodology for this exploration, patient preparation, image acquisition and correct interpretation and the quantification possibilities, defining the specific characteristics of the diagnosis in patients with prosthetic valves, implantable cardiac devices and large vessel vasculitis in the initial diagnosis as well as during follow-up to assess treatment response. We analyze the possible causes of false positive and false negative results and emphasize the special value of a multidisciplinary team for optimal management of these patients.

LACTOBACILLUS ENDOCARDITIS, A SINISTER CONSEQUENCE OF AN INNOCUOUS BACTERIUM

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Lactobacillus species are gram positive rods that are part of the normal flora in gastrointestinal, oropharyngeal and genital tracts. Rarely they are implicated as causative agents of endocarditis in patients who are immunocompromised, undergo dental procedures, use probiotics or have a valvulopathy or prosthetic device. We describe the case of lactobacillus jensenii causing aortic valve endocarditis in an immunocompetent patient with a bicuspid aortic valve. It is important to recognize lactobacillus species as an emerging cause of endocarditis. Treatment involves a synergistic combination of penicillin and gentamicin. CASE PRESENTATION: 55 years old female with past medical history of bicuspid aortic valve presented to the emergency department with chief complaint of fever of 3 weeks' duration. COVID-19 testing was negative. Her medical history was significant for bicuspid aortic valve with aortic regurgitation and hyperlipidemia. Vitals signs were significant for a fever of 103 F. Physical exam was remarkable for a diastolic murmur heard best in the left third intercoastal space. Labs showed a normal blood count, and electrolytes. Patient's blood and urine cultures were obtained, and they were sent home with an oral antibiotic only to be called two days later for a positive blood culture. Blood cultures initially grew gram positive bacilli and patient was started on vancomycin and piperacillin-tazobactam pending final cultures. Due to her history of bicuspid aortic valve, endocarditis was suspected, and patient underwent transesophageal echocardiogram (TEE) which showed a 10-millimeter vegetation attached to the non-coronary cusp of aortic valve. Blood cultures came back positive for lactobacillus jensenii. Patient satisfied the Duke's criteria for endocarditis and was switched to penicillin and gentamicin. Further history did not elicit further risk factors of lactobacillus endocarditis including probiotic use, recent dental work, and immunodeficiency. Patient completed six weeks of antibiotics and had negative final blood cultures. DISCUSSION: This case highlights the importance of lactobacillus species to be a causative factor of endocarditis in patients with a predisposing risk factor. These risk factors include, in order of decreasing frequency, valvulopathy, dental procedures, probiotic use and immunosuppression. It is important to consider lactobacilli as a causative agent of infection if they are isolated on routine blood cultures in predisposed patients with a compatible clinical picture. TEE should be done if endocarditis is suspected. Lactobacilli are highly sensitive to penicillin G and synthetic penicillins. However, they are usually resistant to vancomycin. This is important as vancomycin is an integral regimen of most initial sepsis regimens. CONCLUSIONS: . REFERENCE #1: Campagne, J., J. F. Guichard, M. C. Moulhade, H. Kawski, and F. Maurier. "Lactobacillus endocarditis: a case report in France and literature review." IDCases 21 (2020): e00811. REFERENCE #2: Prendergast, B. D. "Diagnostic criteria and problems in infective endocarditis." Heart 90, no. 6 (2004): 611-613. DISCLOSURES: No relevant relationships by Muhammad Hasib Khalil, source=Web Response

