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Hassan MA, Grewal N, Nepaul D. A Case of Mitral Valve Infective Endocarditis and Atrial Fibrillation Complicated by Hemorrhagic Stroke: A Challenging Clinical Scenario and Approach to Management. Cureus 2023; 15:e41634. [PMID: 37575781 PMCID: PMC10412743 DOI: 10.7759/cureus.41634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 07/10/2023] [Indexed: 08/15/2023] Open
Abstract
This case report presents a rare and intricate clinical scenario involving a 58-year-old male with a history of hypertension, intravenous drug use (IVDU), and cocaine abuse. The patient presented with profound hypotension and symptoms suggestive of impending shock. Septic workup revealed Staphylococcus aureus in all four blood culture bottles, confirming a diagnosis of infective endocarditis (IE). Transthoracic echocardiography demonstrated a large vegetation measuring 1.9x1.7 cm on the mitral valve. Additionally, the patient exhibited non-ST segment elevated myocardial infarction (NSTEMI) type II in the setting of cocaine use, atrial fibrillation, and therapeutic anticoagulation. Subsequent imaging studies raised concerns regarding hemorrhagic stroke. A multidisciplinary team comprising cardiology, cardiothoracic surgery, infectious disease, and neurology collaborated to develop an optimal management strategy. Considering the high-risk features of the IE and the need to address the hemorrhagic stroke, anticoagulation was temporarily halted, and the patient was transferred for urgent mitral valve replacement surgery. This case highlights the complex interplay between substance abuse, cardiovascular complications, IE, and neurological events, underscoring the challenges encountered in managing such patients.
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Affiliation(s)
- Mubariz A Hassan
- Internal Medicine, Howard University Hospital, Washington, D.C., USA
| | - Niyati Grewal
- Internal Medicine, Howard University Hospital, Washington, D.C., USA
| | - Daniel Nepaul
- Cardiovascular Disease, Howard University Hospital, Washington, D.C., USA
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Pisaryuk AS, Zamarashkina VA, Safarova NB, Povalyaev NM, Kotova EO, Babukhina UI, Koltsova EM, Kobalava ZD. Coagulation Disorders in Infective Endocarditis: Role of Pathogens, Biomarkers, Antithrombotic Therapy (Systematic Review). RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2022. [DOI: 10.20996/1819-6446-2022-06-14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The issue of antithrombotic therapy in patients with infective endocarditis has been studied for over 75 years. During that time studying of pathogenesis of the disease and its embolic complications, lead to the introduction of the concept of “immunothrombosis”. That mechanism allows infective agents (mostly bacteria) to be cloaked from the immune system and to multiply freely, leading to growth of vegetation, thus resulting in higher chance of fragmentation. Small-scale experimental and clinical studies on the correction of hemostatic disorders in infective endocarditis, that were performed in 20th century, didn’t show any significant results, that could affect clinical practice. However, reinterpretation of available data on coagulative system will allow to have elements of hemostasis as an application point in treating infective endocarditis. The article will discuss latest insights on the role of hemostasis system in pathophysisology of infective endocarditis, its effects on the development of the embolic complications, perspectives for diagnostics and treatment.
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Affiliation(s)
- A. S. Pisaryuk
- RUDN University; Moscow City Hospital named after V.V. Vinogradov
| | | | | | | | | | | | - E. M. Koltsova
- Center for Theoretical Problems of Physicochemical Pharmacology; Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology
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Jamil M, Kichloo A, Soni RG, Jamal S, Khan MZ, Patel M, Albosta MS, Aljadah M, Bailey B, Singh J, Kanjwal K. Coexisting Cirrhosis Worsens Inpatient Outcomes in Patients With Infective Endocarditis: A Cross-Sectional Analysis of the National Inpatient Sample 2013-2014. Cureus 2020; 12:e11826. [PMID: 33409068 PMCID: PMC7781493 DOI: 10.7759/cureus.11826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Introduction Cirrhosis is known to be an important prognostic factor in determining morbidity and mortality in preoperative cardiac risk assessment for cardiac surgery. Data is limited on outcomes in patients with infective endocarditis (IE) and comorbid liver cirrhosis. The objective of our study is to evaluate the clinical outcomes in patients suffering from IE both with and without underlying liver cirrhosis as well as to determine rates of in-hospital mortality and factors that contribute to this outcome. Hypothesis Liver cirrhosis worsens clinical outcomes in patients with IE. Materials and methods Patients with a principal diagnosis of IE with and without liver cirrhosis were identified by querying the Healthcare Cost and Utilization (HCUP) database, specifically the National Inpatient Sample for the years 2013 and 2014 using International Classification of Diseases, Ninth Revision (ICD-9) codes. Results During 2013 and 2014, a total of 17,952 patients were admitted with a diagnosis of IE, out of whom 780 had concurrent liver cirrhosis. There was increased in-hospital mortality [15.6% vs 10.2%, aOR = 1.57 (1.27-1.93)], acute kidney injury [41.4% vs 32.6%, aOR = 1.45 (1.24-1.69)], and hematologic complications [32.1 vs 14.7%, aOR = 2.87 (2.44-3.37)] in patients with IE with liver cirrhosis when compared to patients with IE without liver cirrhosis. Patients having IE without liver cirrhosis underwent an increased number of interventions, i.e. aortic (7.2 vs 3.7%, aOR = 0.51 (0.34-0.76)) and mitral (4.9% vs 3.4%, aOR = 0.39 (0.23-0.69)) valvular replacements as compared to those with liver cirrhosis, which may explain the increased mortality seen in patients with liver cirrhosis. Conclusion Liver cirrhosis is an important prognostic risk factor for in-hospital mortality in patients with IE. The coagulopathic state in addition to increased rates of bleeding complications and renal dysfunction make these patients poor surgical candidates thus contributing to higher mortality. Further research into the individual risk factors contributing to the increased mortality rates in patients with IE and cirrhosis is required.
