Infective endocarditis--1973

Endocarditis caused by coagulase-negative staphylococci

Sixteen patients with coagulase-negative staphylococcal endocarditis were treated at the University of Minnesota Hospitals between January 1970 and September 1977. In six patients, endocarditis developed after prosthetic valve surgery; among the other ten patients (the medical group), eight had known antecedent valvular disease. The skin was thought to be the source of infection in eight patients, suggesting that prompt treatment of skin infections and avoidance of injections in patients with valvular disease are important measures in the prevention of this disease. Patients with prosthetic valve endocarditis were infected with antibiotic-resistant organisms and had a higher mortality than those in the medical group (83% versus 20%). Bacterial isolates from three patients with prosthetic valve endocarditis were resistant to methicillin, and two of these three isolates also were resistant to cephalothin by quantitative susceptibility testing. The only patient with prosthetic valve endocarditis to survive was operated upon early in the course of his illness. These observation, coupled with the high mortality in this series and in others, has prompted us to advocate early surgery in prosthetic valve endocarditis.

Fever of unknown origin in the elderly

An extensive literature survey was performed and hospital records were reviewed in order to identify cases of fever of undetermined origin in patients aged 65 or older. Analysis of the 111 cases discovered demonstrates a characteristic but not unique spectrum of underlying disorders. Potentially curable entities such as abdominal abscess, bacterial endocarditis, tuberculosis and giant-cell arteritis account for more than half of the serious illnesses presenting with prolonged pyrexia in elderly subjects. A diagnostic approach to the management of the persistently febrile geriatric patient is discussed.

Adherence of glucan-positive and glucan-negative streptococcal strains to normal and damaged heart valves

The adherence of 18 strains of streptococci to sections of normal canine and human aortic, mitral, and tricuspid valves and to canine interatrial septum was compared in an in vitro system. Quantitative measurements of adherence ratios were performed by two independent methods. Adherence ratios for Streptococcus mutans, S. sanguis, S. bovis, and Group D streptococci were higher (0.0058-0.0101) than for the other streptococcal strains studied (0.0025-0.0041). With the exception of Group D streptococci, adherence ratios for each bacterial strain were similar with the aortic, mitral, and tricuspid valve sections. Adherence ratios with normal human and canine valve leaflets were similar, but adherence ratios with interatrial septum were lower than with normal valve sections. Adherence ratios for glucan-positive and glucan-negative strains of streptococci with normal and with damaged aortic valve leaflets were also compared. The adherence ratios of the glucan-positive streptococci (S. mutans, S. sanguis, and S. bovis) and one glucan-negative enterococcal strain (KG-3) were approximately five times higher with damaged aortic valves (0.039-0.051) than with normal aortic valves (0.009-0.010). For glucan-positive strains, adherence ratios with normal aortic leaflets were similar when bacteria were grown in media which contains or lacks sucrose. In striking contrast, growth of the glucan-positive strains in medium which lacks sucrose, with resultant deficiency of glucan production, decreased the adherence ratios with damaged aortic valve leaflets to those found with normal aortic leaflets. Treatment of glucan-positive strains with dextranase resulted in a decrease in their adherence ratios to levels seen with bacteria grown in medium lacking sucrose, but the higher adherence ratios could be restored in the presence of exogenous dextran.It is concluded that glucan production is one quantitatively important factor that contributes to the greater adherence of glucan-positive streptococci to damaged rather than to normal aortic heart valve leaflets. However, glucan production is not the only factor that determines preferential adherence of streptococci to damaged heart valves, because glucan-negative strains may also show some degree of increased adherence to damaged valves. Thus, bacterial glucan production is one of the factors that could contribute to the pathogenesis of bacterial endocarditis.

