Valvular Vegetations Research Articles

Cerebrovascular Complications in Patients with Left‐Sided Infective Endocarditis Are Common: A Prospective Study Using Magnetic Resonance Imaging and Neurochemical Brain Damage Markers

Background. @nbsp; Cerebrovascular complications (CVCs) have remained a major therapeutic and prognostic challenge associated with infective endocarditis, and definite risk factors have not been fully elucidated. This prospective study was designed to the evaluate the total incidence of CVC associated with infective endocarditis and major risk factors. Methods. @nbsp; During 2 study periods, from June 1998 through April 2001 and from September 2002 through January 2005, patients were prospectively enrolled in the study regardless of neurological symptoms. Study patients underwent neurological examinations and magnetic resonance imaging of the brain, and cerebrospinal fluid analyses of inflammatory and neurochemical markers of brain damage (neurofilament protein and glial fibrillary acidic protein) were performed. Results. @nbsp; Sixty patients who experienced episodes of left-sided infective endocarditis were evaluated; 35% of these patients experienced a symptomatic CVC. Silent cerebral complications were detected in another 30% of the patients, and the total CVC rate was 65% (95% confidence interval, 58%-72%). Five percent of patients experienced their first neurological symptom after the initiation of antibiotic treatment without prior surgery. No new symptomatic CVCs were detected after 10 days of antibiotic treatment. No neurological deterioration was observed after surgery in patients who were established to have a symptomatic CVC preoperatively. A larger heart valvular vegetation size was a risk factor for both symptomatic and silent CVCs; Staphylococcus aureus etiology conferred a higher risk for symptomatic cerebral complication only. Conclusions. @nbsp; The use of sensitive methods of detection indicates that the incidence of CVC associated with infective endocarditis is high, but the risk for neurological deterioration during cardiac surgery after a CVC is lower than previously assumed. The major mechanism behind cerebral complications associated with infective endocarditis is cerebral embolization, although the dominant neurological symptoms vary considerably.

Editorial Commentary:Cerebrovascular Complications in Patients with Left‐Sided Infective Endocarditis: Out of Site, Out of Mind

feared, life-threatening form of infective endocarditis that is frequently characterized by acute clinical events that prompt immediate medical attention. This syndrome can include the abrupt onset of CNS complications resulting from embolization from infected valvular vegetations. Moreover, such cerebrovascular complications (CVCs) are well-recognized as risk factors for a worse prognosis in patients with left-sided infective endocarditis [1]. The rate of CVC in patients with infective endocarditis has varied from study to study and is largely determined on the basis of symptomatic events. We know, however, from clinical experience and postmortem findings, that CVCs associated with infective endocarditis may also remain asymptomatic. Of course, asymptomatic embolic events can also involve other organs (especially the spleen and kidneys). An example of this type of scenario is the discovery of asymptomatic re-

Sepsis mit Purpura Fulminans nach Hundebiss

Anamnese und klinischer Befund: Ein 61-jähriger Patient stellte sich mit seit 4 Tagen zunehmenden Rückenschmerzen und abdominellen Beschwerden vor. Seit dem Vortag sei es zu einer Verschlechterung des Allgemeinzustandes mit Schwächegefühl und Dyspnoe gekommen. Bei Aufnahme war der Patient tachykard und tachypnoeisch mit Lippen- und Akrozyanose bei einer Körpertemperatur von 39,1 °C. Bis auf eine epigastrische Druckdolenz war der abdominelle Untersuchungsbefund unauffällig. Die gesamte Haut des Patienten verfärbte sich livide, und es entwickelten sich zunehmende Einblutungen mit zentralen Nekrosen. Fremdanamnestisch war eine Hundebissverletzung einige Wochen vor Aufnahme eruierbar.

