Subacute Endocarditis Research Articles

Cardiovascular infections in Colombia, characterization and estimation of their incidence, 2009-2016

Background: Although not studied widely, cardiovascular infections (CVI) can cause significant morbidity and mortality worldwide. The burden of them in terms of morbidity in certain countries is not well understood. Studies estimating its population-based incidence lack in Latin America and Colombia. Methods & Materials: Observational, retrospective study in which the incidence of CVI (ICD-10 codes I0.0-I0.2,I30.0-I30.1,I30.8-I30.9,I32.0-I32.1,I32.8,I33.0-I33.9,I38.X,I40.0,I41.0-I41.2) corresponding to rheumatic fever, pericarditis, endocarditis and myocarditis, in Colombia, 2009-2016, was estimated based on data extracted from the personal health records system (Registro Individual de Prestación de Servicios, RIPS). Using official population estimates of National Statistics (DANE), crude and adjusted incidence rates were estimated (cases/1,000,000pop). Results: During the period, 35,285 cases were reported (decreasing from 5,509 cases [2009] to 3,624 [2016], r2 = 0.5954;p < 0.05), for period-cumulated crude national rate of 75.3 cases/100,000pop. Cases were reported in all the departments of the country plus Bogota DC. Of the total, 14.2% corresponded to age group of 0-9 y-old, followed by 10-19 y-old (13.9%) and 20-29 y-old (12.4%); 54.3% of cases were males and 45.7% females. From the diagnoses, 48.1% corresponded to acute rheumatic fever (36.2 cases/100,000pop), followed by acute pericarditis (unspecified) 16.6%, acute nonspecific idiopathic pericarditis 9.0%, acute endocarditis (unspecified)(6.0%), valve endocarditis (unspecified) 5.6%, acute and subacute infective endocarditis 4.2% and 2.4% to infective myocarditis, among other diagnoses. Conclusion: Regard the epidemiology of CVI, particularly infective endocarditis, certain studies suggest that these have changed dramatically over the past 20 years with increasing health care contact, ageing and device related infections. However, globally speaking, for Colombia, the trend is to decrease. Despite such fall in incidence over time, acute rheumatic fever incidence rates remain relatively high being the first commonest CVI in this study. Most recent studies have been performed at tertiary referral centres rather than population-based centres, then, these as other few published, provide nation-wide information about its epidemiological trend and features.

Subclinical Endocarditis Might be a Hidden Trigger of Early Prosthetic Valve Calcification: A Histological Study.

Despite various improvements in valve prosthetics, early valve deterioration still occurs, leading to prosthetic failure. Studying the early phase of this deterioration is quite difficult, as the prosthesis to be examined is almost always explanted only after extensive deterioration. The objective of this research is to study the pathology of early valve deterioration in an early stage in order to reveal the possible trigger of the process. Three cusps of the same type of bovine pericardium valve prosthesis underwent comparative examination. Two cusps (cusps 1 and 2) were retrieved from a valve prosthesis explanted three months post-implantation, and the third cusp was from a non-implanted valve prosthesis and used as a reference cusp (ref. cusp). The examination included macroscopic examination, Non-linear Optical Microscopy using a multiphoton microscope, and histological examination with staining, using Hematoxylin and Eosin, Movat Pentachrome stain, Von-Kossa stain, and Alizirin-Red stain. Parallel sections were decalcified using Osteosoft® solution prior to Von-Kossa and Alizirin-Red staining to exclude false positive results. Macroscopically, cusp 1 showed early deterioration, and cusp 2 showed endocarditic vegetations. Histologically, cusp 1 showed calcifications in acellular deposits on the surface of the cusp, with pathological signs of subacute/healed endocarditis and intact cusp tissue. The examination did not show calcifications of the cellular remnants within the valve tissue. Cusp 2 showed florid endocarditis, with microscopic destruction of the valve tissue. Early prosthetic valve deterioration can exist as early as three months post-implantation. Subacute or subclinical endocarditis can be the cause for early valve calcification and deterioration.

