Infective endocarditis as part of psittacosis

Chlamydia psittaci endocarditis: a case report and literature review

OBJECTIVES

Blood-culture-negative infective endocarditis (BCNE) is found in 2 to 48% of cases of infective endocarditis (IE) [1].IE and vertebral osteomyelitis due to Chlamydia sp. are difficult to diagnose.

PATIENTS AND METHODS

A case report of Chlamydia psittaci IE is provided, associated with a literature review.

RESULTS

We report the first case of Chlamydia psittaci IE, revealed by a spondylodiscitis. Questioning of the patient, imaging, serologies and PCR techniques on valves confirmed the diagnosis.

CONCLUSION

C. psittaci IE is rare but probably underdiagnosed. In case of negative blood cultures, questioning patients with IE about their contacts with animals is relevant. PCR techniques are reference tools for diagnosis confirmation when valve or vertebral samples are available.

ARDS in Fulminant Ornithosis and Treatment with Extracorporeal Lung Assist

We report a 47-year-old male patient with fulminant ornithosis who developed severe respiratory failure leading to acute respiratory distress syndrome (ARDS) complicated by gastrointestinal, neurological and renal symptoms. ARDS was successfully treated by extracorporeal lung assist. As leukocytosis is typically absent in ornithosis, C-reactive protein, interleukin 6 and procalcitonin were used as infection parameters in order to monitor clinical development. The English-language literature on severe cases of ornithosis requiring respiratory support over the past 30 years is reviewed.

Seroprevalence of Chlamydophila Psittaci among Employees of Two German Duck Farms

Psittacosis is a zoonotic infectious disease that is caused by Chlamydophila psittaci. To determine the occupational risk of getting the infection, we investigated the seroprevalence of C. psittaci among employees of two German duck farms and two slaughterhouses according to their level of exposure to the pathogen during the years 2010, 2007, and 2004. In summary, we found low seroprevalence (≈ 8%) throughout the study population almost irrespective of the duty of a given worker. Surprisingly, in 2010, the anti-C. psittaci-specific antibody prevalence in the group of slaughterer (38.9%) was significantly increased in comparison to the non-exposed employees (p = 0.00578). This indicates that individuals in the surrounding of slaughterhouses exposed especially to aerosols containing C. psittaci elementary bodies bear a greater occupational risk of getting infected.

Zoonotic Chlamydophila psittaci infections from a clinical perspective

Human psittacosis is a zoonotic infectious disease which is caused by the obligate intracellular bacterium Chlamydophila psittaci. Transmission of the disease usually originates from close contact with infected birds, most frequently in the context of the poultry industry, and from contact with Psittaciformes (cockatoos, parrots, parakeets and lories). Due to a low awareness of the disease and a variable clinical presentation psittacosis is often not recognised as such by general practitioners. This review therefore gives an overview of the epidemiology, symptoms, diagnosis and possible treatments for psittacosis in humans. The current case definition for epidemiological surveillance, as issued by the CDC, is discussed, as well as the possible emergence of Cp. psittaci antibiotic-resistant strains. There is an urgent need for information and for awareness campaigns directed at professional health care workers and the general public. In addition, a broader use of new diagnostic methods in medical laboratories and the development of prophylactics are called for.

Endocarditis due to rare and fastidious bacteria

The etiologic diagnosis of infective endocarditis is easily made in the presence of continuous bacteremia with gram-positive cocci. However, the blood culture may contain a bacterium rarely associated with endocarditis, such as Lactobacillus spp., Klebsiella spp., or nontoxigenic Corynebacterium, Salmonella, Gemella, Campylobacter, Aeromonas, Yersinia, Nocardia, Pasteurella, Listeria, or Erysipelothrix spp., that requires further investigation to establish the relationship with endocarditis, or the blood culture may be uninformative despite a supportive clinical evaluation. In the latter case, the etiologic agents are either fastidious extracellular or intracellular bacteria. Fastidious extracellular bacteria such as Abiotrophia, HACEK group bacteria, Clostridium, Brucella, Legionella, Mycobacterium, and Bartonella spp. need supplemented media, prolonged incubation time, and special culture conditions. Intracellular bacteria such as Coxiella burnetii cannot be isolated routinely. The two most prevalent etiologic agents of culture-negative endocarditis are C. burnetti and Bartonella spp. Their diagnosis is usually carried out serologically. A systemic pathologic examination of excised heart valves including periodic acid-Schiff (PAS) staining and molecular methods has allowed the identification of Whipple's bacillus endocarditis. Pathologic examination of the valve using special staining, such as Warthin-Starry, Gimenez, and PAS, and broad-spectrum PCR should be performed systematically when no etiologic diagnosis is evident through routine laboratory evaluation.

