Complete heart block associated with tricuspid valve endocarditis due to extended spectrum β-lactamase-producing Escherichia coli

Heart Block as a Rare Complication of Tricuspid Valve Endocarditis: Awareness is the Key

Infective endocarditis (IE) occurs when bacterial or fungal pathogens enter the blood and attach to the endocardium. Right-sided endocarditis is usually associated with intravenous drug use (IVDU), intracardiac devices, and central venous catheters. There is more data published about left-side endocarditis when compared to right-sided endocarditis. Tricuspid valve infective endocarditis (TVIE) accounts for 5%-10% of IE, and of those cases, roughly 10% are complicated by conduction deficits due to inflammatory edema, myocarditis, and abscess formation. Tricuspid valve (TV) surgical repair carries its own risks, one of which includes the development of conduction abnormalities. Here, we review the current data of TVIE complicated by heart block after tricuspid valve replacement. Also, we present a case of a 21-year-old IVDU female who presented with tricuspid valve endocarditis, subsequently underwent tricuspid valve replacement, and developed a heart block.

Infective Endocarditis Caused by Extended-Spectrum Beta-Lactamase-Producing Escherichia coli: A Case Report

Introduction

Extended-spectrum β-lactamase-producing Escherichia coli (ESBL-EC) reportedly accounts for >20% of E. coli infections and 2.0% of infective endocarditis cases. Nonetheless, there is a global paucity of reports on infective endocarditis caused by ESBL-EC.

Case

An 83-year-old Japanese man who underwent mitral annuloplasty for mitral valve prolapse 5 years ago developed a fever of 38.5°C. The patient was hospitalized the first time for pyelonephritis and bacteremia due to ESBL-EC and treated successfully with the antimicrobial meropenem for 14 days. Two days after discharge, however, the patient was re-admitted with bacteremia due to ESBL-EC. He was treated successfully with the antimicrobial cefmetazole for 14 days. The patient was admitted to our institution for a third time due to bacteremia again, a day after discharge following meropenem antibiotic therapy. Transesophageal echocardiography showed vegetation in the anterior mitral valve annulus. Magnetic resonance imaging of the head showed septic cerebral embolism. The patient was diagnosed with infective endocarditis due to ESBL-EC and underwent mitral valve replacement. After 6 weeks of antibiotic therapy with meropenem and tobramycin, the patient recovered completely. The causative E. coli strain MS6396 was identified as the E. coli clone ST131 by multilocus sequence typing and confirmed the presence of bla_CTX-M-27 ESBL gene.

Conclusion

Only six cases of infective endocarditis associated with ESBL-EC have been reported in the past. Moreover, this is the first report of a patient with infective endocarditis bacteriologically or genetically analyzed for ESBL-EC. In future, factors that may cause infective endocarditis in ESBL-EC infections may be clarified through more thorough bacteriological/genetic analyses of ESBL-EC.

Transient complete heart block: a case report of a rare complication of tricuspid valve infective endocarditis

Background

Right-sided tricuspid valve (TV) endocarditis can be difficult to identify and may be under-recognized in the absence of traditional risk factors. While generally identified with aortic valve pathology, infective endocarditis that extends beyond the leaflets of the TV have been reported to cause conduction disease.

Case summary

We present the case of a 63-year-old patient who presented with haemodynamically unstable complete heart block requiring temporary venous pacemaker support. Despite the absence of traditional risk factors or significant valvular disease on transthoracic echocardiogram, she was found to be persistently bacteraemic and subsequent transoesophageal echocardiogram identified large vegetation on the septal leaflet of the TV. Conduction disease was noted to reverse with antibiotic therapy and resolution of bacteraemia.

Discussion

Although rare, right-sided endocarditis involving the triangle of Koch may present with conduction disease due to local inflammation and mechanical compression. Conduction disease associated with right-sided disease appears to be readily reversible with medical therapy and temporary device support may be appropriate in the acute setting.

E. coli endocarditis of the tricuspid valve

Infective endocarditis (IE) is a focus of infection which effects the endocardium, specifically the heart valves or intra-cardiac devices.

A 64-year-old male with gastric carcinoma and no prior cardiac history presented to the emergency room with altered mental status. Initial investigations showed the patient had a leukocytosis with a left shift. Blood cultures taken upon arrival eventually grew Esherichia coli, thought to be from the urinary tract, although initial urinalysis was delayed until after initiation of antibiotics. Electrocardiogram showed sinus bradycardia with frequent premature atrial contractions. Chest X-Ray showed bilateral pleural effusions, which were eventually drained and found to be growing E. coli. Transthoracic echocardiogram was done which showed moderate-sized tricuspid valve vegetation with severe tricuspid regurgitation.

IE has been increasing in incidence throughout the years. In prior decades IE was a disease primarily affecting patients with known rheumatic heart disease, prosthetic heart valves, and intravenous drug abusers however more commonly it is becoming healthcare acquired. E. coli is not often seen to be a culprit of IE. We present a rare case of E. coli endocarditis of a native tricuspid valve.