Visualization of pericarditis with fluoro-deoxy-glucose-positron emission tomography/computed tomography

A 38-year-old man presented with recurrent fever, night sweat, retrosternal pain, and vomiting. Laboratory test failed to identify a viral or bacterial agent. The patient did not respond to antibiotics. Transoesophageal echocardiography showed pericardial effusion and no valvular vegetations. The patient was referred to fluoro-deoxy-glucose-positron emission tomography/computed tomography (FDG-PET/CT) to identify an infectious focus. Whole-body FDG-PET/CT was performed after fasting and 1 hour after intravenous administration of 350 MBq FDG. Coronal PET image ( Panel D ) demonstrates increased uptake in the whole pericardium, pronounced on the right side (long arrows). PET/CT technique provides cross-sectional axial CT- ( Panel A ), PET- ( Panel B ), and fused PET/CT-( Panel C ) images. The pericardial …

Abstract 1761: An Uncommon Cause of Stroke in a 41-Year-old Female

A healthy 41-year-old female experienced sudden onset of right hand weakness, right facial droop and garbled speech. The symptoms lasted for several minutes and then resolved spontaneously. Neurologic exam and head CT were unremarkable. Brain magnetic resonance (MR) imaging demonstrated an infarct in the left frontoparietal operculum; head and neck MR angiogram was unremarkable. A trans-thoracic echocardiogram (TTE) was obtained to evaluate for a patent foramen ovale (PFO) as a cause of paradoxical embolus. Although there was no evidence of PFO, the TTE revealed a 7 × 8 mm pedunculated mass attached to the aortic valve. Trans-esophageal echocardiogram (TEE) confirmed the finding of a highly mobile, echo lucent mass most suggestive of a papillary fibroelastoma (PFE). However, valvular vegetation, thrombus and other primary intra-cardiac tumor could not be excluded. A cardiac MR scan was obtained to further characterize the mass. T2-weighted images demonstrated increased signal within the core of the mass, making tumor more likely than infectious vegetation. The mass also more than doubled in signal intensity after intravenous administration of gadolinium confirming the presence of a vascular source and making thrombus unlikely. The results of non-invasive imaging strongly suggested PFE. In the absence of other stroke source, surgical resection was recommended. Histology of the mass demonstrated a typical budding pattern of fibrous and elastic tissue, confirming the diagnosis of PFE. Papillary fibroelastomas are rare, accounting for less than 10% of primary cardiac tumors; however, they are the most common tumor associated with heart valves. Most PFE are asymptomatic and discovered incidentally. However, due to the risk of embolism, surgical resection is recommended for symptomatic or large left-sided tumors. This case illustrates the importance of a broad differential diagnosis when evaluating a common syndrome (ischemic stroke) in an uncommon circumstance (young patient). It also demonstrates the complimentary nature of echocardiography and cardiac MR in confirming the diagnosis of a cardiac mass prior to invasive therapy. As such, multi-modality imaging has become integral in the evaluation and management of cardiovascular disease.

Subaortic Valvular Vegetation Mimicking Severe Aortic Valve Stenosis

Subaortic Valvular Vegetation Mimicking Severe Aortic Valve Stenosis

Unusual Cardiac Complications of Staphylococcus aureus Endocarditis

Bacterial endocarditis is a complex disease that is associated with significant morbidity and mortality. Staphylococcus aureus is an organism commonly responsible for acute bacterial infective endocarditis. Patients many times develop an acute fulminant infection resulting in multiple complications, even in the face of adequate therapy. We report an unusual case of S. aureus acute bacterial infective endocarditis in an immunocompromised patient resulting in multiple cardiac complications, including bacterial pericarditis with effusion, mycotic aneurysm of one of the coronary arteries, a valvular vegetation leading to an aneurysmal dilatation at the mitral-aortic junction (intervalvular fibrosa), and a fistulous communication between the left ventricle and left atrium. We present detailed echocardiographic images of these anomalies, which were subsequently confirmed intraoperatively. The patient underwent open heart surgery with pericardial patch repair of the mitral-aortic intervalvular fibrosa aneurysm and fistula.