Effect of immunization on susceptibility to experimental Streptococcus mutans and Streptococcus sanguis endocarditis

It has been asserted that humoral immunity is an important potentiating factor in pathogenesis of infective endocarditis, in that prior immunization to certain bacteria may predispose the host to endocarditis caused by those organisms. If so, possible future vaccination of humans with streptococcal antigens for the prevention of dental caries might increase the susceptibility of the population to streptococcal endocarditis. To examine this hypothesis further, we immunized rabbits with killed Streptococcus sanguis or Streptococcus mutans. After complement-fixing antibody had developed, the rabbits were tested for susceptibility to experimental infective endocarditis. Rabbits with high titers of complement-fixing antibody to the infecting organism developed streptococcal endocarditis less often (13%) than animals with lower titers (69%; P less than 0.0002). These findings do not support the hypothesis that pre-immunization predisposes to infective endocarditis and lend no credence to the concept that vaccination of human subjects against dental caries might increase their susceptibility to streptococcal endocarditis. On the contrary, the results of these experiments indicate that specific antibody can confer relative immunity to infective endocarditis.

Cerebral mycotic aneurysm of fungal origin. Case report

A young man who had a long history of sinusitis developed subarachnoid hemorrhage and died. Autopsy showed a mycotic aneurysm of fungal origin at the junction of the right posterior cerebral and internal carotid arteries. Four of five reported cases of fungal aneurysm were due to Aspergillus infection.

Technetium-99m stannous pyrophosphate imaging of experimental infective endocarditis

Technetium-99m stannous pyrophosphate (99mTc-PYP) cardiac scintigraphy was performed in 15 rabbits with experimental Streptococcus sanguis aortic valve infective endocarditis. The animals were imaged five to seven days after the administration of bacteria, and in each case abnormal accumulation of the tracer was visualized in the region of the aortic valve. Three types of cardiac scintigraphic patterns were demonstrated: focal, multifocal and extensive, each correlating well with the anatomical extent of the lesion as defined by gross pathology. Tissue distribution studies demonstrated a 30 +/- 5.3 (mean +/- SEM) fold excess of radionuclide uptake in the infective endocarditis lesion compared with that of normal myocardium. Imaging of excised hearts from four animals showed an excellent correlation with in vivo imaging as well as gross pathology. Five animals with nonbacterial thrombotic aortic valve endocarditis demonstrated similar scintigraphic and tissue distribution results. In contrast, four normal animals failed to demonstrate abnormal 99mTc-PYP cardiac scintigrams or tissue uptake. This study demonstrates that 99mTc-PYP cardiac scintigraphy is a sensitive technique to detect experimental aortic valve endocarditis.

Serious infections caused by Streptococcus milleri

Viridans streptococci continue to be the most common etiologic agents in bacterial endocarditis. The spectrum of diseases other than endocarditis caused by these organisms, however, has received sparse attention. Moreover, little clinical information is available concerning the individual viridans streptococcal species. During the 16 months of this study, one species of viridans streptococci, Streptococcus milleri, caused a surprising number of clinically significant suppurative infections. Clinical syndromes included the following: abscesses, 10 cases; peritonitis, four cases; endocarditis, three cases; cholangitis, empyema and cellulitis, one case each. A gastrointestinal source was apparent in eight of these 20 cases. Review of 58 cases of viridans streptococcal endocarditis demonstrated that although Strep. milleri was an infrequent cause of endocarditis, this species was associated with an unusual frequency of suppurative complications. Our experience suggests that Strep. milleri may be more commonly associated with serious suppurative infections than other viridans streptococci and that species identification may be a clinically useful procedure.

Bacterial endocarditis: an analysis of factors affecting long-term survival

The records of 108 patients treated for bacterial endocarditis were reviewed. Six were diagnosed at autopsy and had not been treated for endocarditis. Of the 102 treated patients, 32 died during the first 30 days and 32 more were dead by 365 days. Although some reports indicate a much greater survival rate, our findings are more in keeping with those reports giving a rather poor long-term outlook for patients with endocarditis.

Experimental endocarditis induced by dental manipulation and oral streptococci

Circumstantial evidence has strongly implicated dental manipulation as an etiologic factor in the development of infective endocarditis. The introduction of human oral streptococci via the oral cavity in rabbits with vegetative cardiac lesions yields a 94 per cent incidence of infective endocarditis, if the number of inoculated organisms is above a threshold level of 10(7).

