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Rodríguez-Montolio J, Meseguer-Gonzalez D, Almeida-Zurita M, Revilla-Martí P, Santos-Lasaosa S. Prevalence of neurological complications in infective endocarditis. Neurologia 2024; 39:443-448. [PMID: 37085083 DOI: 10.1016/j.nrleng.2021.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 09/24/2021] [Indexed: 04/23/2023] Open
Abstract
INTRODUCTION Neurological complications are the most frequent type of extracardiac complications of infective endocarditis (IE), and can be the initial manifestation. The objectives of this study were to determine the prevalence of neurological complications in patients with IE and to evaluate whether initial presentation with neurological symptoms causes a diagnostic delay. MATERIAL AND METHODS We conducted a retrospective observational study of patients with IE admitted to a tertiary hospital between 2003 and 2020. RESULTS The study included 222 patients with IE (67% men; mean [SD] age, 66.4 [14.2] years). Neurological complications occurred in 21.2% of patients, with ischaemic stroke (74.5%) and intracerebral haemorrhage (23.4%) being the most frequent. No differences in diagnostic delay were found between the group of patients in whom the disease manifested with neurological complications and the rest of the patients (4.4 vs 4.5; P = .76). CONCLUSIONS A total of 21.2% of patients with IE presented neurological complications, with ischaemic stroke being the most frequent. Neurological symptoms as the initial manifestation of IE did not lead to a delay in diagnosis.
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Affiliation(s)
- J Rodríguez-Montolio
- Servicio de Neurología del Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain.
| | - D Meseguer-Gonzalez
- Servicio de Cardiología del Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - M Almeida-Zurita
- Servicio de Neurología del Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - P Revilla-Martí
- Servicio de Cardiología del Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - S Santos-Lasaosa
- Servicio de Neurología del Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
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Álvarez-Zaballos S, Vázquez-Alen P, Muñoz P, de Alarcón A, Gutiérrez Carretero E, Álvarez-Uría A, Fariñas MC, Rodríguez-García R, Goenaga MÁ, Cuervo G, Plata-Ciezar A, Hidalgo-Tenorio C, Aldamiz-Echevarría G, Martínez-Sellés M. Prevalence and prognostic impact of stroke in a national cohort of infective endocarditis. Int J Stroke 2024:17474930241255560. [PMID: 38708722 DOI: 10.1177/17474930241255560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
BACKGROUND Stroke is a common complication of infective endocarditis (IE). Our aim was to describe the prevalence and prognostic impact of stroke in a national cohort of IE. METHODS Consecutive inclusion at 46 Spanish hospitals between 2008 and 2021. RESULTS Out of 5667 IE cases, 1125 had acute stroke (19.8%): 818 ischemic strokes (811 cardioembolic strokes (193 with hemorrhagic transformation), 4 transient ischemic attacks, 3 lacunar infarctions), 127 intracranial hemorrhages, and 27 other neurological complications (cerebral abscesses, encephalitis, and meningitis). Compared to patients without stroke, those with stroke had a similar mean age (69 years) but were more frequently female (68.2% vs 63.7%, p = 0.04) and had a higher incidence of intracardiac complications (35% vs 30%, p = 0.01), surgical indication (69.9% vs 65.9%, p = 0.001), in-hospital mortality (40.9% vs 22.0%, p < 0.001), and 1-year mortality (46.2% vs 27.9%, p < 0.001). The following variables were independently associated with stroke: mitral location (odds ratio (OR) = 1.5, 95% confidence interval (CI) = 1.34-1.8, p < 0.001), vascular phenomenon (OR = 2.9, 95% CI = 2.4-3.6, p = 0.0001), acute renal failure (OR = 1.2, 95% CI = 1.0-1.4, p = 0.021), septic shock (OR = 1.3, 95% CI = 1.1-1.6, p = 0.007), sepsis (OR = 1.3, 95% CI = 1.1-1.6, p = 0.005), surgery indicated but not performed (OR = 1.4, 95% CI = 1.2-1.7, p < 0.001), community-acquired IE (OR = 1.2, 95% CI = 1-1.4, p = 0.017), and peripheral embolization (OR = 1.6, 95% CI = 1.4-1.9, p < 0.001). Stroke was an independent predictor of in-hospital (OR = 2.1, 95% CI = 1.78-2.51, p < 0.001) and 1-year mortality (hazard ratio = 1.9, 95% CI = 1.6-2.5). CONCLUSION One-fifth of patients with IE have concomitant stroke. Stroke is associated with mortality.