Serological cross-reactions between Bartonella and Chlamydia species: implications for diagnosis

Diagnosis of Chlamydia or Bartonella infections continues to rely mainly on serology. However, serological cross-reactions between members of these genera have recently been described. Sera from eight patients originally diagnosed as having Chlamydia pneumoniae endocarditis reacted with both Chlamydia sp. and Bartonella quintana antigens (microimmunofluorescence technique). Adsorption of sera with B. quintana or C. pneumoniae antigens removed anti-C. pneumoniae antibodies, whereas adsorption with C. pneumoniae antigens did not change antibody titers to B. quintana. Western blot analysis confirmed the presence of cross-reacting antigens and showed antibody patterns in all sera to be compatible with a Bartonella infection. These patients were therefore probably suffering from Bartonella-induced rather than Chlamydia-induced endocarditis. In contrast, sera from 10 patients presumed to be suffering from C. pneumoniae pneumonia did not display anti-B. quintana antibodies, although cross-reacting antigens were revealed by Western blotting. This work highlights the possibility that cases of infective Bartonella endocarditis are erroneously diagnosed as chlamydial infections.

Chlamydia psittaci infections: a review with emphasis on avian chlamydiosis

In the first part of this article the general characteristics of Chlamydia psittaci namely the history, taxonomy, morphology, reproductive cycle, metabolism and genetics are reviewed. For the taxonomy in particular, a considerable amount of new information has become available in recent years, following the application of monoclonal antibodies and restriction enzymes. Using these techniques isolates of Chlamydia psittaci from birds have been subdivided in different serovars, a number of isolates have been classified in a new species (Chlamydia pecorum) and isolates from animals have been classified as Chlamydia trachomatis. In the second part of the article, the current knowledge on avian chlamydiosis is summarized. Emphasis is put on clinical signs, lesions, pathogenesis, epizootiology, immunity, diagnosis, prevention and treatment. Also the public health considerations are reviewed. It is concluded that the diagnosis of avian chlamydiosis is laborious and that there is still a need for more accurate, simple and rapid diagnostic tools, both for antigen and antibody detection in various species of birds.

Chlamydial infections of the heart

Chlamydiae are common human pathogens, causing a broad spectrum of infectious diseases. Chlamydial infections involving the heart have been described in numerous previous reports. These organisms are documented to cause endocarditis, myocarditis and pericarditis. Furthermore, Chlamydia pneumoniae, the recently discovered respiratory pathogen, has also been implicated in coronary artery disease. For the first time the literature on involvement of the heart in chlamydial infections is reviewed. Information on the discovery of Chlamydia species is also included and the problem of the species determination of Chlamydia in interpretation of the older literature is mentioned.

Coxiella burneti endocarditis in a patient with positive chlamydial serology

A 41-year-old man who habitually slept in a car park presented with a culture-negative endocarditis. Serological tests indicated infection with both Coxiella burneti and Chlamydia psittaci. He was treated with doxycycline and clindamycin and required aortic valve replacement. Culture of the excised value for both agents was negative but electron microscopy was suggestive of coxiella endocarditis.

Rational approaches to the treatment of culture-negative infective endocarditis

The microorganism responsible for infective endocarditis may not be grown on blood culture in as many as 25% of cases. While this is to be expected with such relatively uncommon organisms as Coxiella burnetti, in most cases failure to grow the organism is likely to be due to either a low concentration of bacteria in the blood or because antibiotics were given before blood was taken for culture. The antibiotic treatment of culture-negative cases should be based on the assumption that the organisms responsible are the same as those found in cases with positive cultures, covering the most likely possibilities in such different circumstances as spontaneous infections of natural valves, endocarditis following cardiac surgery, early and late prosthetic valve endocarditis and infections associated with intravenous drug abuse.

Dilated cardiomyopathy associated with Chlamydia trachomatis infection

A 26-year-old man was admitted to hospital with acute myocarditis complicated by congestive heart failure, and atrial and ventricular arrhythmias. Detailed investigations to determine the aetiological factors involved yielded negative results, except for serological evidence of infection with Chlamydia trachomatis. During the follow-up period, dilated cardiomyopathy developed. To the best of our knowledge a similar case has not been reported previously.

A progressive pericardial effusion caused by psittacosis

A patient developed signs of a progressive pericardial effusion over a period of eight days. Diagnostic and therapeutic pericardiocentesis was performed. Viral titres to psittacosis rose from less than 1:8 to greater than 1:256 indicating recent infection.