Polymicrobial infective endocarditis: an increasing clinical entity

Polymicrobial endocarditis was very uncommon until ten years ago. However, since that time, at least 21 cases were reported, and 10 patients with this mixed infection were seen at our hospital. All, except one of these infections, occurred in patients who had undergone heart surgery or abused intravenous drugs. Although, generally clinically indistinguishable from mono-microbial endocarditis, these mixed infections carried a very high mortality rate (greater than 30 per cent), and an unusually large number of the patients (greater than 50 per cent) needed heart surgery either to control the infection or to repair cardiac defects resulting from the infection. The prognosis depended on the species rather than the number of organisms isolated and on aggressive antimicrobial and surgical therapy.

Gram-negative endocarditis following cystoscopy

Patients with bacteriuria are at risk for local and distant infectious complications at the time of urologic procedures. The American Heart Association recommends that penicillin and streptomycin be given prophylactically to patients with rheumatic or congenital heart disease without reference to the presence or absence of bacteriuria. A patient with unrecognized calcification of the mitral annulus who underwent cystoscopy for evaluation of urinary retention is reported. Although bacteriuria was present preoperatively antibiotics were not given. Subsequently, Serratia marcescens and possibly Proteus morgani mitral valve infection developed and the patient died. Calcification of the mitral valve annulus and an extensive urinary tract infection were identified at autopsy. This case suggests that calcification of the mitral annulus may be an endocarditis risk factor. The spectrum of prophylactic antibiotic coverage given at the time of urologic procedures to patients with congenital or aquired heart disease, including calcification of the mitral annulus, should include whatever organisms are present in the urine.

Endocarditis due to Hemophilus aphrophilus: report of a case with possible transmission from dog to man

A 44-year-old man was treated for bacterial endocarditis due to Hemophilus aphrophilus. The characteristics of the organism are reviewed, along with other cases of endocarditis. There is an association of this organism with dogs and a potential for transmission from this source to man.

A clinicopathologic study of prosthetic valve endocarditis in 22 patients: morphologic basis for diagnosis and therapy

Although endocarditis is a frequently lethal complication of prosthetic valve replacement, there is little pathological information on which to base diagnosis and treatment. We have studied the clinical and pathological features of 22 patients with prosthetic valve endocarditis seen at The Johns Hopkins Hospital over the past 17 years. Five patients developed endocarditis within two months of operation and 17 between two and 48 months (average 12) after operation. Patients dying early had a more fulminant course and their endocarditis was less often recognized during life. Late deaths, tending to present with fever and bacteremia unmasked by postoperative problems, were more readily recognized. Mitral and aortic prosthetic endocarditis generally led to a different type of prosthetic valve dysfunction: nine of 14 aortic valve prostheses with endocarditis developed incompetence and one other stenosis; five of seven patients with mitral valve prostheses developed stenosis and one, a homograft, developed incompetence. Prosthetic valve dysfunction led to death in 10 patients (45 per cent) and embolic events in five (23 per cent), including four cerebrovascular accidents. Ring infection, often believed to be universally present, and a contraindication to surgery, was found only in 50 per cent of these patients. In four patients (18 per cent) the endocarditis was sterilized by antibiotics but death occurred from valve dysfunction or emboli. These findings suggest that early surgical intervention combined with antibiotics has a chance of providing effective therapy for prosthetic valve endocarditis.

Experience with valved conduits for repair of congenital cardiac lesions

Dacron valved conduits or aortic allografts were placed between the right heart and the pulmonary artery for repair of various complex congenital cardiac anomalies in 56 patients (aged 15 days to 33 years; median, 11 years). Forty-four patients had a total of 56 previous palliative procedures, which contributed to postoperative morbidity and mortality. Six patients had a total of seven episodes of early or late sepsis involving the conduit. One patient, treated for early sepsis, again developed infection in the Hancock graft 1 year postoperatively and died. Three other patients, 2 with calcified allografts, developed infections 4 months to 7 years following repair and required graft replacement. Hemodynamic data 1 month to 5 years (mean, 1.6 years) following repair revealed mild to moderate obstruction (less than 45 mm Hg gradient) at the Hancock conduit valve ring in 13 of 19 patients, while 5 had large pressure gradients (greater than 75 mm Hg). All aortic allografts had severe obstruction and calcification necessitating graft replacement. It is anticipated that improved technique and appropriate timing of palliative and corrective operations will substantially reduce or eliminate these problems.