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Affiliation(s)
- Sara Álvarez-Zaballos
- Cardiology Department, Hospital General Universitario Gregorio Marañón, CIBERCV, Madrid, Spain
| | - Pilar Vázquez-Alen
- Neurology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Patricia Muñoz
- Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain
- Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Arístides de Alarcón
- Infective Diseases, Microbiology and Parasitology Department, (UCEIMP), Hospital Virgen del Rocío Seville, Seville, Spain
- Grupo de Resistencias bacterianas y antimicrobianos (CIBERINFEC), Madrid, Spain
- Institute of Biomedicine of Seville (IBiS), Seville, Spain
- University of Seville/CSIC, Seville, Spain
| | - Encarnación Gutiérrez Carretero
- Institute of Biomedicine of Seville (IBiS), Seville, Spain
- University of Seville/CSIC, Seville, Spain
- Cardiac Surgery Service CIBERCV, Hospital Virgen del Rocío Seville, Seville, Spain
| | - Ana Álvarez-Uría
- Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Mª Carmen Fariñas
- Infectious Diseases Department, Hospital Universitario Marqués de Valdecilla IDIVAL, Santander, Spain
- CIBER de Enfermedades Infecciosas-CIBERINFEC (CB21/13/00068), Instituto de Salud Carlos III, Madrid, Spain
- University of Cantabria, Santander, Spain
| | - Raquel Rodríguez-García
- Intensive Medicine Department, Hospital Universitario Central de Asturias, Oviedo, Spain
- University of Oviedo, Oviedo, Spain
| | - Miguel Ángel Goenaga
- Infectious Diseases Department, Hospital Universitario Donosti, ISS Biodonostia, San Sebastián, Spain
| | - Guillermo Cuervo
- Infectious Diseases Department, Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Antonio Plata-Ciezar
- Infectious Diseases Department, UGC de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Regional Universitario de Málaga, IBIMA, Málaga, Spain
| | - Carmen Hidalgo-Tenorio
- Internal Medicine Department, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Gonzalo Aldamiz-Echevarría
- Cardiac Surgery Department, Hospital Universitario Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Madrid, Spain
| | - Manuel Martínez-Sellés
- Cardiology Department, Hospital General Universitario Gregorio Marañón, CIBERCV, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
- Universidad Europea, Madrid, Spain
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Dai M, Suzuki K, Sato H, Tabata S, Kume H, Nishikata M, Tamada K, Ooigawa H, Kurita H. Intracranial mycotic aneurysm rupture following cupping therapy. Surg Neurol Int 2024; 15:119. [PMID: 38742002 PMCID: PMC11090582 DOI: 10.25259/sni_99_2024] [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] [Received: 02/10/2024] [Accepted: 03/15/2024] [Indexed: 05/16/2024] Open
Abstract
Background Cupping therapy is an alternative treatment that uses a small glass cup to suck the skin with a needle and has been used to manage skin problems and pain. However, serious complications have been reported. Herein, we describe a case of intracranial mycotic aneurysm rupture after cupping therapy. Case Description A 25-year-old male patient presented with a headache and fever after cupping therapy for atopic dermatitis. He was diagnosed with infective endocarditis, and antibiotic therapy was initiated. After that, he suddenly lost consciousness, and head imaging revealed a cerebral hemorrhage due to a ruptured intracranial mycotic aneurysm. He underwent craniotomy, which was successful, and he was transferred to a rehabilitation center with a modified Rankin scale score of 2 at three months post-stroke. Conclusion This case serves as a reminder of life-threatening infectious complication risks after cupping therapy. A patient who has a compromised skin barrier may experience serious adverse effects, especially when cupping is performed without implementing suitable infection prevention measures.
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Affiliation(s)
| | - Kaima Suzuki
- Department of Cerebrovascular Surgery, International Medical Center, Saitama Medical University, Hidaka, Japan
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Fernández-Cisneros A, Andreu A, Hernández-Meneses M, Llopis J, Sandoval E, Pereda D, Alcocer J, Castellá M, Miró JM, Quintana E. Does Quality of Life in Survivors of Surgery for Acute Left-Sided Infective Endocarditis Differ from Non-Endocarditis Patients? Microorganisms 2023; 11:microorganisms11041058. [PMID: 37110481 PMCID: PMC10142739 DOI: 10.3390/microorganisms11041058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 04/29/2023] Open
Abstract
Surgery for left-sided infective endocarditis (IE) has been demonstrated to improve patients' survival rates but information about quality of life (QoL) after surgery is scarce. The aim of this study was to assess the postoperative outcomes and QoL after surgery for IE patients compared to patients undergoing cardiac surgery for non-IE indications. Adult patients with definite acute left-sided IE were matched 1:1 to patients who underwent cardiac surgery for non-endocarditic purposes from 2014 to 2019. QoL was assessed using the SF-36 survey at the last follow-up. A total of 105 patients were matched. The IE group had higher rates of preoperative stroke (21% vs. 7.6%, p = 0.005) and higher stages of NYHA class (p < 0.001), EuroSCORE II (12.3 vs. 3.0, p < 0.001) and blood cell count abnormalities (p < 0.001). The IE group had higher incidence of low cardiac output syndrome (13.3% vs. 4.8%, p = 0.029), dialysis (10.5% vs 1.0%, p = 0.007) and prolonged mechanical ventilation (16.2% vs. 2.9%, p = 0.002) after surgery. At the last follow-up, subcomponents of the SF-36 QoL survey were not different between the groups. Patients who underwent cardiac surgery for IE demonstrated a higher risk profile with a higher rate of postoperative complications. Once recovered from the acute phase of the disease, the reported QoL at follow-up was comparable to that of matched cardiac patients operated for non-IE purposes.
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Affiliation(s)
| | - Aida Andreu
- Cardiovascular Surgery Department, Hospital Clinic-IDIBAPS, University of Barcelona, 08036 Barcelona, Spain
| | - Marta Hernández-Meneses
- Infectious Diseases Department, Hospital Clinic-IDIBAPS, University of Barcelona, 08036 Barcelona, Spain
| | - Jaume Llopis
- Department of Genetics, Microbiology and Statistics, Faculty of Biology, University of Barcelona, 08036 Barcelona, Spain
| | - Elena Sandoval
- Cardiovascular Surgery Department, Hospital Clinic-IDIBAPS, University of Barcelona, 08036 Barcelona, Spain
| | - Daniel Pereda
- Cardiovascular Surgery Department, Hospital Clinic-IDIBAPS, University of Barcelona, 08036 Barcelona, Spain
| | - Jorge Alcocer
- Cardiovascular Surgery Department, Hospital Clinic-IDIBAPS, University of Barcelona, 08036 Barcelona, Spain
| | - Manuel Castellá
- Cardiovascular Surgery Department, Hospital Clinic-IDIBAPS, University of Barcelona, 08036 Barcelona, Spain
| | - Jose M Miró
- Infectious Diseases Department, Hospital Clinic-IDIBAPS, University of Barcelona, 08036 Barcelona, Spain
- CIBERINFEC, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Eduard Quintana
- Cardiovascular Surgery Department, Hospital Clinic-IDIBAPS, University of Barcelona, 08036 Barcelona, Spain
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Musthafa I, Kandel D, Rajlawot K, Neupane NP, Sitaula A. Infective endocarditis complicated by cerebral abscess and mycotic intracranial aneurysm: A case report. Radiol Case Rep 2022; 17:3690-3693. [PMID: 35942268 PMCID: PMC9356087 DOI: 10.1016/j.radcr.2022.06.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/13/2022] [Accepted: 06/21/2022] [Indexed: 11/25/2022] Open
Abstract
Infective endocarditis (IE), is an infection of the endocardial surfaces of the heart, which primarily affects the valve leaflets, the mural endocardium, chordae tendinae and prosthetic valves among others. IE has various complications among which neurological complications include stroke, infected intracranial aneurysms, intracranial abscesses, meningitis, encephalopathy and seizures which could prove fatal if not treated on time. We report a case of a 17 year old girl, who was a known case of bacterial endocarditis that presented with sudden onset deterioration of mental status, fever and dizziness. On CT scan imaging of the brain, the patient showed features of intracranial abscess and mycotic aneurysm. Since early detection, diagnosis and timely management is crucial for the prognosis of the patient, we should always opt for timely imaging in patients of infective endocarditis with neurological symptoms.