Primitive neuroectodermal tumor of the myometrium with cardio-vascular symptoms

Background. Non-bacterial thrombotic endocarditis is a severe complication of cancer, rarely reported in gynecologic tumors. However, it can be inaugural and lead to complex diagnostic pathways. Case. A 40-year-old woman presented with a stroke, related to an endocarditis. The valvular vegetation was surgically removed, and a malignant node was resected. A PET-scan led to the diagnosis of a myometrial tumor, which was found to be a primitive neuroectodermal tumor (PNET). The patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy, and systemic chemotherapy which allowed a complete remission of tumoral and cardio-vascular symptoms. Conclusion. To our knowledge, this is the first case report of a PNET of the myometrium revealed by cardio-vascular symptoms.

A 38-Year-Old Hispanic Woman with Paradoxical Embolism and Libman-Sacks Endocarditis Involving the Tricuspid Valve

Libman-Sacks endocarditis is a well-described clinical entity in patients with systemic lupus erythematosus. Transesophageal echocardiography is the definitive imaging modality used in assessing cardiac valvular involvement in this disease process. Herein we describe a young Hispanic woman with systemic lupus erythematosus and multiple tricuspid valvular vegetations who developed splenic and cerebral infarctions while on optimal anticoagulation therapy with warfarin in the setting of a newly diagnosed patent foramen ovale. A review of the literature on Libman-Sacks endocarditis and patent foramen ovale closure is presented.

Sepsis mit Purpura Fulminans nach Hundebiss

A 61-year-old man presented with a four-day history of back pain and nonspecific abdominal pain. His condition had significantly worsened since the day before admission with generalized weakness and dyspnea. His temperature was 39.1 C, he had tachycardia and was tachypneic. Peripheral cyanosis was noted. The abdomen was soft with mild epigastric tenderness. A diffuse skin rash developed with increasing petechial bleeding and central necrosis. It was revealed that he had been bitten by a dog several weeks before admission. Laboratory data indicated an acute inflammatory process with a marked increase in white blood cells and C-reactive protein. An elevated procalcitonin level suggested a systemic bacterial infection. Chest X-ray and abdominal CT scan were unremarkable. Echocardiography revealed a globally hypokinetic heart with no evidence of valvular vegetations. One set of blood cultures grew micro-aerophilic, Gram-negative rods. Gene sequencing identified the slow growing, fastidious bacillus as CAPNOCYTOPHAGA CANIMORSUS. The patient was admitted to the intensive care unit and initially treated with intravenous piperacillin/tazobactam and hydrocortisone for septic shock. Transfusions of platelets and blood products were given because of disseminated intravascular coagulation. The patient developed multi-organ failure requiring ventilation and hemodialysis; he died four days after admission. As a rare cause of septicemia, especially in immunocompromised patients, Capnocytophaga canimorsus infection should be considered after an animal bite. Given the slow growth of this bacterium in culture, Gram-staining of a peripheral blood smear may provide an early diagnosis and avoid delay before appropriate antibiotic therapy, which may favorably influence the potentially fatal course, is started.

CT Radiographic Findings

Radio-frequency catheter ablation (RFCA) is an ever increasing modality for treating refractory atrial fibrillation. Radiologists should not only be able to interpret and convey anatomic variations of pulmonary veins and left atrium to referring electrophysiologists, but also should be aware of all the post-RFCA complications and their radiographic findings including this rare, but often fatal complication. This report describes a fatal atrio-esophageal fistula (AEF) involving a normal variant single left common pulmonary vein after transcatheter ablation. A 59-year-old man who presented to the Emergency Department (ED) with altered mental status previously complaining of fatigue and malaise. The patient underwent a total of 2 uneventful circumferential percutaneous pulmonary vein ablations for atrial fibrillation. The most recent was performed 5 weeks before admission to ED. Within hours of initial evaluation, the patient quickly deteriorated owing to overwhelming sepsis requiring both inotropic and ventilatory support. Transthoracic echocardiography within ED showed no evidence of valvular vegetation or gas bubbles in the left atrium. Computed tomography (CT) of the chest with intravenous contrast revealed findings compatible with AEF. Head CT was negative for ischemic changes or emboli. Patient underwent emergent cardiac and esophageal surgery at which point the patient later died on the operating table. Patients who present with signs and symptoms of endocarditis, and particularly with new neurologic symptom after RFCA should be promptly evaluated for AEF. In our case, radiographic findings in correlation with clinical history and high suspicion strongly suggested this rare, often fatal complication. During review of the chest CT, particular vigilance should be made to the left pulmonary vein/posterior left atrium junction at which site fistulous tracts tend to occur. Prompt diagnosis necessitates emergent cardiac and esophageal surgery to prevent rapid deterioration and death.