Successful treatment by doxycycline of endocarditis caused by ornithosis

The case of a 59 year old man with ornithosis endocarditis and a history of contact with pheasants is reported. Treatment with oxytetracycline was not tolerated and so doxycycline was substituted. Over the two year follow up the patient's clinical condition and serial echocardiographic appearances improved and Chlamydia psittaci complement fixation titres returned to normal. Valve replacement was not required.

Chlamydial endocarditis

Echocardiographic diagnosis of a case of endocarditis, subsequently proven to be due to a chlamydial organism, is described. Early echocardiographic diagnosis guided initial medical management and directed urgent surgical intervention when the patient deteriorated. Reported cases of chlamydial endocarditis are reviewed.

"Prolonged pregnancy" after oral contraceptive therapy

A prospective study of 151 patients whose last menstrual period was an oral contraceptive induced haemorrhage indicated that, in many, ovulation was considerably delayed and that the calculated due date of delivery was therefore erroneous; prolonged pregnancy (more than 42 weeks gestation) occurred in 37.4% and, in 9%, gestation exceed 44 weeks.

Fulminant psittacosis

Two patients died of psittacosis after presenting with generalised toxaemia, acute renal failure, and evidence of pancreatitis. Death was attributed to the virulence of the chlamydial strain and the delay in antemortem diagnosis. In one case Chlamydia psittaci was isolated from necropsy lung tissue. A third case of psittacosis suggested person-to-person or fomite spread, which is rarely reported. Infection was acquired from an apparently healthy, imported and quarantined cockatiel. Import restrictions on psittacines should thus be tightened and psittacosis should be made a notifiable disease.

Isolation of Chlamydia psittaci from a patient with interstitial keratitis and uveitis associated with otological and cardiovascular lesions

A case history of a 15-year-old schoolgirl with fluctuating bilateral uveitis, bilateral stromal keratitis with vascularisation, and bilateral deafness associated with tinnitus and balance disturbance is described. Three years from the onset of her clinical signs she died of a sudden cardiac arrest caused by endocarditis associated with valvular and arterial lesions. Chlamydia psittaci was isolated from her conjunctiva. In her blood type-specific antichlamydial antibody at a level of 1/64 against her own isolate was detected. The clinical findings in this patient were suggestive of a Cogan's syndrome. It is highly probable that the chlamydia isolated from the eyes was responsible for her various lesions.

Chlamydia trachomatis endocarditis

A case of infective endocarditis due to Chlamydia trachomatis immunotype F is reported. Multiple negative blood cultures were a major deterrant from the initial clinical diagnosis of infective endocarditis. Postmortem ultrastructural identification of Chlamydia in the aortic valve vegetation led to an intensive retrospective study of retrieved serum samples utilizing microimmunofluorescent tests. Likewise an unusual echocardiographic finding was discovered to be the ultrasonic visualization of an aortic ring abscess. No similar case could be found in the literature. Clinicopathologic correlations are presented.

Endocarditis as a manifestation of Chlamydia B infection (psittacosis)

A case of Chlamydia B (psittacosis) endocarditis is described in a patient with no known previous valve disease. After mitral valve replacement a fall in Chlamydia B antibody titre occurred. At repeat mitral valve replacement five months later for a paravalve leak no evidence of continuing endocarditis was present. Direct confirmation of infection in the patient's apparently healthy budgerigar was obtained. Aspects of the pathogenesis, diagnosis, and treatment are discussed.

Insidious endocarditis caused by Chlamydia psittaci

Images

Endocarditis caused by a psittacosis agent

Images

Cell-mediated immune response in vitro. 3. The requirement for macrophages in cytotoxic reactions against cell-bound and subcellular alloantigens

All efficient cell separation procedure and specific anti-macrophage serum were used to investigate the requirement of macrophages in the in vitro allograft response of mouse lymphoid cells. The efficiency of the macrophage-depletion procedure used and the undiminished capacity of the purified lymphocytes to respond were verified by also testing the antibody responses to sheep red cells (SRC) and dinitrophenylated polymeric flagellin (DNP POL) as well as the proliferative response to allogeneic cells. It was found that the generation of cytotoxic lymphocytes were diminished after macrophage depletion by surface adherence. The combination of anti-macrophage serum and column purification resulted in the total abolition of cytotoxic activity. The cell-mediated immune response was restored completely by addition of peritoneal macrophages, with as few as 1 macrophage to 600 lymphocytes permitting a significant restoration. Macrophages were not involved in the cytotoxic effector phase, but were essential in immune induction. A subcellular H-2 alloantigen preparation was only immunogenic in the presence of macrophages, indicating that a mere reduction in the size of the antigen from cell-bound alloantigens to membrane fragments was not the sole function of macrophages. The results suggest that macrophages collaborate with T cells in the initiation of an allograft response in vitro.