Changing concepts in management of infective endocarditis

Sixty-four patients were treated for 73 episodes of infective endocarditis over the five-year period 1970 to 1974 at St Vincent's Hospital, Sydney. There were 13 deaths with a mortality rate of 18-1% compared with 38% (1950 to 1959). Included were 13 cases of infection on prosthetic valves with three deaths. Fifty-one per cent of patients were studied by cardiac catheterization. Early or emergency surgery was performed in 28% of cases and late surgery in 16%. The improved results were due to multiple factors, including early diagnosis, prompt investigation in a specialized unit, rational use of appropriate antibiotics, careful management of complications and early surgery.

Staphylococcus aureus bacteremia in hemodialysis patients

Fifteen male hemodialysis patients developed 21 episodes of S. aureus bacteremia. Infections involving vascular access were responsible for 65% of initial bacteremias. The arteriovenous fistula was the most prevalent type of access used, and thus was responsible for the majority of these illnesses. Phage typing indicated that recurrent episodes were due to reinfection rather than relapse. Complications included endocarditis, osteomyelitis, septic embolism, and pericarditis. One patient died of infectious complications. It is recommended that hemodialysis patients developing bacteremia due to S. aureus receive at least 6 weeks of beta lactamase-resistant antimicrobial therapy.

Management of the patient with a prosthetic heart valve

Approximately 20,000 heart valve prostheses are inserted yearly in the United States. Even after successful heart operations, the patients who receive them cannot be regarded as healthy individuals but are a special group with special problems who need close medical attention for the rest of their lives. They are susceptible to many unusual complications because of their implanted foreign body, and it is a challenge to all physicians in contact with them to be aware of their peculiar problems in order to prevent complications if possible and to treat them immediately if they occur. General therapy, surgical complications, infection, and mechanical problems are reviewed, with means for management outlined. These difficulties can be dealt with only by careful follow-up and well-coordinated teamwork between the family physician and the institution where the operation was performed.

Echocardiography in bacterial endocarditis

We examined 129 standard M-mode echocardiograms obtained in 65 patients (16 to 73 years old) with bacterial endocarditis. Twenty of the 22 patients with vegetations recognizable by echocargiography died, or underwent cardiac operation (mean interval from admission 22 days, and range two to 120 days). Vegetations were seen on the echocardiograms in 22 (aortic 10, mitral nine and tricuspid three, with anatomic confirmation in 19). Of patients without vegetations on echocardiography none underwent emergency operation or died as a result of cardiac disease (mean follow-up period of 14 months, range of two to 38 months). Other echocardiographic findings in those with vegetations included early mitral-valve closure (six), "flail" aortic leaflet (three), and "flail" mitral leaflet (three). Echocardiography can provide a rapid, reliable noninvasive diagnosis of bacterial vegetations in certain patients with bacterial endocarditis and may identify patients with more severe disease who may require operative intervention.

Fever with dissecting aneurysm of the aorta

Following acute aortic dissection, it two of the four cases we describe the patients experienced a prolonged febrile syndrome which spontaneously resolved five and 11 weeks later. Because of fever and a murmur of aortic regurgitation, the two other patients with aortic dissection were initially treated for acute bacterial endocarditis. These four cases serve to re-emphasize fever as an important clinical manifestation of dissecting aneurysm of the aorta.

Endocarditis due to accidental penetrating foreign bodies

A 15 year old boy had an eight month history of recurrent fever, malaise and poor appetite. Chest roentgenogram revealed a foreign object overlying the right ventricle. Multiple blood cultures grew Enterobacter cloacae. The patients condition improved and blood cultures became negative following gentamicin and carbenicillin therapy. E. cloacae was isolated from the foreign body (a finishing nail) at surgery. Antimicrobial therapy was continued for a total of 30 days, and the patient made an uneventful recovery.