Viridans streptococcal infective endocarditis associated with fixed orthodontic appliance managed surgically by mitral valve plasty

Rationale:Streptococcus viridans, a heterogeneous group of alpha-hemolytic streptococci, is part of the normal flora of the mouth, usually responsible for dental caries (Streptococcus mutans, Streptococcus sanguinis), and pericoronitis, as well as for subacute infective endocarditis. They are responsible for 40-60% of the endocarditis cases occurring on the normal valves, especially in male patients and over 45 years of age. A change in the bacterial flora of the oral cavity is taking part after orthodontic fixed appliances are introduced into the oral cavity, change that is associated with an increased concentration of the acidogenic bacteria. Bacteraemia is the consequence of oral cavity infections, the association of infective endocarditis with fixed orthodontic appliance, as it has been described by us for the first time, caused by Abiotrophia defectiva.Patient concerns:We present the case of a female Caucasian patient, aged 22 years, who developed infective endocarditis with Streptococcus viridans associated with fixed orthodontic appliance, located on the mitral valve, without previous cardiac pathology, and the therapeutic difficulties associated with allergic reactions (to vancomycin, and spironolactone).Diagnoses:Repetitive haemocultures were positive with Streptococcus viridans, while transthoracic echography revealed a severe mitral failure through anteromedial segment of the anterior mitral valve leaf prolapse with eccentric jet to the posterior wall.Interventions:During hospitalization, the decision to undergo surgical intervention was taken after obtaining negative haemocultures. The patient underwent surgically intervention, and a mitral valve plasty with insertion of neochords was performed.Outcomes:Intraoperative and subsequently post-discharge transesophageal echography, highlighted normofunctional mitral plasty with a remaining regurgitation grade I-II of IV, with good openness, minor tricuspid regurgitation, and mild pulmonary hypertension.Lessons:Endocarditis with oral streptococci associated with fixed orthodontic appliance seems to be not so unlikely even in young or without previous cardiac pathology patients, requiring attention in identifying possible pre-existing cardiac conditions like mitral valve prolapse with clinical and echographic monitoring of such cases. Educating and motivating the patient to observe the oral hygiene represent key steps for an optimal oral health during orthodontic treatment. Mechanical tooth cleaning helps maintaining a good oral hygiene during fixed orthodontics and decreasing the oral health risks.

Endocarditis by Staphylococcus sp. in Cow and Sheep Leading to Osteoarthritis and Sepsis as Unusual Outcomes

Background: Endocarditis is one of the most important heart diseases in cattle and a rare disease in sheep. This illness could be caused by any bacteria when related to bacteremia, being Staphylococcus aureus one uncommon cause for this disorder in ruminants. The clinical sings at the early stages are unspecific and many cases are only diagnosed just at thefinal stages of the disease, resulting in heart insufficiency with bad prognosis. The aim of this study is to report two cases of endocarditis caused by Staphylococcus spp. leading to sepsis in a sheep and osteoarthritis in a cow, showing the importance of this bacteria in the pathogenesis of this disease.Cases: Case 1. A 8-month-old sheep, female, Texel showed lameness in the left thoracic limb, and even treated with nonsteroidal anti-inflammatory drug had anorexia, locomotion difficulty and on the day before of death showed neurological sings, with less than one week of total clinical course. At necropsy, in the heart was observed thrombus in the tricuspid,mitral and aortic valves and pale areas in the myocardium. Multiples abscesses were observed in the lungs, liver and kidneys and infarcts in kidneys, spleen and brain. At the histopathology exam was observed in the tricuspid, mitral and aortic valves subacute endocarditis with intralesional coccoids bacteria Gram positives. There were multifocal fibrinonecrotic myocarditis, abscess in lung, liver and kidney with intralesional bacterial myriads. In kidneys, spleen and brain was observedthrombosis associated to multiple infarct areas. Samples of cardiac thrombus, heart, spleen, kidney and meningeal swabs were submitted for bacterial cultivation and was isolated Staphylococcus aureus in all samples, in pure culture.Case 2. A 2-year-old cow, female, mixed breed Angus and Charolais showed a wound in the distal part of the thoracic limb that was done topical treatment. After a month, was noted submandibular and dewlap edema, prostration, lethargy and fever. Antibiotic treatment was performed having remission of edema and fever, however being lethargic yet. Aftera month post antibiotic treatment, the animal showed bilateral increased of joint volume and a new antibiotic treatment was performed. The X-ray and cytology of the synovial fluid presented septic osteoarthritis in both radiocarpal joint. At necropsy was observed a thrombus in the tricuspid valve of approximately 20x4cm ascending to caudal and cranial cavaveins and a pulmonary abscess. In the left carpometacarpal joint, right antebrachiocarpal joint and stifle joint were observed severe purulent exudation and erosions. At histopathology evaluation of the heart was noted subacute septic endocarditis in tricuspid valve and in the joints was observed subacute fibrinopurulent osteoarthritis. In the swabs of joints and thrombus was identified Staphylococcus coagulase positive.Discussion: Despite the fact of to be skin commensal, S. aureus can enter in the bloodstream and to cause endocarditis, sepsis, abscesses and arthritis. Regard to possible entryways, interdigital pododermatitis and skin superficial lesions can be the entrance of the agent. In both cases the animals showed lesions on the limbs, as possible cause. The relationshipbetween endocarditis and osteoarticular infections is not fully known. In cattle with heart disease was noted that lameness is an important clinical sign and osteoarthritis could be related with endocarditis. Staphylococcus aureus rarely is reported in endocarditis cases in ruminants and the outcomes showed here are uncommon and poorly studied.Descritores: estafilococose, doença cardíaca, poliartrite, bacteremia, ruminantes.