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Optimal Timing for Cardiac Surgery in Infective Endocarditis with Neurological Complications: A Narrative Review. J Clin Med 2022; 11:jcm11185275. [PMID: 36142922 PMCID: PMC9501443 DOI: 10.3390/jcm11185275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/26/2022] [Accepted: 09/01/2022] [Indexed: 11/17/2022] Open
Abstract
In patients with infective endocarditis and neurological complications, the optimal timing for cardiac surgery is unclear due to the varied risk of clinical deterioration when early surgery is performed. The aim of this review is to summarize the best evidence on the optimal timing for cardiac surgery in the presence of each type of neurological complication. An English literature search was carried out from June 2018 through July 2022. The resulting selection, comprising observational studies, clinical trials, systematic reviews and society guidelines, was organized into four sections according to the four groups of neurological complications: ischemic, hemorrhagic, infectious, and asymptomatic complications. Cardiac surgery could be performed without delay in cases of ischemic vascular neurological complication (provided the absence of severe damage, which can be avoided with the performance of mechanical thrombectomy in cases of major stroke), as well as infectious or asymptomatic complications. In the presence of intracranial hemorrhage, a delay of four weeks is recommended for most cases, although recent studies have suggested that performing cardiac surgery within four weeks could be a suitable option for selected cases. The findings of this review are mostly in line with the recommendations of the current European and American infective endocarditis guidelines.
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Pothiawala S, Tanaka Y. Thinking out of the cranial box in meningitis. Aging Med (Milton) 2022; 5:142-144. [PMID: 35783111 PMCID: PMC9245173 DOI: 10.1002/agm2.12204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 03/12/2022] [Accepted: 03/21/2022] [Indexed: 11/22/2022] Open
Abstract
Staphylococcus aureus is a leading cause of infective endocarditis. Meningitis is a rare initial presenting feature of S. aureus infective endocarditis, especially with the absence of other cardio-vascular signs. Differentiating patients with uncomplicated S. aureus bacteraemia from those with underlying infective endocarditis is often challenging.
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Affiliation(s)
- Sohil Pothiawala
- Department of Emergency MedicineWoodlands HealthSingaporeSingapore
| | - Yuki Tanaka
- Department of Emergency MedicineWoodlands HealthSingaporeSingapore
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Impact of Brain MRI on the Diagnosis of Infective Endocarditis and Treatment Decisions: Systematic Review and Meta-Analysis. AJR Am J Roentgenol 2022; 218:958-968. [PMID: 35043667 DOI: 10.2214/ajr.21.26896] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND. Despite increasing use of brain MRI to evaluate patients with suspected infective endocarditis, the clinical impact of brain MRI in this setting has not yet been systematically reviewed. OBJECTIVE. The purpose of this study was to evaluate the frequency of brain MRI findings in patients with suspected or confirmed infective endocarditis and to determine the impact of such findings on clinical decisions. EVIDENCE ACQUISITION. A systematic search of the PubMed, Embase, and Cochrane databases was performed from January 1, 1990, to December 31, 2020, to identify original research investigations of brain MRI in patients with suspected or confirmed infective endocarditis. Study quality was assessed with QUADAS-2. Study endpoints included the frequency of brain MRI findings and the frequency of diagnostic modifications, modification of therapeutic plan, and modification of valve surgery plan resulting from MRI findings. Frequencies were pooled by means of the inverse variance method. Subgroup analysis was performed. EVIDENCE SYNTHESIS. A total of 21 studies with 2133 patients were included. Overall study quality was considered moderate. In terms of brain MRI findings, the pooled frequency of acute ischemic lesions was 61.9% (95% CI, 50.7-71.9%); of cerebral microbleeds, 52.9% (95% CI, 41.6-63.9%); hemorrhagic lesions, 24.7% (95% CI, 15.1-37.9%); abscess or meningitis, 9.5% (95% CI, 5.6-15.6%); and intracranial mycotic aneurysm, 6.2% (95% CI, 4.0-9.4%). Subgroup analysis after exclusion of three studies in which neurologic findings were the indication for all brain MRI examinations yielded similar frequencies of these findings. Six studies included results on the impact of brain MRI findings on clinical decisions. The frequencies of diagnostic modifications in two studies were 5.4% and 32.1%. The pooled frequency of therapeutic plan modification in six studies was 12.8% (95% CI, 6.5-23.7%) and of surgical plan modification in five studies was 14.2% (95% CI, 8.2-23.4%). CONCLUSION. In patients with suspected or confirmed infective endocarditis, brain MRI examinations commonly show relevant abnormalities that affect diagnostic and therapeutic clinical decisions. CLINICAL IMPACT. The findings support a potential role for screening brain MRI in the evaluation of patients with suspected or confirmed infective endocarditis, regardless of the presence or absence of neurologic symptoms.