Staphylococcus aureus bacteremia. Current clinical patterns

One hundred and five cases of bacteremia due to Staphylococcus aureus were reviewed to assess the current clinical spectrum of serious staphylococcal disease. Mortality was 21 percent, lower than previously reported. Patients could be separated into two groups according to the presence of identifiable primary staphylococcal infections; 63 bacteremic patients had such lesions, the remaining 42 lacked them. The latter group contained 24 of 26 cases of endocarditis. Illnesses in that group were marked by the presence (in 38 of 42 patients) of staphylococcal foci occurring secondary to bacteremia. Such foci were responsible for five of seven instances of relapse or treatment failure encountered in that group. Secondary staphylococcal foci occurred in only five of 63 patients with primary infections, and the response of this group to conventional therapy for bacteremia was satisfactory. This study suggests that endocarditis has become an unusual complication of identifiable primary staphylococcal infection. A clinical classification based on the presence of such lesions therefore separates bacteremic patients likely to be cured by conventional antibiotic therapy (those with primary infections but no secondary foci) from others (those with secondary foci, suggesting endocarditis) who should receive a more prolonged course of antibiotics.

Alterations in myocardial function during bacterial infective cardiomyopathy

The status of myocardial function in rabbits subjected to cardiac catheterization and infection with Streptococcus viridans was assessed at 3 and 6 days. Sham-operated control animals as well as uninfected catheterized animals were used for comparison. Although left heart hypertrophy and interstitial edema were evident in both uninfected and infected animals, the infected animals exhibited in addition mononuclear cell infiltration and muscle degeneration as well as lung congestion and accumulation of pleural fluid. Both uninfected and infected animals has elevated levels of serum creatine phosphokinase, lactic dehydrogenase and glutamic oxaloacetic transaminase as well as electrocardiographic abnormalities such as increased amplitude of the ORS complex and flattening or inversion of the T wave. Unlike findings in the uninfected animals, the serum calcium, magnesium and sodium levels were slightly but significantly decreased and serum potassium levels were increased in the infected rabbits. Both heart rate and pulse pressure were higher in 6 day uninfected and 3 day infected animals whereas 6 day infected animals showed a decrease in heart rate. In comparison to the sham-operated control rabbits and the uninfected animals, the infected animals exhibited depression in the rates of left ventricular pressure development and relaxation as well as prolongation in time for half relaxation in situ. Relative maximal contractile element velocity extrapolated from intraventricular pressure-velocity curves was decreased by 24, 52 and 76 percent, respectively, of control values in the uninfected hearts and those with 3 and 6 days of infection. The isolated perfused hearts from infected animals also generated less contractile force and showed a decrease in the rates of contraction and relaxation, but half-relaxation time was increased. These results demonstrate myocardial dysfunction during experimental bacterial endocarditis and provide evidence that infective cardiomyopathy is associated with heart failure.

Cyanotic congenital heart disease

This review describes the evolving concepts of diagnosis and management of patients with cyanotic congenital heart disease. Early palliative surgical procedures were followed by reparative operations and are now to a large extent replaced by these operations which are designed to relieve the problem. Collaboration of the team of cardiologists, surgeons, radiologists, anesthesiologists and nurses has made the many developments possible. The teamwork has not only widened the scope of what can be accomplished but has also extended the opportunities for beneficial reparative surgery down to the first weeks and months of life. Precise diagnosis and meticulous operative and perioperative care by the team are essential elements of success. Long-term follow-up and regular analyses of results have led to continuing improvements. Although these patients were born to be blue, their color and their outlook have been changed during these last 3 decades to something close to rosy.