Brom Aortoplasty for Supravalvular Aortic Stenosis

Controversy remains regarding the optimal surgical approach for children with supravalvular aortic stenosis (SVAS). Since 1997 we have used Brom three-patch aortoplasty for patients with SVAS. We prefer computed tomography (CT) imaging for preoperative evaluation rather than cardiac catheterization as it avoids the well-known morbidity of general anesthesia. The purpose of this study was to present our intermediate-term results of this strategy. Twenty consecutive patients with SVAS were treated with Brom aortoplasty. Mean age was 3.7 ± 5.9 years (median, 1.5 years). Twelve patients had Williams syndrome. Ten patients had preoperative advanced medical imaging (seven CT, three magnetic resonance imaging) and did not have cardiac catheterization. Mean times for cardiopulmonary bypass and cross-clamp were 172 ± 29 minutes and 110 ± 21 minutes, respectively. Ten patients had simultaneous pulmonary artery stenosis patching. Median length of stay was seven days. There was no operative or late mortality. Mean follow-up was 6 ± 5 years. There were no reoperations on the aortic root. Fifteen patients had mild or less aortic insufficiency (AI) and two had moderate AI. One patient who had infant balloon dilation of the aortic valve and postoperative subacute bacterial endocarditis had moderate-to-severe AI and aortic stenosis (AS). One patient had moderate residual SVAS; all others had no AS. No patients had late coronary insufficiency. Brom aortoplasty promotes restoration of normal aortic root geometry and relief of coronary ostial stenosis, which is important in preventing myocardial ischemia. Computed tomography imaging is our preferred diagnostic modality. Intermediate-term outcomes are excellent with no recurrent SVAS, coronary events, or reoperations on the aortic valve.

Increased Risk of Bartonella Infections in Humans

Bartonellosis has emerging zoonoses of the Vector Borne Diseases (VBD) complex. Progress in evolution and changes of causer, enabled the expansion, and increased number of clinically manifest forms of disease appearance of severe disseminated forms of infections and co-infections in humans, difficult for diagnosis, therapy and prognosis. The Bartonellosis may have a benign and self-limiting evolution in a host, or potentially fatal infections. Etiological agents can provoke a granulomatous or an angioproliferative histology damages. In severely immunodeficient cases (pulmonary tuberculosis, carcinomatosis, HIV infection, patients who underwent organ transplantation etc.), Bartonella infections can be difficult and often with unpredictable course of the fatal prognosis. Present the large specter of clinical manifestations: prolonged fever, erythema nodosum like syndrome, and the other skin manifestations, sub-acute bacterial endocarditis, difficult pulmonary disturbances, bacillary angiomatosis (BA) and hepatic peliosis (HP), bacteriemia or a combination of these. In period 2007-2015 on Clinic for Infectious Diseases in Podgorica, 25 cases with Bartonella infection were diagnosed. In total sample, the most frequent were diagnosed CSD in 19 cases. During 2015 in two cases with HIV/AIDS infection, BA was diagnosed, and in four cases PH was diagnosed.