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Giri S, Shrestha B, Gajurel BP, Sapkota D, Gautam N, Shrestha A. Staphylococcal endocarditis with meningitis and basal ganglia infarcts mimicking meningococcemia. Clin Case Rep 2022; 10:e05548. [PMID: 35261776 PMCID: PMC8888920 DOI: 10.1002/ccr3.5548] [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] [Received: 01/10/2022] [Accepted: 02/16/2022] [Indexed: 12/03/2022] Open
Abstract
Staphylococcus aureus is one of the common causes of infective endocarditis (IE). IE can present with various neurological complications such as stroke, brain abscess, and meningitis, the mortality rate can be very high in such cases.
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Affiliation(s)
- Subarna Giri
- Maharajgunj Medical CampusTribhuvan University Institute of MedicineKathmanduNepal
| | - Bhushan Shrestha
- Maharajgunj Medical CampusTribhuvan University Institute of MedicineKathmanduNepal
| | | | - Dharmendra Sapkota
- Maharajgunj Medical CampusTribhuvan University Institute of MedicineKathmanduNepal
| | - Niraj Gautam
- Department of NeurologyTribhuvan University Institute of MedicineKathmanduNepal
| | - Ashish Shrestha
- Department of NeurologyTribhuvan University Institute of MedicineKathmanduNepal
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Rodríguez-Montolio J, Meseguer-Gonzalez D, Almeida-Zurita M, Revilla-Martí P, Santos-Lasaosa S. Prevalencia de las complicaciones neurológicas en la endocarditis infecciosa. Neurologia 2022. [DOI: 10.1016/j.nrl.2021.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Alegria S, Marques A, Cruz I, Broa AL, Pereira ARF, João I, Simões O, Pereira H. Neurological Complications in Patients with Infective Endocarditis: Insights from a Tertiary Centre. Arq Bras Cardiol 2021; 116:682-691. [PMID: 33886711 PMCID: PMC8121414 DOI: 10.36660/abc.20190586] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 12/27/2019] [Indexed: 12/13/2022] Open
Abstract
Fundamento: Complicações neurológicas são comuns em pacientes com endocardite infecciosa (EI). Dados recentes sugerem que os eventos neurológicos são os principais determinantes do prognóstico e que a cirurgia é crítica para melhorar o resultado. Objetivo: Caracterizar pacientes com EI e complicações neurológicas e determinar preditores de embolização para o sistema nervoso central (SNC) e mortalidade. Métodos: Análise retrospectiva de pacientes internados em centro terciário com diagnóstico de EI no período de 2006 a 2016. Significância estatística foi definida por um valor de p <0,05. Resultados: Identificamos 148 episódios de EI, 20% dos quais tinham evidências de embolização do SNC. Em pacientes com embolização do SNC, 76% apresentaram acidente vascular cerebral isquêmico. Durante o seguimento, 35% foram submetidos à cirurgia e a mortalidade hospitalar e em um ano foi de 39%. Esses pacientes tiveram hospitalizações mais longas, mas não houve diferenças significativas em relação à mortalidade em pacientes com e sem embolização do SNC. Os preditores independentes de complicações neurológicas foram diabetes (p = 0,005) e ausência de febre na apresentação (p = 0,049). A cirurgia foi associada a menor mortalidade (0 vs. 58%; p = 0,003), enquanto os pacientes com choque séptico tiveram pior prognóstico (75 vs. 25%; p = 0,014). Na regressão multivariada de Cox, a infecção pelo vírus da imunodeficiência humana (HIV) foi o único preditor independente de mortalidade hospitalar e de 1 ano (p = 0,011 em ambos). Conclusões: Nessa população, a embolização para o SNC foi comum, mais frequentemente apresentada como acidente vascular cerebral isquêmico, e esteve associada a maior tempo de internação, embora sem diferenças significativas na mortalidade. Nos pacientes com embolização do SNC, os submetidos à cirurgia tiveram boa evolução clínica, enquanto os pacientes com choque séptico e infecção pelo HIV tiveram pior evolução. Esses resultados devem ser interpretados com cautela, levando em consideração que os pacientes com complicações mais graves ou mais frágeis foram provavelmente menos considerados para a cirurgia, resultando em viés de seleção.
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Affiliation(s)
- Sofia Alegria
- Hospital Garcia de Orta EPE - Cardiologia,1 Almada - Portugal
| | - Ana Marques
- Hospital Garcia de Orta EPE - Cardiologia,1 Almada - Portugal
| | - Inês Cruz
- Hospital Garcia de Orta EPE - Cardiologia,1 Almada - Portugal
| | - Ana Luísa Broa
- Hospital Garcia de Orta EPE - Cardiologia,1 Almada - Portugal
| | | | - Isabel João
- Hospital Garcia de Orta EPE - Cardiologia,1 Almada - Portugal
| | - Otília Simões
- Hospital Garcia de Orta EPE - Cardiologia,1 Almada - Portugal
| | - Hélder Pereira
- Hospital Garcia de Orta EPE - Cardiologia,1 Almada - Portugal
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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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Congenital Heart Disease and Risk of Central Nervous System Infections: A Nationwide Cohort Study. Pediatr Cardiol 2020; 41:869-876. [PMID: 32162026 DOI: 10.1007/s00246-020-02324-z] [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: 11/01/2019] [Accepted: 02/17/2020] [Indexed: 12/30/2022]
Abstract
Congenital heart disease (CHD) is associated with risk factors of central nervous system (CNS) infections including infective endocarditis, cardiac shunt physiology, and immune deficiencies. We aimed to investigate the risk of CNS infections in the CHD population compared to the general population. In this cohort study, we used Danish nationwide medical registries to identify individuals diagnosed with CHD at any age, born between 1977 and 2012. For each CHD individual, we matched 10 individuals on sex and birth year from the general population. Subjects were followed until first-time hospital diagnosis of CNS infection, death, emigration, or end of study. We computed cumulative incidences of CNS infections with death as a competing risk, as well as hazard ratios (HRs) with corresponding 95% confidence intervals (CIs) adjusted for birth year and sex. We identified 17,550 individuals with CHD (50% male). Among subjects with CHD, the cumulative incidence of CNS infection at age 30 years was 1.0% compared to 0.6% in the general population. The overall HR of CNS infections in CHD subjects relative to the general population was 2.1 (95% CI 1.6-2.7). The HR was 1.9 (95% CI 1.4-2.7) for mild to moderate CHD, 2.1 (95% CI 1.3-3.3) for severe CHD and 3.0 (95% CI 1.1-8.2) for univentricular physiology. The HR for CHD subjects without record of infective endocarditis was 2.0 (95% CI 1.5-2.5). The risk of CNS infections was increased among individuals with CHD compared to the general population, and the risk was not limited to individuals with infective endocarditis.