Acute aortic regurgitation and abscess of sinus of Valsalva due to fulminating ulcerative endocarditis. Report of three fatal cases in children

Acute aortic regurgitation due to ulcerative endocarditis developed in 3 children aged 10, 6, and 7 years, respectively. All had congenital aortic valve lesions. Intractable congestive heart failure ensued about 2 weeks, 1 week, and a few days, respectively, after onset of infection. Two patients were operated on in the acute stage, and in both, perivalvular spread of the infection was found with abscess formation of the right sinus of Valsalva perforating through the interventricular septum to the right ventricle; valve replacement and repair were performed, but both patients died. The correct diagnosis was missed in the third patient, who was thought to have myocarditis and who died one week after onset of infection: at autopsy a perforation of a bicuspid aortic valve and an aneurysm of the sinus of Valsalva were found.

Streptococcal pancarditis

An unusual association of pancarditis due to Streptococcus viridans is described. The pathologic findings appear to indicate that the myocardial infection and pericarditis were blood borne.

Assessing the hemodynamic severity of acute aortic regurgitation due to infective endocarditis

Nine patients who underwent aortic-valve replacement for acute aortic regurgitation due to infective endocarditis were studied for clinical features that may be useful in assessing the severity of this condition. The traditional physical signs of a wide pulse pressure were absent. As compared to a group of patients with chronic aortic regurgitation, the mean (plus or minus S.D.) pulse pressure (55 plus or minus 7 vs. 105 plus or minus 22 mm Hg), left ventricular end diastolic volume (146 plus or minus 28 vs. 264 plus or minus 64 ml per square meter) and stroke volume (89 plus or minus 22 vs. 163 plus or minus 57 ml per square meter) were significantly smaller in the acute group (P less than 0.01). Left ventricular pressure exceeded left atrial pressure in late diastole, causing premature closure of the mitral valve, and the degree of early closure reflected the increase in left ventricular end diastolic pressure. Premature closure of the mitral valve was demonstrated by echocardiography in all patients. Those with echocardiographic signs of very early mitral-valve closure have severely volume-overloaded ventricles and are candidates for early valve replacement.

Clinical, microbiologic and therapeutic aspects of purulent pericarditis

Twenty-six patients with purulent pericarditis were seen at the Massachusetts General Hospital between 1960 and 1974. The diagnosis was made in 18 of them during life, but only 6 survived, with an over-all mortality rate of 77 per cent. In eight patients, purulent pericarditis developed in the early postoperative period after thoracic surgery. In seven, purulent pericarditis was the result of contiguous spread of infection from a pleural, mediastinal or pulmonary focus in nonsurgical patients. In five patients, it was the result of direct spread to the pericardium from an intracardiac infection. In the remaining six patients, purulent pericarditis developed as the result of a systemic bactermia. Immunosuppressive therapy, extensive thermal burns, lymphoproliferative disease and other systemic processes affecting host resistance were present in at least half the patients. Staphylococcus aureus was the etiologic agent in the largest number of patients (8 of 26 in this report). However, in contrast to previous studies, in a significant number of the patients (five), purulent pericarditis was the result of fungal infection (in three patients subjected to thoracic surgery and in two immunosuppressed patients). This report confirms that purulent pericarditis is an acute disease with a fulminant course. The diagnosis is easily missed since classic signs of pericarditis (including chest pain, friction rub and diagnostic electrocardiographic abnormalities) may be absent. The echocardiogram shows considerable promise in allowing earlier diagnosis of the pericardial effusion which accompanies purulent pericarditis. Optimal therapy consists of prolonged antibiotic therapy and aggressive drainage of the pericardium. In this series, there were 6 survivors among the 11 patients (55 per cent) who received appropriate therapy.