Fever and haemoptysis in an injecting drug user

A 46-yr-old injecting drug user was admitted with a history of repeated haemoptysis, pleuritic chest pain and fevers. He had a neutrophilia and elevated C-reactive protein. A pulmonary embolus was diagnosed by computed tomography (CT) pulmonary angiography and he was treated with low molecular weight heparin. He received i.v. antibiotics (flucloxacillin, amoxicillin, gentamicin and metronidazole) for polymicrobial bacteraemia (methicillin-sensitive S taphylococcus aureus , Enterococcus , viridans type Streptococcus) caused by a right groin abscess, which was subsequently incised and drained, and was associated with iliofemoral thrombosis. No valvular vegetation was seen on transthoracic or subsequent transoesophageal echocardiogram. The patient had a fluctuating clinical course, requiring respiratory support with supplemental oxygen and noninvasive ventilation. He had a persistent neutrophil leukocytosis and greatly elevated C-reactive protein at >100 mg·L−1. Clinically, there was evidence of bilateral pleural effusions, which cultured Enterococcus on aspiration. Attempted thoracocentesis was unsuccessful with minimal fluid drained. An ultrasound scan of the chest revealed loculated pleural effusions. He continued to cough blood and 17 days after admission had an episode of massive haemoptysis requiring a blood transfusion. At this point the anticoagulation was discontinued given the risk of further massive haemoptysis. A repeat CT of the chest was performed to clarify the cause of the continuing haemoptysis (fig. 1⇓). Despite halting the anticoagulation, further fresh haemoptysis occurred a few days later and he was referred to a cardiothoracic surgeon with a view to surgical intervention. Due to …

Clusters of disease manifestations in patients with antiphospholipid syndrome demonstrated by factor analysis

The antiphospholipid syndrome (APS) is now recognized as a multi-system disease, the clinical expression of which may include various target-organs involvements. Despite the reported heterogeneity in clinical presentation of APS, the interrelations between various manifestations of the disease has not yet been studied. We evaluated the principle associations between a variety of clinical manifestations in APS patients, applying factor analysis. Two-hundred and forty-six APS patients were studied. The following disease manifestations were used for the factor analysis: recurrent fetal loss, intrauterine growth restriction (IUGR), venous and arterial thrombosis, cardiac valves thickening/dysfunction, valvular vegetations, stroke, epilepsy, migraine, arthritis, livedo reticularis, thrombocytopenia, leukopenia and autoimmune hemolytic anemia (AIHA). The results were further analysed in relation to sex and to primary APS versus APS associated with SLE. Five factors were derived, which accounted for 59.7% of the variance of the matrix. Factor 1 (which explained 18.5% of variance of the original matrix) represented the association between cardiac valves abnormalities, livedo reticularis and AIHA. Factor 2 (13.8% of variance) represented association between arthritis, thrombocytopenia and leukopenia. Factor 3 (10.3% of variance) represented an association between recurrent fetal loss and IUGR. Factor 4 (9.3% of variance) represented inverse correlation between arterial and venous thrombosis. Factor 5 (7.8% of variance) represented an association between epilepsy and migraine. Application of factor analysis revealed specific clusters of cardiac, cutaneous, hematological and neurological manifestations. Our result also point to a possible divergence of arterial and venous thrombotic tendency. Awareness of these patterns might give us a better understanding of the disease.