Native valve endocarditis due to Escherichia coli infection: a case report and review of the literature

Background

Infective endocarditis due to Escherichia coli is a rare disease but is increasing in frequency, especially among older women. In addition, its mortality rate is higher than that of endocarditis due to the HACEK-group gram-negative bacteria (Haemophilus spp., Aggregatibacter spp., Cardiobacterium hominis, Eikenella corrodens, and Kingela spp.).

Case presentation

A 58-year-old Japanese woman with a history of alcohol abuse was admitted to our hospital because of a fever. She was diagnosed with infective endocarditis due to E. coli based on repeated blood cultures and transthoracic echocardiography, which revealed vegetations attached to the anterior leaflet and chordae tendineae of the mitral valve. Despite administration of sulbactam/ampicillin and gentamycin, she developed purulent spondylitis during hospitalization and required treatment with meropenem administration for 6 weeks, leading to resolution of the endocarditis. She took oral levofloxacin for 2 months, and the spondylitis was completely cured 7 months after discharge.

Conclusion

Escherichia coli affects native valves without degenerative valvulopathy rather than prosthetic valves, especially in patients with risk factors such as an immunosuppressive status, excessive alcohol consumption, or treatment with hemodialysis. Peripheral embolization, congestive heart failure, and valve-ring abscesses are major complications of E. coli endocarditis; notably, infective myocarditis can also occur. The mortality and surgical intervention rates are 21% and 42%, respectively. Physicians should be cognizant of the necessity of surgical intervention when E. coli endocarditis is resistant to antibiotic therapy.

Infective Endocarditis Presenting as Complete Heart Block With an Unexpected Finding of a Cardiac Abscess and Purulent Pericarditis

Intracardiac abscess resulting in complete heart block is an infrequent complication of infective endocarditis. Most presentations of endocarditis are limited to valvular and perivalvular structures, with varying degrees of heart block occurring in the minority of cases. We report a case of endocarditis manifesting as chest pain associated with ST segment elevation and complete heart block. The patient expired unexpectedly within a few hours of presentation. Postmortem examination revealed an atrial septal abscess, purulent pericardial collection, and fibrinous pericarditis. Spread of the abscess into the atrial septum was postulated to be the cause of the complete heart block. In endocarditis, the ominous development of heart block and a poor response to antibiotic therapy imply significant extension of the infection. Management therefore requires prompt ventricular pacing with consideration for valve replacement and possible pericardial drainage.

Transrectal prostate biopsy-associated prophylaxis and infectious complications: report of a query to the emerging infections network of the infectious diseases society of america

Emerging Infection Network members perceive post-prostate biopsy infections as serious, increasingly common, and caused by resistant organisms. Prophylaxis, although in flux, still usually entails ciprofloxacin monotherapy, often for excessively long durations. Better evidence and approaches are needed for preventing post-TRBP infections.

Background. Fluoroquinolone-resistant infections after transrectal prostate biopsy (TRPB) are increasing.

Methods. Members of the Emerging Infections Network, a consortium of adult infectious diseases physicians sponsored by the Centers for Disease Control and Prevention and the Infectious Diseases Society of America, were administered an electronic 9-question survey regarding post-TRPB infections and associated prophylaxis. Results were compared with respondent characteristics.

Results. The overall response rate was 47% (552 of 1180). Of the 552 respondents, 234 (42%) reported that this problem was not applicable to their practice. The remaining 318 (58%) reported that, despite widespread recent changes in prophylactic regimens, fluoroquinolone monotherapy still was most common, but diverse alternate or supplemental oral and parenteral antibiotics (including imipenem) also were used. Reports of culture-guided prophylaxis were rare (9%). The most common duration of prophylaxis was a single prebiopsy antibiotic dose. However, 16%–23% of respondents reported prophylaxis continuing for ≥24 hours postbiopsy. Post-TRPB infections were reported as being more frequent now than 4 years ago, with sepsis and genitourinary presentations predominating, but with osteomyelitis, endocarditis, and epidural abscess also occurring. Infection isolates reportedly were usually resistant to the prophylactic regimen.

Conclusions. Emerging Infections Network members perceive post-TRPB infections as increasingly frequent, caused by resistant strains, and involving serious illness. Prophylactic approaches, although in flux, still usually entail ciprofloxacin monotherapy, which often is given for excessive durations. Multiple opportunities exist for infectious diseases specialists to partner with proceduralists in devising, studying, and implementing improved prophylaxis regimens for TRPB.

Successful management of a case of electrical storm due to invasive endocarditis

We present a 44-year-old man with invasive aortic and tricuspid valve endocarditis complicated by electrical storm, which was immediately diagnosed and successfully treated due to the patient's telemetry electrocardiogram (ECG). This case highlights a rare but potentially fatal complication in patients with invasive endocarditis and the need for very careful clinical evaluation and monitoring of these patients.