A RARE CASE OF RIGHT-SIDED TRICUSPID VALVE ENDOCARDITIS

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Right-sided endocarditis is a well-known condition that occurs predominantly in intravenous drug users (IVDA) and patients with cardiovascular implantable electronic devices, central venous lines, and congenital heart disease. The objective of this report is to describe a rare case of right-sided endocarditis that leads to cardiogenic shock and death. CASE PRESENTATION: A 29-year-old caucasian male with a history of polysubstance abuse, acromioclavicular joint septic arthritis, status epilepticus secondary to cerebral septic emboli, presented to the emergency department with complaints of shortness of breath, generalized weakness, and malaise. He was noted to have significant respiratory distress requiring initially noninvasive mechanical ventilation, he was intubated due to worsening respiratory failure. Cardiovascular examination revealed a pansystolic murmur heard over the left parasternal border. Transthoracic echocardiogram showed severe tricuspid valve regurgitation and moderately dilated right ventricle with an ejection fraction of 63%. A transesophageal echocardiogram revealed severe 3+ to 4+ tricuspid valve regurgitation along with large vegetation on the anterior leaflet of the tricuspid valve measuring 2.2 cm x 0.8 cm. There is the involvement of the subvalvular apparatus with another large vegetation measuring 1.1 cm x 0.8 cm on the chordal apparatus (FIGURE 1). The patient was found to be in cardiogenic versus septic shock related to tricuspid valve recurrent infective endocarditis. Despite the patient being placed on intravenous antibiotics and two pressors he still continued to deteriorate. Discussion with the family decided to make the patient comfort-care. The patient ultimately expired. DISCUSSION: Right-sided infective endocarditis (RSIE) patients represent 5-10% of all infective endocarditis cases, making it a rare clinical entity. It is most commonly seen in patients with a history of IVDA; however, it is also seen in patients on dialysis, congenital heart disease, immunocompromised states patients, and patients who have an intracardiac device. The diagnosis of RSIE is often delayed due to its signs and symptoms relatively different than left-sided infective endocarditis which is the specific target of the modified duke's criteria. Common symptoms include cough, hemoptysis, dyspnea, chest pain, and persistent fever. The primary diagnostic modalities are echocardiography and positive blood cultures. The mainstay of medical treatment is antibiotics; however if refractory then surgery is indicated in cases of right-sided heart failure due to severe tricuspid regurgitation, persistent bacteremia, refractory to culture-directed antibiotics, and tricuspid valve vegetations greater than 20 mm in length. CONCLUSIONS: Clinicians should be aware of the variety of presentations a patient with suspected endocarditis could have as disease prognosis relies on a prompt diagnosis. REFERENCE #1: Narvaez Muñoz Adrian Fernando, Ibarra Vargas Daniela Albina. Right-Sided Infective Endocarditis, Infective Endocarditis, Peter Magnusson and Robin Razmi. IntechOpen. March 24th 2019 REFERENCE #2: Varona J., Guerra J. Tricuspid Valve Endocarditis in a Nonaddicted Patient Without Predisposing Myocardiopathy. Revista Española De Cardiología (English Edition) 2004;57(10):993–996. REFERENCE #3: Ye R., Zhao L., Wang C., Wu X., Yan H. Clinical characteristics of septic pulmonary embolism in adults: A systematic review. Respiratory Medicine. 2014;108(1):1–8. DISCLOSURES: No relevant relationships by Adeeb Alquthami, source=Web Response No relevant relationships by Nishad Barve, source=Web Response No relevant relationships by HANAD BASHIR, source=Web Response No relevant relationships by NICOLE LAO, source=Web Response No relevant relationships by Gauranga Mahalwar, source=Web Response

Infective Endocarditis in Patients with Hypertrophic Cardiomyopathy

A literature review is presented, reflecting the incidence, etiology, hemodynamics, localization, clinical manifestations, outcomes and treatment of infective endocarditis (IE) in patients with hypertrophic cardiomyopathy (HCM). Despite the relative rarity of IE in patients with HCM, the combination of these pathologies is characterized by mutual aggravation and poor prognosis. The addition of IE increases the risk of death in patients with obstructive HCM, deteriorating circulatory disorders, increasing the likelihood of uncontrolled sepsis and embolism. Conservative treatment of IE in patients with HCM does not differ from that without HCM. Interdisciplinary interaction is needed in the management of patients with IE against the background of HCM in determining the indications for cardiac surgery and choosing the optimal method. Antibacterial prophylaxis of IE before invasive medical manipulations in patients with HCM is not recommended by the current consensus documents, however, the decision for each patient should be made individually, with a mandatory assessment of the risk of IE, the severity of hemodynamic disorders and prognosis.