Quadrivalvular marantic endocarditis (ME) mimicking acute bacterial endocarditis (ABE)

Marantic endocarditis (ME) is defined by noninfectious valvular vegetations. The most common disorders associated with ME are malignancy with or without hypercoagulable state, intercardiac instrumentation, residual vegetations from previously treated infective endocarditis (IE), renal insufficiency, and burns. Another important cause of ME is systemic lupus erythematosus when accompanied by vegetations, that is, Libman-Sacks endocarditis. ME should be differentiated from IE because they may present with similar clinical features. Both ME and IE may present with fever and a heart murmur with or without embolic phenomenon. Leukocytosis and elevated erythrocyte sedimentation rate suggest the diagnosis of IE. The hallmark of IE is a cardiac vegetation and continuous high-grade bacteremia. After exclusion of the causes of culture negative endocarditis, the absence of bacteremia clearly differentiates ME from IE. We present a case of ME mimicking acute bacterial endocarditis (ABE). The differential diagnostic features of ME versus IE are discussed. To the best of our knowledge, this is the first reported case of quadrivalvular ME with massive vegetations on all cardiac valves, as well as the aorta, atria, and pulmonary artery.

Splenic Abscess due to Clostridium perfringens

To the Editor: Splenic abscess is an uncommon clinical entity with an incidence of 0.14% to 0.7%.1 The common causative organisms are aerobic. Anaerobic organisms such as clostridial species are rarely implicated. We present a case of an elderly woman with splenic abscess that grew Clostridium perfringens. CASE REPORT A 64-year-old woman presented with a 2-week history of left upper quadrant abdominal pain associated with fever, nausea, vomiting, and diarrhea. She denied any history of recent antibiotic use, travel, or sick contacts. Patient had a colonoscopy 4 years before presentation which revealed a polypoid leiomyoma in the sigmoid colon; a follow-up colonoscopy a year later revealed hyperplastic polyps in the transverse colon that were removed. History was otherwise noncontributory. On examination, patient was in mild distress because of abdominal pain. Vital signs showed a temperature of 36.4°C and a pulse rate of 110/min. Abdominal examination was significant for left upper quadrant tenderness and splenomegaly. The rest of the physical examination finding was unremarkable. Laboratory data showed marked leukocytosis (white blood cell count of 21.8 × 103/mm3 with 82% neutrophils and 7% bands) and C-reactive protein of 17.5 mg/dL. The rest of the laboratory results were within normal limits. Chest radiograph revealed an elevated left hemidiaphragm. Computed tomography (CT) of the abdomen with contrast revealed an air-fluid level along the posterior part of the spleen consistent with an abscess (Fig. 1). The patient was empirically started on intravenous piperacillin-tazobactam and had a CT-guided percutaneous catheter drainage of the abscess. Abscess drain cultures were positive for C. perfringens, and the antibiotics were changed to ampicillin-sulbactam. Stool was negative for Clostridium difficile toxin. Blood cultures were negative. An echocardiogram of the heart revealed no valvular vegetations. Malignancy workup was negative. Colonoscopy revealed adenomatous polyps in the transverse colon, and she underwent polypectomy. The patient was discharged on intravenous clindamycin for dosage convenience. Her condition improved, and serial abdominal CT scans done over the next few weeks revealed a decrease in the abscess size. The drain was removed after she completed a 6-week course of antibiotics.FIGURE 1: Computed tomography of the abdomen with contrast showing air-fluid level in the spleen.She presented with similar complaints 4 weeks later. A repeat CT of the abdomen revealed recurrence of the splenic abscess. She then underwent splenectomy; dense adhesions were noted along the splenocolic ligament on exploratory laparotomy. She was discharged uneventfully on postoperative day 8. DISCUSSION Splenic abscess is rare with a subtle clinical presentation and requires a high index of suspicion. The most common clinical features are fever, left upper quadrant pain, and splenomegaly.2 Diagnosis is mainly radiological. Ultrasonography is a good noninvasive technique, but CT has the highest sensitivity and specificity.2 Aerobic organisms are the most common organisms isolated and include staphylococcus and streptococcus species, salmonella, and Escherichia coli1-3; anaerobes account for 10% only. Most of the cases reported in the past due to clostridial species had predisposing factors such as malignancy, colitis, hematologic diseases, diabetes, or trauma.4-7 A review of literature revealed 2 reported cases of splenic abscess due to C. perfringens6,8; one had trauma as a predisposing cause, and the other one speculated diabetic microvascular injury as a possible factor. The source of C. perfringens in our patient remained obscure except for the history of diarrhea suggesting colitis and repeated polypectomies with breach in colonic mucosa acting as a possible portal of entry.