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Neurologic Complications of Infective Endocarditis: A Joint Model for a Septic Thromboembolism and Inflammatory Small Vessel Disease. Crit Care Med 2020; 47:e685-e692. [PMID: 31149963 DOI: 10.1097/ccm.0000000000003796] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES Embolic events from vegetations are commonly accepted as the main mechanism involved in neurologic complications of infective endocarditis. The pathophysiology may imply other phenomena, including vasculitis. We aimed to define the cerebral lesion spectrum in an infective endocarditis rat model. DESIGN Experimental model of Staphylococcus aureus or Enterococcus faecalis infective endocarditis. Neurologic lesions observed in the infective endocarditis model were compared with three other conditions, namely bacteremia, nonbacterial thrombotic endocarditis, and healthy controls. SETTING Research laboratory of a university hospital. SUBJECTS Male Wistar rats. INTERVENTIONS Brain MRI, neuropathology, immunohistochemistry for astrocyte and microglia, and bacterial studies on brain tissue were used to characterize neurologic lesions. MEASUREMENTS AND MAIN RESULTS In the infective endocarditis group, MRI revealed at least one cerebral lesion in 12 of 23 rats (52%), including brain infarctions (n = 9/23, 39%) and cerebral microbleeds (n = 8/23, 35%). In the infective endocarditis group, neuropathology revealed brain infarctions (n = 12/23, 52%), microhemorrhages (n = 10/23, 44%), and inflammatory processes (i.e., cell infiltrates including abscesses, vasculitis, meningoencephalitis, and/or ependymitis; n = 11/23, 48%). In the bacteremia group, MRI studies were normal and neuropathology revealed only hemorrhages (n = 2/11, 18%). Neuropathologic patterns observed in the nonbacterial thrombotic endocarditis group were similar to those observed in the infective endocarditis group. Immunochemistry revealed higher microglial activation in the infective endocarditis group (n = 11/23, 48%), when compared with the bacteremia (n = 1/11, 9%; p = 0.03) and nonbacterial thrombotic endocarditis groups (n = 0/7, 0%; p = 0.02). CONCLUSIONS This original model of infective endocarditis recapitulates the neurologic lesion spectrum observed in humans and suggests synergistic mechanisms involved, including thromboembolism and cerebral vasculitis, promoted by a systemic bacteremia-mediated inflammation.
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Acute Ischemic Stroke Treatment in Infective Endocarditis: Systematic Review. J Stroke Cerebrovasc Dis 2020; 29:104598. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.104598] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 12/07/2019] [Accepted: 12/09/2019] [Indexed: 01/16/2023] Open
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Xu N, Fu Y, Wang S, Li S, Cai D. High level of D-dimer predicts ischemic stroke in patients with infective endocarditis. J Clin Lab Anal 2020; 34:e23206. [PMID: 32017240 PMCID: PMC7246349 DOI: 10.1002/jcla.23206] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 12/08/2019] [Accepted: 12/18/2019] [Indexed: 12/11/2022] Open
Abstract
Background Ischemic stroke is one of the most prominent and serious neurological complications of infective endocarditis (IE). Our study was designed to evaluate the predictive value of higher level of plasma D‐dimer on admission for the development of ischemic stroke in patients with IE. Methods In this prospective study, a total of 173 consecutive patients with IE were recruited from January 2016 to December 2018. Plasma D‐dimer and other clinical indexes of IE patients were measured after admission. The number of patients who developed ischemic stroke during 6‐month follow‐up was recorded, as well as the occurrence time of ischemic stroke. Results Ischemic stroke was observed in 38 (22%) patients during 6‐month follow‐up since definite diagnosis of IE. Patients with ischemic stroke had significantly higher levels of plasma D‐dimer than those of patients without stroke (4982 vs 2205 μg/L, P < .001). In addition, Staphylococcus aureus infection (HR: 1.96, 95% CI: 1.51‐2.42), mitral valve vegetation (HR: 1.52, 95% CI: 1.32‐1.75), and higher levels of on‐admission plasma D‐dimer (HR: 1.35, 95% CI: 1.27‐1.43) were significantly associated with ischemic stroke. Moreover, D‐dimer levels ≥3393 μg/L served as a strong predictor for ischemic stroke in patients with IE, and the sensitivity and specificity were 78% and 83%, respectively. Conclusion Our study suggested that higher level of D‐dimer on admission was an independent predictor for ischemic stroke in patients with IE. These patients may require special attention, in particular within the first trimester after IE diagnosis.