Cat Scratching Your Valve: An Elusive Case of Bartonella Endocarditis

Bartonella Henselae is an uncommon, but significant cause of “culture-negative” endocarditis. While six Bartonella species have reportedly caused infective endocarditis (IE) in humans, the vast majority of cases are secondary to either B. quintana or B. henselae. The epidemiologic features of patients predisposed to Bartonella endocarditis are varied. Alcoholism, body lice infestation, and homelessness have been associated with B. quintana endocarditis, while B. henselae endocarditis has been linked to prior valvular disease and cat exposure.1-4 Patients with Bartonella endocarditis have clinical manifestations similar to those seen with traditional forms of subacute bacterial endocarditis. However, the rarity of the disease compounded by limitations of diagnostic testing make this entity a diagnostic challenge. This case exemplifies a classic presentation of Bartonella endocarditis while highlighting the systemic repercussions of inadequate source control and challenges associated with surgical intervention.

Bartonella henselae infective endocarditis with dissemination: A case report and literature review in Southeast Asia.

Bartonella is among the most common causes of culture-negative infective endocarditis, with B. henselae being one of the most frequently reported species. The clinical presentation of Bartonella endocarditis is similar to that of subacute bacterial endocarditis caused by other bacteria and the diagnosis can be challenging since the organism is difficult to isolate using standard microbiologic culture techniques. In clinical practice, Bartonella endocarditis is usually diagnosed based on serology. To date, only a handful of cases of infective endocarditis caused by Bartonella have been reported in Thailand. Here, we report the case of 51-year-old Thai male with B. henselae endocarditis with dissemination to the lungs, bones, subcutaneous tissue, epididymis, and lymph nodes with a successful outcome.

Iotrophia defectiva: A Rare Gut Pathogen Resulting Endocarditis in Inflammatory Bowel Disease

Abiotrophia defectiva (formerly referred to as nutritionally variant Streptococcus) is a normal flora of the human gastrointestinal tract. Abiotrophia defectiva is associated with high morbidity and mortality, yet timely diagnosis is challenging. Higher incidence of endocarditis was reported among patients with inflammatory bowel disease (IBD) from a retrospective study. We highlighted the diagnostic and management challenges of a case of rare subacute endocarditis by Abiotrophia defectiva in an IBD patient without predisposing valvular defect, prior central catheter insertion or intravenous drug abuse, suggesting gut translocation as a possible etiology of infective endocarditis among IBD patients. J Microbiol Infect Dis 2017; 7(4):217-219

Commentary

Commentary

Infections as a Cause of Unexplained Fever

Fever of unexplained (or unknown) origin (FUO) remains a relevant clinical problem even with modern diagnostic methods. In addition to the classical definition, new categories of FUO describe different clinical situations: nosocomial FUO, FUO in neutropenic/immundeficient patients and FUO in patients with HIV-infection. The new categories are defined by much shorter duration of fever, i. e. mostly three days. Each category of FUO shows a different spectrum of infectious diseases. Often, subacute bacterial endocarditis is very difficult to verify. In many cases, patients in intensive care suffer from FUO caused by reactivation of CMV. In patients with HIV the most important diagnostic indicator concerning the origin of infection is the degree of immundeficiency. Biological and nuclear medical (PET-CT) verification procedures have been established in diagnostics. A national or international register should be created with the purpose of data transfer and validation of strategies concerning the treatment of FUO.

C-ANCA-positive glomerulonephritis associated with subacute infective endocarditis caused by Bartonella infection

C-ANCA-positive glomerulonephritis associated with subacute infective endocarditis caused by Bartonella infection