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Affiliation(s)
- Mohammad Jamil
- Internal Medicine, Central Michigan University College of Medicine, Saginaw, USA
| | - Asim Kichloo
- Internal Medicine, Central Michigan University College of Medicine, Saginaw, USA
| | - Ronak G Soni
- Internal Medicine, University of Toledo College of Medicine, Toledo, USA
| | - Shakeel Jamal
- Internal Medicine, Central Michigan University College of Medicine, Saginaw, USA
| | - Muhammad Zatmar Khan
- Internal Medicine, Central Michigan University College of Medicine, Saginaw, USA
| | - Mitra Patel
- Internal Medicine, University of Toledo College of Medicine, Toledo, USA
| | - Michael S Albosta
- Internal Medicine, Central Michigan University College of Medicine, Saginaw, USA
| | - Michael Aljadah
- Internal Medicine, Medical College of Wisconsin, Milwaukee, USA
| | - Beth Bailey
- Internal Medicine, Central Michigan University College of Medicine, Saginaw, USA
| | - Jagmeet Singh
- Nephrology, Geisinger Commonwealth School of Medicine, Scranton, USA
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Diab M, Musleh R, Lehmann T, Sponholz C, Pletz MW, Franz M, Schulze PC, Witte OW, Kirchhof K, Doenst T, Günther A. Risk of postoperative neurological exacerbation in patients with infective endocarditis and intracranial haemorrhage. Eur J Cardiothorac Surg 2020; 59:ezaa347. [PMID: 33036027 DOI: 10.1093/ejcts/ezaa347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 07/28/2020] [Accepted: 07/29/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Cardiac surgery in patients with infective endocarditis (IE) and preoperative intracranial haemorrhage (pre-ICH) is a highly debatable issue, and guidelines are still not well defined. The goal of this study was to investigate the effect of cardiac surgery and its timing on the clinical outcomes of patients with IE and pre-ICH. METHODS We did a single-centre retrospective analysis of data from patients with preoperative brain imaging who had surgery for left-sided IE between January 2007 and May 2018. RESULTS Among the 363 patients included in the study, 34 had pre-ICH. Hospital mortality was similar between the patients with and without pre-ICH (29% vs 27%, respectively; P = 0.84). Unadjusted, postoperative neurological deterioration appeared higher in patients with pre-ICH (24% vs 17%; P = 0.35). In multivariable analysis, pre-ICH did not qualify as an independent predictor for either postoperative neurological deterioration [odds ratio 1.10, 95% confidence interval (CI) 0.44-2.73; P = 0.84] or hospital mortality (odds ratio 1.02, 95% CI 0.43-2.40; P = 0.96). Postoperative partial thromboplastin time was significantly elevated in 4 patients with relevant post-ICH compared with those patients without relevant post-ICH (65.5 vs 37.6, respectively; P = 0.004). CONCLUSIONS Pre-ICH was not an independent predictor for postoperative neurological deterioration or hospital mortality in patients with IE. Postoperative coagulation management seems to be crucial in patients with IE with ICH. Although this is to date the largest monocentric study addressing surgical decision and timing, the number of patients with pre-ICH was low. Therefore, these conclusions should be regarded with caution; randomized clinical trials are needed.