Echocardiography and FDG-PET/CT scan in Gram-negative bacteremia and cardiovascular infections.

Current evidence on cardiovascular infections in Gram-negative blood stream infections (GNBSI) with focus on the use of transesophageal echocardiography (TEE) and 18F-Fluorodeoxyglucose - positron emission tomography/Computed tomography (FDG-PET/CT) in the diagnostic workup. Most evidence focuses on characteristics of diagnosed cardiovascular infections and the proportion caused by GNBSI. These proportions are low (1-5%) when it comes to native and prosthetic valve endocarditis as well as cardiac implantable electronic device (CIED) infections whereas the proportion of vascular graft infections caused by GNBSI seems substantially higher (30-40%). Information on the prevalence of cardiovascular infection in patients with GNBSI is limited to a few studies finding around 3% endocarditis in patients with GNBSI and a prosthetic heart valve and 4-16% device-related infection in patients with CIED and GNBSI. Patients with GNBSI and native or prosthetic valves should only undergo work-up for endocarditis (TEE and FDG-PET/CT) if they present GNBSI relapse or signs suggestive of endocarditis. CIED patients with GNBSI with Pseudomonas or Serratia spp. should undergo TEE and PET/CT because of the high prevalence of device-related infection. In other GNBs without IE suggestive signs, normal BSI treatment is reasonable and only cases with relapse need work-up. GNBSI in patients with vascular grafts should lead to consideration of PET/CT.

Aortic valve endocarditis in patients with bicuspid and tricuspid aortic valves

ObjectiveTo determine the long-term survival and rate of reoperation after surgical treatment of infective endocarditis (IE) in patients with a bicuspid aortic valve (BAV) and patients with a tricuspid aortic valve (TAV). MethodsBetween 1997 and 2017, 210 patients underwent surgical treatment for native aortic valve endocarditis, including 51 patients with BAV (24%) and 159 patients with TAV (76%). Data were obtained from the Society of Thoracic Surgeons data warehouse and hospital medical record review, supplemented with surveys and national death index data for more complete follow-up. ResultsCompared with the TAV IE group, the BAV IE group was significantly younger (42 years vs 54 years) and had lower incidence rates of hypertension, coronary artery disease, and congestive heart failure (CHF). There were no significant between-group differences in postoperative stroke, sepsis, pacemaker requirement, or in-hospital mortality (2.0% vs 4.4%). Liver disease was a risk factor for operative mortality (odds ratio [OR], 13; 95% CI, 3.3-30; P = .0002). The 10-year survival rate was 64% for the BAV group versus 46% for the TAV group (P = .0191). Significant risk factors for long-term mortality were intravenous drug use (hazard ratio [HR], 4.5; P < .0001), preoperative renal failure requiring dialysis (HR, 4.13; P < .0001), CHF (HR, 1.7; P = .04), and liver disease (HR, 2.6; P = .02). The HR for BAV was 0.67 (95% confidence interval [CI], 0.3-1.4). The 10-year postoperative cumulative incidence of reoperation was significantly higher in the BAV patients compared with the TAV patients (5.7% vs 4.5%; P = .045) with an HR of 2.4 (95% CI, 0.8-7.1; P = .11) for BAV. ConclusionsBAV patients develop IE requiring surgery at a younger age than TAV patients, but have significantly better long-term survival. Early detection of BAV is important to prevent IE and provide aggressive surgical treatment should IE occur.

Connected care for endocarditis and heart failure patients: ahospital-at-home programme.