A Rare Case of Nephrotic Syndrome in Cardiac Patients

AbstractIntroduction: Renal disease due to infective endocarditis (IE) is well established, with the earliest reports of glomerular lesions published over 100 years ago. Although initially believed to be primarily embolic it later became clear that over 80% of cases represented focal, segmental, or diffuse proliferative glomerulonephritis (GN) with prominent endo-capillary proliferation and occasional infiltrating leukocytes. However, the literature describing nephritis associated with IE still relies heavily on autopsy studies conducted in the pre- and early post-antibiotic era or small renal biopsy studies from the 1970s. Over the past decades, IE outcomes have not improved, and infection rates are steadily increasing.Case Report: This thirty seven year old female patient came to OPD with chief complaints of facial puffiness, abdominal distension, swelling of feet, numbness of head since one month duration. She also complained of shortness of breath (SOB) which was insidious onset and gradually progressive NYHA Class 2. She was non-diabetic and non-hypertensive. She was anemic with bilateral pitting edema. She also had significant thyromegaly. Her cardiovascular examination revealed a regular, normo-volemic pulse at a rate of 120 bpm, blood pressure of 170/100 mm of Hg. On auscultation, both heart sounds were normally audible with early diastolic high pitched murmur heard best in left 2ndintercostal space during expiration. 2-dimensional echocardiography showed mild Aortic regurgitation with vegetation on the aortic valve. Her routines showed she was anemic, proteinuric (2400mg in 24 hr urine) with hypo-albuminemia (albumin:1.4g/l), hypothyroid, and hyperlipidemic (total cholesterol:408mg/dl). Her renal parameters were suggestive of pre-renal azotemia with serum urea of 40mg/dl. These findings led to a diagnosis of nephrotic syndrome. Her blood and urine culture showed negative findings. She underwent renal biopsy. Electron microscopic study of a renal biopsy specimen was suggestive of Focal Segmental Glomerulosclerosis. Her collagen profile was not suggestive of any collagen vascular disease.She was started on immunosuppressive therapy for recurrent relapses. She had an episode of short duration weakness of left upper limb from which she recovered spontaneously within 10 minutes. Two-dimensional echocardiography and Transesophageal echocardiography showed healed vegetation over non-coronary cusp of aortic valve. Nephrologist opinion was taken regarding the nephrotic syndrome and healed vegetation over non-coronary cusp.Conclusion: Nephrotic syndrome being immunodeficient state may lead to infective endocarditis in underlying valvular predisposing condition. Complementary to this subacute endocarditis may lead to nephrotic range proteinuria due to deposition of complements in glomeruli leading to massive proteinuria in some patients.In this case, the patient presented with nephrotic syndrome with recurrent remissions and relapses which are quite a rare entity and further cases have to be studied regarding the implications of this complication in the management of nephrotic syndrome and infective endocarditis.

Streptococcus oralis Neuraminidase Modulates Adherence to Multiple Carbohydrates on Platelets.

Adherence to host surfaces is often mediated by bacterial binding to surface carbohydrates. Although it is widely appreciated that some bacterial species express glycosidases, previous studies have not considered whether bacteria bind to multiple carbohydrates within host glycans as they are modified by bacterial glycosidases. Streptococcus oralis is a leading cause of subacute infective endocarditis. Binding to platelets is a critical step in disease; however, the mechanisms utilized by S. oralis remain largely undefined. Studies revealed that S. oralis, like Streptococcus gordonii and Streptococcus sanguinis, binds platelets via terminal sialic acid. However, unlike those organisms, S. oralis produces a neuraminidase, NanA, which cleaves terminal sialic acid. Further studies revealed that following NanA-dependent removal of terminal sialic acid, S. oralis bound exposed β-1,4-linked galactose. Adherence to both these carbohydrates required Fap1, the S. oralis member of the serine-rich repeat protein (SRRP) family of adhesins. Mutation of a conserved residue required for sialic acid binding by other SRRPs significantly reduced platelet binding, supporting the hypothesis that Fap1 binds this carbohydrate. The mechanism by which Fap1 contributes to β-1,4-linked galactose binding remains to be defined; however, binding may occur via additional domains of unknown function within the nonrepeat region, one of which shares some similarity with a carbohydrate binding module. This study is the first demonstration that an SRRP is required to bind β-1,4-linked galactose and the first time that one of these adhesins has been shown to be required for binding of multiple glycan receptors.