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Affiliation(s)
- Mahmoud Diab
- Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany
| | - Rita Musleh
- Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany
- Department of Neurology, Jena University Hospital, Jena, Germany
| | - Thomas Lehmann
- Institute of Medical Statistics, Computer and Data Sciences, Jena University Hospital, Jena, Germany
| | - Christoph Sponholz
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Mathias W Pletz
- Institute for Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
| | - Marcus Franz
- Division of Cardiology, Department of Internal Medicine I, Jena University Hospital, Jena, Germany
| | - P Christian Schulze
- Division of Cardiology, Department of Internal Medicine I, Jena University Hospital, Jena, Germany
| | - Otto W Witte
- Department of Neurology, Jena University Hospital, Jena, Germany
| | - Klaus Kirchhof
- Division of Neuroradiology, Department of Radiology, Jena University Hospital, Jena, Germany
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany
| | - Albrecht Günther
- Department of Neurology, Jena University Hospital, Jena, Germany
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Sheibani H, Salari M, Azmoodeh E, Kheirieh A, Chaghazardi S. Culture-negative endocarditis with neurologic presentations and dramatic response to heparin: a case report. BMC Infect Dis 2020; 20:476. [PMID: 32631238 PMCID: PMC7339518 DOI: 10.1186/s12879-020-05206-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 06/29/2020] [Indexed: 12/11/2022] Open
Abstract
Background Blood culture-negative endocarditis (BCNE) is diagnosed in 2–7% of patients with infective endocarditis (IE) and recent antibiotic use is a known risk factor. Altered mental status may be a presenting symptom. Besides empiric antibiotics, intravenous anticoagulation using heparin may have a role in the management of such patients. Case presentation A 23-year-old male patient was referred to our center with fever, altered mental status and abnormal gait. Neurologic examination revealed Wernicke’s aphasia. Cardiac auscultation revealed systolic murmur at the left sternal border. ECG (electrocardiogram) was unremarkable. Brain MRI showed multiple cerebellar lesions. Transthoracic echocardiography (TTE) demonstrated three large masses on the right ventricle (RV), tricuspid valve (TV), and anterior mitral valve (MV) leaflet. Blood cultures (three sets) were negative. Intravenous heparin therapy was administered. After 48 h, the second TTE demonstrated that one valvular lesion disappeared and the other two lesions showed a significant decrease in size. The patient’s neurological symptoms resolved gradually. Further workup for collagen vascular disorders did not show any abnormality. Conclusion BCNE should be considered in patients with fever and neurologic manifestations. TTE should be performed to detect valvular abnormalities. Intravenous heparin could be used in such patients when TTE demonstrate valvular vegetations.
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Affiliation(s)
- Hossein Sheibani
- Clinical Research Development Unit, Imam Hossein Hospital, Shahroud University of Medical Science, 3616911151, Imam Ave, Shahroud, Iran.
| | - Mohammad Salari
- Clinical Research Development Unit, Imam Hossein Hospital, Shahroud University of Medical Science, 3616911151, Imam Ave, Shahroud, Iran
| | - Elham Azmoodeh
- Student Research Committee, School of Medicine, Shahroud University of Medical Science, Shahroud, Iran
| | - Amirhessam Kheirieh
- Student Research Committee, School of Medicine, Shahroud University of Medical Science, Shahroud, Iran
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Wang Y, Zhao W, Lu J, Li G, Peng B, Wang H. Recurrent Acute Ischemic Stroke after Infective Endocarditis Caused by Streptococcus Constellatus : First Case Report and Analysis of the Case Series. J Stroke Cerebrovasc Dis 2018; 27:e180-e189. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.03.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 03/07/2018] [Accepted: 03/28/2018] [Indexed: 12/31/2022] Open
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Preston AH, Williams S, Archer J. A review of the role of anticoagulation for patients with infective endocarditis and embolic stroke. Clin Case Rep 2016; 4:513-6. [PMID: 27190618 PMCID: PMC4856248 DOI: 10.1002/ccr3.556] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 02/02/2016] [Accepted: 03/14/2016] [Indexed: 11/25/2022] Open
Abstract
Stroke is a common embolic complication of infective endocarditis. The most important treatment to prevent stroke in endocarditis is the initiation of antibiotic therapy. It is unclear whether the initiation of de novo anticoagulation (i.e, warfarin) in patients with infective endocarditis is beneficial, since there are no large or randomized controlled trials in this area. However, this case report suggests, despite the limited evidence, that anticoagulation in this patient caused no harm and could suggest a hint of possible benefit.
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Affiliation(s)
| | - Stefan Williams
- Pinderfields General Hospital Aberford Road Wakefield WF1 4DG UK; Leeds General Infirmary Great George Street LS1 3EX UK
| | - Judy Archer
- Pinderfields General Hospital Aberford Road Wakefield WF1 4DG UK
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