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Affiliation(s)
- Nan Xu
- Department of Infectious Diseases, Tianjin Medical University General Hospital, Tianjin, China
| | - Yakun Fu
- NHC Key Laboratory of Hormones and Development (Tianjin Medical University), Tianjin Key Laboratory of Metabolic Diseases, Tianjin Medical University Chu Hsien-I Memorial Hospital & Tianjin Institute of Endocrinology, Tianjin, China
| | - Shuanglin Wang
- Department of Cardio-Thoracic Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Shenghui Li
- Department of Neurosurgery, Key Laboratory of Post-Neurotrauma Neurorepair and Regeneration in Central Nervous System Ministry of Education in China and Tianjin, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Dong Cai
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China
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Venn RA, Ning M, Vlahakes GJ, Wasfy JH. Surgical timing in infective endocarditis complicated by intracranial hemorrhage. Am Heart J 2019; 216:102-112. [PMID: 31422194 DOI: 10.1016/j.ahj.2019.07.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 07/13/2019] [Indexed: 12/24/2022]
Abstract
Given the growing incidence of infective endocarditis (IE), understanding the risks and benefits of valvular surgery is critical. This decision is particularly complex for the 1 in 10 cases complicated by intracranial hemorrhage (ICH). While guideline recommendations currently favor early surgery in general, delayed intervention of at least 4 weeks is still recommended for patients with ICH. To date, there are no randomized controlled trials that inform management of patients with an indication for surgery but concomitant ICH, and even reported observational data are rare. This paper reviews the current literature on timing of surgery with a specific focus on cases of ICH. It emphasizes a growing body of literature challenging the current paradigm that surgery within 4 weeks is associated with neurologic deterioration and high mortality rates by demonstrating favorable outcomes for patients with pre-operative ICH who undergo early valvular surgery. Based on these data, we propose a practical management algorithm to facilitate decisions on surgical timing in these complicated cases. Since more rigorous evidence may never be available, clinicians should make patient-specific surgical timing decisions that attempt to balance the competing risks of neurologic versus cardiac complications.
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Affiliation(s)
- Rachael A Venn
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - MingMing Ning
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Gus J Vlahakes
- Cardiac Surgery Division, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jason H Wasfy
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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The imaging features of cerebral septic infarction in two patients with infective endocarditis. Neurol Sci 2018; 40:899-903. [PMID: 29948467 DOI: 10.1007/s10072-018-3467-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 06/02/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Neurologic complications are frequently seen in infective endocarditis (IE) and were identified in about 70% of patients with IE. However, the imaging features of the cerebral septic infarction were less investigated. PURPOSE To demonstrate the imaging features of the cerebral septic infarction of IE. MATERIAL AND METHODS Two patients were clinically diagnosed as IE according to the modified Duke criterion. We studied their imaging profiles and reviewed the literature of the imaging features of neurologic complications of IE. RESULTS The critical features are multiple ischemic and hemorrhagic lesions, most of which locate at the cortical-medullary junction. The septic infarctions are irregular patchy in shape and have characteristic imaging features indicating complications of IE. CONCLUSION Magnetic resonance imaging (MRI) with different sequences can detect the features and provide clinical evidence to physicians to make the correct diagnoses and then the treatment plans.
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Ilhão Moreira R, Coutinho Cruz M, Moura Branco L, Galrinho A, Coutinho Miranda L, Fragata J, Cruz Ferreira R. Infective endocarditis: Surgical management and prognostic predictors. Rev Port Cardiol 2018; 37:387-394. [PMID: 29731322 DOI: 10.1016/j.repc.2017.08.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 06/26/2017] [Accepted: 08/05/2017] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION AND AIM Infective endocarditis (IE) is associated with high morbidity and mortality. It is important to determine which factors increase the risk of poor outcome in order to enable early detection and aggressive treatment, including surgery. The aim of our study was to identify factors predicting complications and in-hospital mortality in patients with IE and to analyze conditions predisposing to surgery and its outcome. METHODS We performed a retrospective study including patients with IE who underwent transesophageal echocardiography in a tertiary hospital center (2006-2014). RESULTS A total of 233 patients were analyzed (69.1% male; mean age 63.4±15.2 years; mean follow-up 28.4±30.7 months). The complication rate was 56.6% and in-hospital mortality was 16.3%. Independent predictors of mortality were chronic obstructive pulmonary disease (OR 4.89; CI 1.36-17.63; p=0.015), clinical course complicated by cerebral embolism (OR 9.38; CI 3.26-26.96; p<0.001), and IE due to Staphylococcus spp. (OR 3.78; CI 1.32-10.85; p=0.014) and non-HACEK Gram-negative bacilli (OR 12.85; CI 2.61-63.23; p=0.002). Surgery was performed in 36.9%. This group had higher percentages of males, younger patients, aortic valve IE, large vegetations, perivalvular extension, severe valvular regurgitation and heart failure. In patients with surgical indication (n=133), those who underwent surgery had lower in-hospital mortality (15.5% vs. 32.6%, p=0.028) and better long-term survival (log-rank p=0.029). CONCLUSION The results of this study may help to identify IE patients who are at increased risk of worse outcome, offering the opportunity to change the course of the disease and to improve prognosis with earlier and more aggressive intervention.
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Affiliation(s)
- Rita Ilhão Moreira
- Serviço de Cardiologia, Hospital de Santa Marta, Centro Hospitalar de Lisboa Central, Lisboa, Portugal.