BackgroundHealthcare expenditure in the Netherlands is increasing at such a rate that currently 1 in 7 employees are working in healthcare/curative care. Future increases in healthcare spending will be restricted, given that 10% of the country’s gross domestic product is spent on healthcare and the fact that there is a workforce shortage. Dutch healthcare consists of a curative sector (mostly hospitals) and nursing care at home. The two entities have separate national budgets (€25 bn + €20 bn respectively)AimIn a proof of concept, we explored a new hospital-at-home model combining hospital cure and nursing home care budgets. This study tests the feasibility of (1) providing hospital care at home, (2) combining financial budgets, (3) increasing workforces by combining teams and (4) improving perspectives and increasing patient and staff satisfaction.ResultsWe tested the feasibility of combining the budgets of a teaching hospital and home care group for cardiology. The budgets were sufficient to hire three nurse practitioners who were trained to work together with 12 home care cardiovascular nurses to provide care in a hospital-at-home setting, including intravenous treatment. Subsequently, the hospital-at-home programme for endocarditis and heart failure treatment was developed and a virtual ward was built within the e‑patient record.ConclusionThe current model demonstrates a proof of concept for a hospital-at-home programme providing hospital-level curative care at home by merging hospital and home care nursing staff and budgets. From the clinical perspective, ambulatory intravenous antibiotic and diuretic treatment at home was effective in safely achieving a reduced length of stay of 847 days in endocarditis patients and 201 days in heart-failure-at-home patients. We call for further studies to facilitate combined home care and hospital cure budgets in cardiology to confirm this concept.

Nomogram based on neutrophil-to-platelet ratio to predict in-hospital mortality in infective endocarditis.

Aim: To develop a nomogram based on neutrophil-to-platelet ratio (NPR) to predict in-hospital mortality in infective endocarditis (IE) patients. Methods: We retrospectively analyzed 294 consecutive patients classified as survivors or nonsurvivors according to hospitalization outcome. Logistic regression analyses were performed to identify independent predictors for in-hospital mortality. A nomogram based on them was established and assessed by receiver operating characteristic (ROC) curve analysis. Results: Admission NPR (odds ratio [OR] = 1.095, 95% CI: 1.037-1.156), positive blood culture (OR = 9.220; 95% CI: 1.478-57.521) and left-sided endocarditis (OR = 5.099; 95% CI: 1.104-23.553) independently predicted in-hospital mortality in IE. The area under the ROC curve for the nomogram based on these predictors was 0.832. Conclusion: The nomogram based on NPR could be used for early risk stratification of IE patients.

A Case of Enterococcus Spp. Endocarditis in a Seemingly Cured Hemorrhoidal Disease. Case Report

Abstract Background Infective endocarditis with Enterococcus spp. is common in patients with digestive tract diseases. Such patients should be monitored periodically through clinical examination and colonoscopy, to detect the recurrence of seemingly cured disease. There are currently no studies on the incidence of infective endocarditis in patients with hemorrhoidal disease. Case report The case of a 48-year-old man is addressed, known with type 2 diabetes mellitus, with a seemingly cured hemorrhoidal disease, who developed infective endocarditis of the mitral and aortic valve, complicated by ischemic stroke as the first symptom. After six weeks of antibiotic treatment, an almost complete echocardiographic resolution of the vegetation was achieved, such that surgical intervention was postponed. Conclusion Performing a colonoscopy in all Enterococcus spp. infective endocarditis patients, regardless of the presumed source of infection, could be helpful in diagnosing colorectal disease and avoiding a new bacteraemia episode - and eventually infective endocarditis - by the same or a different microorganism. The presented case emphasizes the importance of periodic monitoring of the digestive tract for hemorrhoidal disease in patients with a high risk of recurrence - due to high risk of bacteraemia and systemic complications. Moreover, it is worth noting that in certain cases, efficient antibiotic treatment on its own can achieve an outstanding result for patients with large vegetations, presenting with an embolic episode, and thus postpone (indefinitely) a surgical intervention.

Usefulness of 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in the Diagnosis of Infective Endocarditis in Patients With Adult Congenital Heart Disease.