Noncompaction and endocarditis in suspected mitochondrial disorder

Objectives To report the echocardiographic and autopsy findings of left ventricular hypertrabeculation (LVHT), also known as noncompaction, in a patient with central and peripheral nervous system disease, who died shortly after diagnosing noncompaction. Case report In a 75 year old woman with cognitive decline, Parkinson syndrome, stroke-like-episodes, basal ganglia calcification, neuromuscular disorder, cataract, diabetes, anemia, arterial hypertension, recurrent heart failure, left anterior hemiblock, and right bundle branch block, acute heart failure developed during treatment of a suspected urosepsis. Transthoracic echocardiography revealed severely reduced fractional shortening, valvular vegetations, and LVHT. Endocarditis was suspected. She died shortly afterwards from renal failure and ventricular fibrillation. Endocarditis and LVHT were confirmed at autopsy. Conclusions This case shows that endocarditis may occur together with LVHT and central and peripheral nervous system disease indicative of a mitochondrial disorder. Whether LVHT predisposes for endocarditis remains speculative.

Propionibacterium endocarditis: A case series from the International Collaboration on Endocarditis Merged Database and Prospective Cohort Study

Propionibacterium species are occasionally associated with serious systemic infections such as infective endocarditis. In this study, we examined the clinical features, complications and outcome of 15 patients with Propionibacterium endocarditis using the International Collaboration on Endocarditis Merged Database (ICE-MD) and Prospective Cohort Study (ICE-PCS), and compared the results to 28 cases previously reported in the literature. In the ICE database, 11 of 15 patients were male with a mean age of 52 y. Prosthetic valve endocarditis occurred in 13 of 15 cases and 3 patients had a history of congenital heart disease. Clinical findings included valvular vegetations (9 patients), cardiac abscesses (3 patients), congestive heart failure (2 patients), and central nervous system emboli (2 patients). Most patients were treated with beta-lactam antibiotics alone or in combination for 4 to 6 weeks. 10 of the 15 patients underwent valve replacement surgery and 2 patients died. Similar findings were noted on review of the literature. The results of this paper suggest that risk factors for Propionibacterium endocarditis include male gender, presence of prosthetic valves and congenital heart disease. The clinical course is characterized by complications such as valvular dehiscence, cardiac abscesses and congestive heart failure. Treatment may require a combination of medical and surgical therapy.

Thalidomide Use and Digital Gangrene

A 60-year-old woman who presented initially with splenomegaly and petechiae underwent evaluation with a bone marrow biopsy, which revealed a diagnosis of chronic idiopathic myelofibrosis (with extramedullary hematopoiesis). She was initiated on therapy with thalidomide (100 mg daily) and prednisone (30 mg daily). Eight weeks into her treatment course, she developed erythema and pain, specifically in the right index distal phalanx (Fig 1) she used to push open the thalidomide blister packs. She subsequently developed gangrene in the involved fingertip. Hypercoagulation diagnostic interpretive studies revealed no abnormalities, the patient had no prior history of thromboembolism, and tests for connective tissue disorders were negative. ECG imaging revealed no evidence of valvular disease or vegetations. Treatment with thalidomide was stopped and the patient underwent successful debridement. There were no recurrences. Thalidomide, a glutamic acid derivative, is US Food and Drug Administration approved for the treatment and maintenance of cutaneous manifestations of multiple myeloma and erythema nodosum leprosum. Its unlabeled applications, which constitute the majority of its use, include the treatment of myelodysplastic syndromes, myeloproliferative disorders, Crohn’s disease, graft-versus-host reactions after bone marrow transplantation, and AIDS-related aphthous stomatitis. The mechanism of action by which thalidomide produces benefits in cancer patients is unclear, but theories include direct inhibition of myeloma cells, oxidative damage to DNA mediated by free radicals, manipulation of adhesion molecules, and alterations in cytokine activity, specifically tumor necrosis factor alpha, interleukin 1 beta, tumor growth factor beta, and cyclooxygenase 2. Thalidomide use has been associated with venous thrombosis; however, to date there have been only a few case reports of arterial thrombosis, and even fewer with development of gangrene. The mechanism by which thalidomide produces this adverse effect may include alterations in von Willebrand factor levels and direct action on previously damaged endothelial cells. Concern for thromboembolic events has been raised, especially for patients concurrently receiving chemotherapy and steroid therapy. In combination therapy series, rates of venous thrombosis were 20% to 30%. Most of these studies involved thalidomide therapy in myeloma and the myelodysplastic syndromes, and in fact, this is the first report describing arterial thrombosis in patients with idiopathic myelofibrosis treated with thalidomide. Idiopathic myelofibrosis is a myeloproliferative process characterized by intramedullary reticulin formation (fibrosis) and extramedullary hematopoiesis. It commonly produces cytopenias, as well as dysfunctional platelets, and a predisposition to bleeding rather than hypercoagulability. Early studies and single institution experiences have shown that thalidomide therapy can improve cytopenias, transfusion dependency, and splenomegaly; although, there are other studies that found the adverse effects outweighed its benefits. This case is a demonstration of the unusual occurrence of arterial thrombosis that occurs with thalidomide use and trauma related to taking the medicine.