Diagnosis and management of complications of prosthetic heart valves

Complications after heart valve replacement remain a substantial source of morbidity and mortality despite continuing advances in surgical care and prosthetic design. Infectious endocarditis occurs in about 4 percent of patients and may appear early (within 60 days) or late after operation. Endocarditis of early onset is commonly due to staphylococcal, fungal or gram-negative organisms and is fatal in 70 percent or more of cases. Infection of late onset is more often of streptococcal origin and the mortality rate is lower, about 35 percent. With either type, prompt recognition, vigorous and appropriate antimicrobial therapy and early consideration of surgical intervention are crucial. The postperfusion and postpericardiotomy syndromes are relatively common and relatively benign syndromes associated with postoperative fever. Their recognition is important to prevent confusion with endocarditis or sepsis and thus to reassure the patient and physician. Treatment is primarily symptomatic. Intravascular hemolysis occurs with most prosthetic heart valves but is more common with certain prostheses and with paraprosthetic valve regurgitation, with significant hemolytic anemia in 5 to 15 percent. Oral iron replacement therapy is effective in the majority of patients, but occasionally blood transfusion or reoperation for leak around the prosthesis is necessary. Prosthesis dysfunction due to thrombus may be recognized clinically by recurrence of heart failure, syncope, cardiomegaly and altered prosthetic valve sounds or new murmurs. Hemodynamic studies verify the diagnosis, and prompt reoperation is indicated for this potentially lethal problem. Systemic embolization has decreased markedly with the introduction of cloth-covered prostheses and is frequently related to erratic or ineffective anticoagulant therapy. We continue to recommend anticoagulant therapy for all patients with prosthetic heart valves unless there is a major contraindication.

Recognition of infection associated with intravenous catheters

Four cases are described in which the patients suffered from bacteriaemia due to infected intravenous infusions. Although all the patients were pyrexial, the white cell count was normal in all 4 cases at diagnosis and the infusion site appeared innocent. Following removal of the intravenous catheter and the institution of antibiotic therapy in each case, neutrophilia and localizing signs developed. It is stressed that a normal white cell count and an innocent appearance at the infusion site do not exclude this complication of intravenous therapy. Possible reasons for this presentation for sepsis are discussed.

Hemophilus aphrophilus endocarditis: review of 23 cases

A case of bacterial endocarditis caused by Hemophilus aphrophilus is described, and 22 previously reported cases are reviewed. Eleven patients died and 12 survived; comparison of these two groups reveals that the patients who died were in the older population. The male/female ratio was 3.6:1. The organism was difficult to identify but had a wide range of in vitro bacteriologic sensitivities. This type of endocarditis is frequently associated with emboli and congestive heart failure; each occurred in 9 of 11 fatal cases and 3 of 12 nonfatal cases. Among the nonfatal cases, two patients had both emboli and congestive heart failure, requiring aortic valve replacement despite their precarious clinical condition. Initial drug therapy before results of antibiotic sensitivity tests are known should consist of penicillin combined with streptomycin. When emboli or congestive heart failure appears in Hemophilus aphrophilus endocarditis, early surgical intervention with valve replacement is indicated.

Bacterial endocarditis in subjects 60 years of age and older

Forty-two cases of bacterial endocarditis with pathologic confirmation are reviewed. Infection was restricted to one or both left-sided valves in 31 cases, right-sided valves in five cases, and valves in both sides of the heart in six cases. In those specimens available for review, underlying valvular disease was identifiable in 24 of 38 cases (63%). The common underlying diseases, in order of decreasing frequency, were calcified or otherwise deformed aortic valves (11 cases) and rheumatic fibrosis of the mitral valve (eight cases). The floppy mitral valve was the underlying condition in two cases and amyloid infiltration of the tricuspid valve in one. Among the 34 cases from which a specific organism was identified, the dominant organisms were Staphylococcus (14 cases) and various types of Streptococci(ten cases). Fungi were the causative organisms in two cases. The clinical suspicion for the presence of bacterial endocarditis was low (40% of 40 cases with adequate data). In those cases with adequate data, murmurs were present in 68% and fever in 93%. Of those patients with fever, clinical diagnosis was made or suspected in only 38%. When a murmur was present, the clinical diagnosis was made or suspected in 54% of the cases, while when a murmur was absent the disease was suspected in only 9% of the cases. The clinical diagnosis of bacterial endocarditis in older subjects depends upon 1) knowledge that the disease may occur in such subjects and 2) recognition that, although fever is commonly present, murmurs may be absent.