A Leuconostoc Lung Abscess With Empyema in an Immunocompetent Host

SESSION TITLE: Student/Resident Case Report Poster - Chest Infections II SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Leuconostocs are gram positive, catalase negative bacteria comprising of L mesenteroides, citreum, lactis and others. Infections due to Leuconostocs in immunocompetent individuals without risk factors are rare. We present this case of a Leuconostoc lung empyema in a healthy immunocompetent individual. CASE PRESENTATION: A 63 year old male with a history of COPD and thoracic aortic aneurysm was transferred to our hospital because of findings of right middle lobe abscess and empyema. He initially presented with complaints of 6 weeks cough with brownish sputum, and right-sided pleuritic chest pain. Initial labs had revealed a WBC of 22,000 while CXR showed right middle lobe consolidation. He had been treated with clindamycin and meropenem because he had failed outpatient levofloxacin. When he failed to improve, a chest CT revealed a right middle lobe abscess with possible empyema. Subsequently, patient was transferred to our facility where he underwent thoracotomy with decortication. Intraoperatively, consolidation of the right middle lobe with purulent oozing was noted and right middle lobectomy was done. He was started on vancomycin and meropenem, which were discontinued when pleural fluid cultures revealed Leuconostoc. The patient was treated with 14 days of clindamycin. DISCUSSION: Leuconostocs are lactobacilli which were previously classified under the Streptococcacae family. They are resistant to vancomycin due to alterations in the cell wall binding site. They are commonly found in pickles, legumes, dairy products and fermentation industries including wine and sugar industries. Predisposing factors include prior vancomycin treatment, immunocompromise, ESRD with hemodialysis, central venous catheterization and severe burns. Leuconostocs are known to cause a wide range of infections including meningitis, line-associated infection, pneumonia, osteomyelitis, subacute bacterial endocarditis and intra-abdominal infections. Very few cases have been reported in immunocompetent individuals with no risk factors. Treatment is recommended with ampicillin, clindamycin, aminoglycosides, cephalosporins or imipenem. CONCLUSIONS: Leuconostocs are morphologically similar to streptococcus but is differentiated by being the only catalase-negative cocci that are also leucin aminopeptidase and pyrrolidonylarylamidase negative. Our patient was unique in his presentation with Leuconostoc lung abscess and empyema in the absence of risk factors. Reference #1: Facklam R, Elliott JA. Identification, classification, and clinical relevance of catalase-negative, gram-positive cocci, excluding the streptococci and enterococci. Clin Microbiol Rev. 1995;8(4):479-495. Reference #2: Yang C, Wang D, Zhou Q, Xu J. Bacteremia due to vancomycin-resistant leuconostoc lactis in a patient with pneumonia and abdominal infection. Am J Med Sci. 2015;349(3):282-283. Reference #3: Golan Y, Poutsiaka DD, Tozzi S, Hadley S, Snydman DR. Daptomycin for line-related leuconostoc bacteraemia. J Antimicrob Chemother. 2001;47(3):364-365. DISCLOSURE: The following authors have nothing to disclose: Siddique Chaudhary, Wajdi Al Shweiat, Ahmed Hamdi, John Youssef, Susan Smith No Product/Research Disclosure Information

Long-Term Nonmalignant Disease Mortality in Subjects Exposed to Transmissible Agents Present in Animals Used for Food.

To study mortality from nonmalignant diseases in subjects with high exposure to transmissible agents present in animals used for food, and in their raw or inadequately cooked products. Mortality was compared in a cohort of meat handlers in slaughtering and processing plants with that of the U.S. general population. Excess mortality was observed for conditions known to be associated with infections-these include, septicemia, chronic nephritis, diseases of the kidney and ureter, diseases of the pancreas, cirrhosis of the liver, acute and subacute endocarditis, acute rheumatic fever, functional diseases of the heart, aortic aneurysm, intracranial and intraspinous abscess, and meningitis. Excess mortality was also observed for ischemic heart disease and diabetes, conditions without an established infectious etiology, but which have been linked with infections. If transmissible agents present in food animals and their raw products cause long-term diseases and mortality in humans, this study importantly points to the likely diseases, many of which are already known to be associated with infections. The excess mortality observed for ischemic heart disease and diabetes is consistent with existing evidence linking these conditions with infections, and gives rise to the novel hypothesis that microbial agents present in food animals and their products may be candidates for an infective role in the occurrence of these conditions, and therefore needs further investigation.

AJKD Atlas of Renal Pathology: Subacute Bacterial Endocarditis-Associated Glomerulonephritis.

Antibiotic therapy has decreased the incidence of glomerulonephritis related to subacute bacterial endocarditis (SBE). Kidney involvement may be the initial manifestation of SBE in about 20% of patients. Hematuria and mild proteinuria are commonly present. Hypertension and nephrotic syndrome are rare. Serum complement levels may be low. Gross hematuria may be present in patients with renal infarctions related to embolic events. The degree of GFR loss correlates with the severity of glomerulonephritis; diffuse glomerulonephritis causes moderate GFR loss, and necrotizing glomerulonephritis with crescents can cause a rapid GFR decline. More extensive glomerulonephritis is commonly associated with high-titer ANCA positivity. Antibiotic therapy can result in partial to complete resolution of kidney disease. Light microscopy: Glomerular lesions show variable and often mixed active and chronic lesions. Focal or diffuse proliferative glomerulonephritis is present in about half of cases, and may have neutrophils within the glomerular tuft. Focal necrotizing lesions with crescents may be present. Chronic lesions include segmental glomerulosclerosis, as well as fibrocellular and fibrous crescents. Renal infarction related to an embolic event can occur. Necrotizing glomerulonephritis with crescents without endocapillary hypercellularity can occur. Immunofluorescence microscopy: Mesangial and capillary wall irregular, granular staining for IgG, IgM, C3, and sometimes IgA are usually present in cases with proliferative glomerulonephritis. IgM staining is usually greater than IgG and IgA. IgA may be dominant in cases with staphylococcal infection. However, there is typically little or no staining in