| | - Madalena Coutinho Cruz
- Serviço de Cardiologia, Hospital de Santa Marta, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Luísa Moura Branco
- Serviço de Cardiologia, Hospital de Santa Marta, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Ana Galrinho
- Serviço de Cardiologia, Hospital de Santa Marta, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Luís Coutinho Miranda
- Serviço de Cirurgia Cardiotorácica, Hospital de Santa Marta, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - José Fragata
- Serviço de Cirurgia Cardiotorácica, Hospital de Santa Marta, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Rui Cruz Ferreira
- Serviço de Cardiologia, Hospital de Santa Marta, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
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Ilhão Moreira R, Coutinho Cruz M, Moura Branco L, Galrinho A, Coutinho Miranda L, Fragata J, Cruz Ferreira R. Infective endocarditis: Surgical management and prognostic predictors. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.repce.2017.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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21
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Yuan SM, Wang GF. Cerebral mycotic aneurysm as a consequence of infective endocarditis: A literature review. COR ET VASA 2017. [DOI: 10.1016/j.crvasa.2016.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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22
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Morotti A, Gamba M, Costa P, Poli L, Gilberti N, Delrio I, Mardighian D, Gasparotti R, Padovani A, Pezzini A. Infective Endocarditis Presenting with Intracranial Bleeding. J Emerg Med 2016; 51:50-4. [PMID: 27236244 DOI: 10.1016/j.jemermed.2016.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 02/24/2016] [Accepted: 04/05/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Infective endocarditis (IE) can be complicated by intracranial bleeding (ICB) caused by different pathologic mechanisms. The occurrence of ICB in patients with IE significantly influences therapeutic decisions and has a negative impact on outcome. CASE REPORT We describe the clinical courses of 3 patients with aortic prosthetic valve IE presenting with ICB. Patients 1 and 2 experienced subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH), respectively, caused by rupture of an intracranial infectious aneurysm (IIA). Both underwent endovascular treatment of IIA with good outcome. In patient 3, ICB was the hemorrhagic conversion of an acute ischemic lesion from septic brain embolization. In the subacute phase of the disease, aortic valve replacement was performed, with excellent outcome. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: ICB is a relevant complication and sometimes the first clinical feature of IE. Imaging of brain vessels should be performed to investigate the pathologic mechanism underlying ICB. The prevalence of IIA is probably underestimated and may influence the therapeutic strategy. Cerebrovascular imaging may therefore also be considered in asymptomatic subjects with left-sided IE. Withdrawal of anticoagulant treatment and delay of cardiac surgery are recommended in all cases of IE complicated by ICB. Because of the impact of ICB on IE management and outcome, a high level of clinical suspicion and prompt recognition and treatment of this complication are necessary.
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Affiliation(s)
- Andrea Morotti
- Dipartimento di Scienze Cliniche e Sperimentali, Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italy
| | - Massimo Gamba
- Dipartimento di Scienze Neurologiche e della Visione, Neurologia Vascolare, Spedali Civili di Brescia, Brescia, Italy
| | - Paolo Costa
- Dipartimento di Scienze Cliniche e Sperimentali, Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italy
| | - Loris Poli
- Dipartimento di Scienze Cliniche e Sperimentali, Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italy
| | - Nicola Gilberti
- Dipartimento di Scienze Neurologiche e della Visione, Neurologia Vascolare, Spedali Civili di Brescia, Brescia, Italy
| | - Ilenia Delrio
- Dipartimento di Scienze Neurologiche e della Visione, Neurologia Vascolare, Spedali Civili di Brescia, Brescia, Italy
| | - Dikran Mardighian
- Dipartimento di Diagnostica per Immagini, Neuroradiologia, Università degli Studi di Brescia, Brescia, Italy
| | - Roberto Gasparotti
- Dipartimento di Diagnostica per Immagini, Neuroradiologia, Università degli Studi di Brescia, Brescia, Italy
| | - Alessandro Padovani
- Dipartimento di Scienze Cliniche e Sperimentali, Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italy
| | - Alessandro Pezzini
- Dipartimento di Scienze Cliniche e Sperimentali, Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italy
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Affiliation(s)
- B Cherie Millar
- Northern Ireland Public Health Laboratory, Department of Bacteriology, Belfast City Hospital, Belfast, UK
| | - Gilbert Habib
- Aix-Marseille Université, Marseille, France Cardiology Department, APHM, La Timone Hospital, Marseille, France
| | - John E Moore
- Northern Ireland Public Health Laboratory, Department of Bacteriology, Belfast City Hospital, Belfast, UK
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Abstract
A wide range of infections (virus, bacteria, parasite and fungi) may cause cerebral vasculitides. Headache, seizures, encephalopathy and stroke are common forms of presentation. Infection and inflammation of intracranial vessels may cause pathological vascular remodelling, vascular occlusion and ischemia. Vasculitis in chronic meningitis may cause ischemic infarctions, and is associated with poor outcome. Appropriate neuroimaging (CT-angiography, MR-angiography, conventional 4-vessel angiography) and laboratory testing (specific antibodies in blood and CSF, CSF culture and microscopy) and even brain biopsy are needed to quickly establish the aetiology. Enhancement of contrast, wall thickening and lumen narrowing are radiological signs pointing to an infectious vasculitis origin. Although corticosteroids and prophylactic antiplatelet therapy have been used in infectious cerebral vasculitis, there are no randomized clinical trials that have evaluated their efficacy and safety. Stable mycotic aneurysms can be treated with specific antimicrobial therapy. Endovascular therapy and intracranial surgery are reserved for ruptured aneurysms or enlarging unruptured aneurysms.
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Affiliation(s)
- Francisco Javier Carod Artal
- a Neurology Department , Raigmore hospital , Inverness , UK.,b Health Sciences Faculty , Universitat Internacional de Catalunya (UIC) , Barcelona , Spain
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25
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Medani S, O'Callaghan P. Rare manifestations of infective endocarditis: the long known, never to be forgotten diagnosis. BMJ Case Rep 2015. [PMID: 26219292 DOI: 10.1136/bcr-2015-211276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Infective endocarditis (IE) is a life-threatening condition often manifesting as a multisystem disease; its heterogeneous features present a diagnostic challenge. We report two cases of IE masquerading as rare extracardiac complications: a splenectomised patient with a periarticular ankle abscess and acute encephalopathy; and a young man with a cutaneous vasculitis following a spontaneous intracerebral haemorrhage. In both cases, the diagnosis was suspected following detection of afebrile bacteraemia and confirmed with echocardiography. Risk factors included a pneumococcal bacteraemia in the asplenic patient and a previously undiagnosed bicuspid aortic valve in the second patient. Both patients recovered well with appropriate antibiotic therapy followed by valve surgery. IE is an important diagnosis to consider in patients with systemic symptoms or organ specific, otherwise unexplained relevant pathology especially in the presence of a cardiac murmur or risk factors for IE including structural heart disease, prosthetic valves or intravascular devices, and in immunosuppressed patients.