Infective endocarditis (IE) in patients with adult congenital heart disease (ACHD) remains a diagnostic challenge due to difficulties in detecting endocardial lesions by echocardiography. 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) has shown good diagnostic performance in prosthetic valve IE. This study aimed to assess its additional diagnostic value in ACHD-associated IE and to characterize its advantages. Overall, 22 patients with ACHD and clinical suspicion of IE were retrospectively studied. 18F-FDG PET/CT was performed in addition to conventional assessment based on the modified Duke criteria. The final IE diagnosis was determined by an expert team during a 3-month clinical course, resulting in 18 patients diagnosed with IE. Seven patients (39%) were diagnosed with definite IE only by initial echocardiography. An 18F-FDG PET/CT assessment revealed endocardial involvement in the other 9 patients, resulting in the diagnosis of definite IE in 16 in total (88%). Right-sided endocardial lesions were more common (n=12, 67%) but rarely identified by echocardiography, whereas 18F-FDG PET/CT revealed right-sided lesions in 9 patients. A negative 18F-FDG PET/CT (n=7, 39%) assessment was associated with a native valve IE (71% vs. 0%). In 4 patients who were identified with not-IE, neither echocardiography nor 18F-FDG PET/CT detected any suspicious cardiac involvement. In the diagnosis of ACHD-associated IE, characterized by right-sided IE, 18F-FDG PET/CT assessment should be useful.

Brucella Prosthetic Valve Endocarditis: A Systematic Review.

ObjectiveBrucella prosthetic valve endocarditis is a rare but a life-threatening complication of brucellosis. It remains a diagnostic challenge. Optimal treatment of Brucella prosthetic valve endocarditis is debated. Available data is limited to case reports or small case series. The purpose of this study was to systematically review all published cases of Brucella prosthetic valve endocarditis in the literature.MethodA systematic review of PubMed database, Google, Google Scholar, and Scopus (From January 1974 to the present) for studies providing epidemiological, clinical and microbiological data as well as data on treatment and outcomes of Brucella prosthetic valve endocarditis was performed.ResultsA total of 51 reported cases were reviewed. Brucella melitensis (45%) and Brucella abortus (11.7%) were the most frequently isolated species. Most common type of prosthesis valve was mechanical prothesis (84.3%) and ten patients had double valve prosthesis (19.6%). Fever and dyspnea were present in 100% and 37.2% of the cases, respectively. The diagnosis was set with echocardiographic finding in 30 cases (93.7%), which revealed vegetation in 27 cases (84.3%). Most used antibiotics were rifampicin, doxycycline and aminoglycoside or cotrimoxazole. No deaths were noted in patients treated by combined medical and surgical treatment, but mortality was noted in 27.7% of the cases treated by antibiotics alone (p = 0.006).ConclusionThis systematic review highlights diagnostic challenges and demonstrates that surgery improved outcome by reducing mortality in patients treated with the combined surgical and medical treatment option. Brucellosis should be considered in the differential diagnosis of prosthetic valve endocarditis in patients residing in or traveling to areas of endemicity.

Analysis of sleep characteristics and clinical outcomes of 139 adult patients with infective endocarditis after surgery.

BACKGROUNDLittle is known about the postoperative sleep quality of infective endocarditis patients during hospitalization and after discharge. AIMTo investigate the sleep characteristics of infective endocarditis patients and to identify potential risk factors for disturbed sleep quality after surgery. METHODSThe Pittsburgh Sleep Quality Index (PSQI) and the Epworth Sleepiness Scale were used to assess patient sleep quality. Logistic regression was used to explore the potential risk factors. RESULTSThe study population (n = 139) had an average age of 43.40 ± 14.56 years, and 67.6% were men (n = 94). Disturbed sleep quality was observed in 86 patients (61.9%) during hospitalization and remained in 46 patients (33.1%) at 6 mo after surgery. However, both PSQI and Epworth Sleepiness Scale scores showed significant improvements at 6 mo (P < 0.001 and P = 0.001, respectively). Multivariable logistic regression analysis showed that the potential risk factors were age (odds ratio = 1.125, 95% confidence interval: 1.068-1.186) and PSQI assessed during hospitalization (odds ratio = 1.759, 95% confidence interval: 1.436-2.155). The same analysis in patients with PSQI ≥ 8 during hospitalization suggested that not using sleep medication (odds ratio = 15.893, 95% confidence interval: 2.385-105.889) may be another risk factor. CONCLUSIONThe incidence of disturbed sleep after infective endocarditis surgery is high. However, the situation improves significantly over time. Age and early postoperative high PSQI score are risk factors for disturbed sleep quality at 6 mo after surgery.