Marfan Syndrome: new diagnostic criteria, same anesthesia care? Case report and review

Marfan's Syndrome (MFS) is a disorder of connective tissue, mainly involving the cardiovascular, musculoskeletal, and ocular systems. The most severe problems include aortic root dilatation and dissection. Anesthetic management is vital for the improvement on perioperative morbidity. 61-year-old male with MFS, presenting mainly with pectus carinatum, scoliosis, ectopia lens, previous spontaneous pneumothorax and aortal aneurysm and dissection submitted to thoracoabdominal aortic prosthesis placement. Underwent routine laparoscopic cholecystectomy due to lithiasis. Important findings on preoperative examination were thoracolumbar kyphoscoliosis, metallic murmur on cardiac exam. Chest radiograph revealed Cobb angle of 70°. Echocardiogram showed evidence of aortic mechanical prosthesis with no deficits. Preoperative evaluation should focus on cardiopulmonary abnormalities. The anesthesiologist should be prepared for a potentially difficult intubation. Proper positioning and limb support prior to induction is crucial in order to avoid joint injuries. Consider antibiotic prophylaxis for subacute bacterial endocarditis. The patient should be carefully positioned to avoid joint injuries. Intraoperatively cardiovascular monitoring is mandatory: avoid maneuvers that can lead to tachycardia or hypertension, control airway pressure to prevent pneumothorax and maintain an adequate volemia to decrease chances of prolapse, especially if considering laparoscopic surgery. No single intraoperative anesthetic agent or technique has demonstrated superiority. Adequate postoperative pain management is vitally important to avoid the detrimental effects of hypertension and tachycardia.

Acute Embolic Ischemic Stroke as the Sole Presentation of Subacute Enterococcal Endocarditis

Neurological complications are the most frequent extra cardiac complications of infective endocarditis (IE) dominated by the stroke with a high mortality . These manifestations might be the first sign of IE in rare cases. Atrial fibrillation and infective endocarditis (IE) are two of the most common causes of cardio embolic strokes. The patients with infective endocarditis (IE) can present with variable symptoms ranging from vague complaints of fever and chills to any embolic complication. Duke’s criteria is the most common criteria used to diagnose infective endocarditis. We present a case of an acute ischemic stroke in a young patient, which was the sole presentation of subacute infective endocarditis associated with Enterococcus faecalis, thus leading to delayed diagnosis and treatment.

Infective endocarditis following Melody valve implantation: comparison with a surgical cohort.

Infective endocarditis has been reported post Melody percutaneous pulmonary valve implant; the incidence and risk factors, however, remain poorly defined. We identified four cases of endocarditis from our first 25 Melody implants. Our aim was to examine these cases in the context of postulated risk factors and directly compare endocarditis rates with local surgical valves. We conducted a retrospective review of patients post Melody percutaneous pulmonary valve implant in New Zealand (October, 2009-May, 2015) and also reviewed the incidence of endocarditis in New Zealand among patients who have undergone surgical pulmonary valve implants. In total, 25 patients underwent Melody implantation at a median age of 18 years. At a median follow-up of 2.9 years, most were well with low valve gradient (median 27 mmHg) and only mild regurgitation. Two patients presented with life-threatening endocarditis and obstructive vegetations at 14 and 26 months post implant, respectively. Two additional patients presented with subacute endocarditis at 5.5 years post implant. From 2009 to May, 2015, 178 surgical pulmonic bioprostheses, largely Hancock valves and homografts, were used at our institution. At a median follow-up of 2.9 years, four patients (2%) had developed endocarditis in this group compared with 4/25 (16%) in the Melody group (p=0.0089). Three surgical valves have been replaced. The Melody valve offers a good alternative to surgical conduit replacement in selected patients. Many patients have excellent outcomes in the medium term. Endocarditis, however, can occur and if associated with obstruction can be life threatening. The risk for endocarditis in the Melody group was higher in comparison with that in a contemporaneous surgical pulmonary implant cohort.