Autoimmune Hemolytic Anaemia in the Antiphospholipid Syndrome

Antiphospholipid syndrome (APS) is a multisystem disease with recurrent thrombosis in the presence of antiphosphlipid antibodies, which may include cardiac, neurological, gastrointestinal, hematologic or cutaneous manifestations. The occurrence of autoimmune hemolytic anaemia (AIHA) in APS has not been well established. The purpose of this study was to review the occurrence of AIHA in patients with APS and its relation to other disease manifestations. Three-hundred and eight patients with APS from seven medical centers in Israel, Serbia and the Slovac Republic were included and evaluated for associations between AIHA and various manifestations of APS. AIHA was documented in 32 patients (10.4%). The odds ration for AIHA was increased in the presence of anticardiolipin antibodies and livedo reticularis (5.4 and 7.8, respectively). There was a highly significant association between AIHA and cardiac valvular vegetations and thickening (P < 0.0001), arterial thrombosis (P < 0.02), livedo reticularis (P < 0.0001) and CNS signs of epilepsy or chorea (P < 0.02 and P < 0.03, respectively). Thus, APS patients with AIHA are at risk of developing these manifestations, and should therefore be investigated for them. In addition, the occurrence of AIHA may define a subgroup of patients with a significant risk for subsequent development of SLE.

Influence of diabetes mellitus on the clinical manifestations and prognosis of infective endocarditis: A report from the International Collaboration on Endocarditis – Merged Database

The purpose of this investigation was to study the influence of diabetes mellitus (DM) on outcomes of infective endocarditis (IE). Outcomes were compared between 150 diabetic and 905 non-diabetic patients with IE from the International Collaboration on Endocarditis Merged Database. Compared to non-diabetic patients, diabetic patients were older (median age 63 vs 57 y, p<0.001), were more often female (42.0% vs 31.9%, p=0.01), more often had comorbidities (41.5% vs 26.7%, p<0.001), and were more likely to be dialysis dependent (12.7% vs 4.0%, p<0.001). S. aureus was isolated more often (30.7% vs 21.7%, p=0.02), and microorganisms from the viridans Streptococcus group less often (16.7% vs 28.2%, p = 0.001) in the diabetic group. There was no difference with respect to the presence of congestive heart failure, embolism, intra-cardiac abscess, new valvular regurgitation, or valvular vegetation. Diabetic patients underwent surgical intervention less frequently (32.0% vs 44.9%, p = 0.003), and had higher overall in-hospital mortality (30.3% vs 18.6%, p = 0.001). On multivariable analysis, DM was an independent predictor of mortality (odds ratio (OR) = 1.71, 95% confidence interval (CI) 1.08-2.70), especially in male patients, as diabetic males had higher mortality than non-diabetic males (OR 2.18, CI 1.08-4.35). DM is an independent predictor of in-hospital mortality among patients hospitalized with IE.