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Affiliation(s)
- Samar Medani
- Department of Cardiology, University Hospital Waterford, Waterford, Ireland
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Merkler AE, Chu SY, Lerario MP, Navi BB, Kamel H. Temporal relationship between infective endocarditis and stroke. Neurology 2015; 85:512-6. [PMID: 26163428 DOI: 10.1212/wnl.0000000000001835] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 04/08/2015] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE Stroke frequently complicates infective endocarditis (IE). However, the temporal relationship between these diseases is uncertain. METHODS We performed a retrospective study of adult patients hospitalized for IE between July 1, 2007, and June 30, 2011, at nonfederal acute care hospitals in California. Previously validated diagnosis codes were used to identify the primary composite outcome of ischemic or hemorrhagic stroke during discrete 1-month periods from 6 months before to 6 months after the diagnosis of IE. The odds of stroke in these periods were compared with the odds of stroke in the corresponding 1-month period 2 years earlier, which was considered the baseline risk of stroke. RESULTS Among 17,926 patients with IE, 2,275 strokes occurred within the 12-month period surrounding the diagnosis of IE. The risk of stroke was highest in the month after diagnosis of IE (1,640 vs 17 strokes in the corresponding month 2 years prior). This equaled an absolute risk increase of 9.1% (95% confidence interval 8.6%-9.5%) and an odds ratio of 96.5 (95% confidence interval 60.1-166.0). Stroke risk was significantly increased beginning 4 months before the diagnosis of IE and lasting 5 months afterward. Similar temporal patterns were seen when ischemic and hemorrhagic strokes were considered separately. CONCLUSIONS The association between IE and stroke persists for longer than previously reported. Most diagnoses of stroke and IE are made close together in time, but a period of heightened stroke risk becomes apparent several months before the diagnosis of IE and lasts for several months afterward.
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Affiliation(s)
- Alexander E Merkler
- From the Department of Neurology (A.E.M., M.P.L., B.B.N., H.K.) and Feil Family Brain and Mind Research Institute (B.B.N., H.K.), Weill Cornell Medical College, New York, NY; and Department of Neurology (S.Y.C.), Yale School of Medicine, New Haven, CT.
| | - Stacy Y Chu
- From the Department of Neurology (A.E.M., M.P.L., B.B.N., H.K.) and Feil Family Brain and Mind Research Institute (B.B.N., H.K.), Weill Cornell Medical College, New York, NY; and Department of Neurology (S.Y.C.), Yale School of Medicine, New Haven, CT
| | - Michael P Lerario
- From the Department of Neurology (A.E.M., M.P.L., B.B.N., H.K.) and Feil Family Brain and Mind Research Institute (B.B.N., H.K.), Weill Cornell Medical College, New York, NY; and Department of Neurology (S.Y.C.), Yale School of Medicine, New Haven, CT
| | - Babak B Navi
- From the Department of Neurology (A.E.M., M.P.L., B.B.N., H.K.) and Feil Family Brain and Mind Research Institute (B.B.N., H.K.), Weill Cornell Medical College, New York, NY; and Department of Neurology (S.Y.C.), Yale School of Medicine, New Haven, CT
| | - Hooman Kamel
- From the Department of Neurology (A.E.M., M.P.L., B.B.N., H.K.) and Feil Family Brain and Mind Research Institute (B.B.N., H.K.), Weill Cornell Medical College, New York, NY; and Department of Neurology (S.Y.C.), Yale School of Medicine, New Haven, CT
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Torres-Miranda D, Al-Saffar F, Ibrahim S, Diaz-Font S. Rapid Progressive Seeding of a Community Acquired Pathogen in an Immune-Competent Host: End Organ Damage from Head to Bone. Infect Dis Rep 2015; 7:5849. [PMID: 26294951 PMCID: PMC4508536 DOI: 10.4081/idr.2015.5849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 03/24/2015] [Accepted: 03/26/2015] [Indexed: 11/23/2022] Open
Abstract
Methicillin-sensitive Staphylococcus aureus (MSSA) meningitis is a rare disease when not related to neurosurgery: there are only few reported cases in the literature to date. We describe a case that highlights not only meningeal but also diffuse and rapidly progressive systemic involvement with multi-organ failure. A 64-year-old male presented to our hospital with a chief complaint of acute worsening of his usual chronic lower back pain, progressive weakness in lower extremities and subjective fevers at home. Hospital course demonstrated MSSA bacteremia, of questionable source, that resulted in endocarditis affecting right and left heart in a patient with no history of intravenous drug use. The case was complicated by septic emboli to systemic circulation involving the kidneys, vertebral spine, lungs and brain with consequent meningitis and stroke, even when treated empirically with vancomycin and then switched to nafcillin as indicated. Even though MSSA infections are well known, there are very few case reports describing such an acute-simultaneous-manifestation of multi-end-organ failure, including meningitis and stroke. Our case, also presented with an uncommon manifestation of persistent infection dissemination despite adequate antibiotic treatment.
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Morris NA, Matiello M, Lyons JL, Samuels MA. Neurologic complications in infective endocarditis: identification, management, and impact on cardiac surgery. Neurohospitalist 2014; 4:213-22. [PMID: 25360207 DOI: 10.1177/1941874414537077] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Neurologic complications of infective endocarditis (IE) are common and frequently life threatening. Neurologic events are not always obvious. The prediction and management of neurologic complications of IE are not easily approached algorithmically, and the impact they have on timing and ability to surgically repair or replace the affected valve often requires a painstaking evaluation and joint effort across multiple medical disciplines in order to achieve the best possible outcome. Although specific recommendations are always tailored to the individual patient, there are some guiding principles that can be used to help direct the decision-making process. Herein, we review the pathophysiology, epidemiology, manifestations, and diagnosis of neurological complications of IE and further consider the impact they have on clinical decision making.
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Affiliation(s)
- Nicholas A Morris
- Department of Neurology, Brigham and Women's Hospital, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Marcelo Matiello
- Department of Neurology, Brigham and Women's Hospital, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Jennifer L Lyons
- Department of Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Martin A Samuels
- Department of Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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