SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Gemella morbillorum is a Gram-positive coccus, catalase negative facultative anaerobe that is normal flora in the oropharynx and gastrointestinal and genitourinary tracts. It is a rare pathogen in infective endocarditis, accounting for <1% of cases. CASE PRESENTATION: A 23 year old male presented to the emergency department complaining of a three day history of nocturnal cough producing bloody, yellow sputum. He denied fever, intravenous drug use, significant past medical history or ill contacts. He had immigrated from Guatemala to Colorado eight months before presentation to work as a painter. In the ED, he developed respiratory failure, presumed a result of pneumonia, and rapidly decompensated into cardiogenic and distributive shock. A transthoracic echocardiogram showed a bicuspid aortic valve and large vegetations on the mitral and aortic leaflets, severe mitral and aortic regurgitation with perforated leaflets, findings consistent with infective endocarditis. Blood cultures were positive with Gram positive cocci in clusters. His tenuous condition required urgent cardiothoracic surgery to replace both mitral and aortic valves. G.morbillorum was identified employing matrix-assisted laser desorption/ionization using time-of-flight mass spectroscopy (MALDI-TOF MS). Consequently, he began intravenous gentamicin and ampicillin. The source of infection was identified on dental panorex as a lucency in his left lateral incisor; on subsequent questioning, the patient disclosed a history of dental carie with filling that fell out and was replaced before arriving in the US. His postoperative course was complicated by recurrent pneumothoraces, complete heart block, atrial fibrillation with rapid ventricular response, and cardiac arrest due to torsades de pointe and ventricular fibrillation ultimately requiring pacemaker/defibrillator implantation prior to discharge. The aforementioned antibiotics were completed over his 31-day hospitalization. DISCUSSION: This case highlights pre-disposing factors associated with endocarditis: male sex, a congenital bicuspid aortic valve, and recent dental work. G. morbillorum is not easily identified with traditional microbiologic methods and requires more sophisticated techniques utilizing mass spectroscopy and advanced PCR. Biofilm production and downregulation of Interleukin-12 / Interferon-γ support this organism’s opportunistic pathogenicity. A recent case series from Cleveland Clinic identified this Gemella species in <1% of endocarditis patients in their registry. CONCLUSIONS: G. morbillorum, although normal flora, may become pathogenic and cause endocarditis in patients with underlying risk factors such as valvular abnormalities, intravenous drug use and prosthetic heart valves. Utilization of advanced identification microbiologic technology facilitates identification and consequent treatment with appropriate antibiotics. Reference #1: A.Ramanathan, S.M.Gordon and N.K.Shrestha, Acaseseries of patients with Gemellaendocarditis, Diagnostic Microbiology&Infectious Disease (2020),https://doi.org/10.1016/j.diagmicrobio.2020.115009 Reference #2: Nagy, E., Becker, S., Kostrzewa, M., Barta Noémi, & Urbán Edit. (2012). The value of MALDI-TOF MS for the identificationof clinically relevant anaerobic bacteria in routinelaboratories. Journal of Medical Microbiology, 61(10), 1393–1400. doi: 10.1099/jmm.0.043927-0 Reference #3: Benedetti, M., Rassu, M., Branscombe, M., Sefton, A., & Giampietro,P. (2009). Gemella morbillorum: an underestimated aetiology of central nervous system infection. Journal of Medical Microbiology. 58, 1652-1656. doi:10.1099/jmm.0.013367-0 DISCLOSURES: No relevant relationships by Geoffrey Blossom, source=Web Response No relevant relationships by Lauren Spaeth, source=Web Response
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