Change of the Pattern of the Demographic Characteristics of the Patients with Endocarditis: Clinical Case of Infectious Endocarditis in Man with Injectible Drug Dependence, Complicated with Pneumonia and Peripheral Necroses of Feet, Arms, Nose (Own Clinical Observations and Experience of Education in State and English Language)

Infectious endocarditis is multisystem disease, which is the result of the infection (usually bacterial) of endocardial heart surface. Despite of the latest medical achievements in diagnostics and treatment, infectious endocarditis is still a disease with high mortality rate and severe complications. During last decades in developed countries there are obvious changes of demographic characteristics of the patients with infectious endocarditis, namely increasing of aged patients with degenerative valvular diseases, of patients with anamnesis of invasive manipulations and procedures. Beside with well known risk factors (artificial valves and implanted heart devices), there are increasing roles of injectible drug-dependence, human immunodeficiency virus and wide contact with health protection system as predisposing factors for infectious endocarditis. The article contains literature data of the main populational risk groups of infectious endocarditis. Clinical case of severe (fatal) infectious endocarditis in patient with injectible drug dependence is submitted. Special features of the case are peripheral dry necroses of feet, arms, nose, which are very close to the description of symmetrical peripheral gangrene. This rare disorder was first described by Hutchinson in 1891 in 37-year old man, who had gangrene of fingers, hands and ears after shock. Symmetrical peripheral gangrene can be induced by different infection and non-inflection causes. The majority of these cases are connected to the treatment of cardiogenic shock with disseminated intravascular coagulation. Submitted description of the case of symmetrical peripheral gangrene in patient with infectious endocarditis will be useful for different medical care specialists as a reminder of the necessity of constant monitoring of the skin color of the distal parts of the limbs in severe sick patients.

Prediction Rules for Ruling Out Endocarditis in Patients With Staphylococcus aureus Bacteremia.

Staphylococcus aureus bacteremia (SAB) is in 10% to 20% of cases complicated by infective endocarditis. Clinical prediction scores may select patients with SAB at highest risk for endocarditis, improving the diagnostic process of endocarditis. We compared the accuracy of the Prediction Of Staphylococcus aureus Infective endocarditiseTime to positivity, Iv drug use, Vascular phenomena, preExisting heart condition (POSITIVE), Predicting Risk of Endocarditis Using a Clinical Tool (PREDICT), and VIRSTA scores for classifying the likelihood of endocarditis in patients with SAB. Between August 2017 and September 2019, we enrolled consecutive adult patients with SAB in a prospective cohort study in 7 hospitals in the Netherlands. Using the modified Duke Criteria for definite endocarditis as reference standard, sensitivity, specificity, negative predictive (NPV), and positive predictive values were determined for the POSITIVE, PREDICT, and VIRSTA scores. An NPV of at least 98% was considered safe for excluding endocarditis. Of 477 SAB patients enrolled, 33% had community-acquired SAB, 8% had a prosthetic valve, and 11% a cardiac implantable electronic device. Echocardiography was performed in 87% of patients, and 42% received transesophageal echocardiography (TEE). Eighty-seven (18.2%) had definite endocarditis. Sensitivity was 77.6% (65.8%-86.9%), 85.1% (75.8%-91.8%), and 98.9% (95.7%-100%) for the POSITIVE (n = 362), PREDICT, and VIRSTA scores, respectively. NPVs were 92.5% (87.9%-95.8%), 94.5% (90.7%-97.0%), and 99.3% (94.9%-100%). For the POSITIVE, PREDICT, and VIRSTA scores, 44.5%, 50.7%, and 70.9% of patients with SAB, respectively, were classified as at high risk for endocarditis. Only the VIRSTA score had an NPV of at least 98%, but at the expense of a high number of patients classified as high risk and thus requiring TEE. Netherlands Trial Register code 6669.