Two cases of acute endocarditis misdiagnosed as COVID-19 infection

Impact of the SARS-CoV-2 Pandemic on the Management and Prognosis of Infective Endocarditis

BACKGROUND

Infective endocarditis (IE) is a serious condition which is difficult to diagnose and to treat, both medically and surgically.

OBJECTIVES

The objective of this study was to evaluate the impact of the SARS-CoV-2 pandemic on the management of patients with IE.

METHODS

We conducted a single-centre retrospective study including patients hospitalized for IE during the pandemic (Group 2) compared with the same period the year before (Group 1). We compared clinical, laboratory, imagery, therapeutic, and patient outcomes between the two groups.

RESULTS

A total of 283 patients were managed for possible or definite IE (164 in Group 1 and 119 in Group 2). There were more intravenous drug-related IE patients in Group 2 (p = 0.009). There was no significant difference in surgery including intra-cardiac device extraction (p = 0.412) or time to surgery (p = 0.894). The one-year mortality was similar in both groups (16% versus 17.7%, p = 0.704). The recurrence rate was not significantly different between the two groups (5.9% in Group 2 versus 9.1% in Group 1, p = 0.311).

CONCLUSIONS

The SARS-CoV-2 pandemic did not appear to have had a negative impact on the management of patients with IE. Maintenance of the activities of the endocarditis team within the referral centre probably contributed to this result. Nevertheless, the high proportion of intravenous drug-addicted patients in the pandemic cohort suggests that the SARS-CoV-2 pandemic had a major psychosocial impact.

Infective endocarditis presentations during the COVID-19 pandemic: have they paid an untold toll?

Background: COVID-19 caused restrictions and re-allocation of medical resources among all healthcare services. During the peak of the pandemic, several unrelated-yet critical-conditions had silently taken their toll. Infective endocarditis (IE), owing to its non-specific clinical presentation, may have been largely mislabeled as COVID-19 in a number of cases. Results: This retrospective observational study reviewed all IE presentations at an IE unit in a university hospital during the peak of COVID-19. Patient characteristics, courses, and outcomes were compared with historical controls from our IE database published before the COVID era. We identified 30 IE cases [Group A] during the COVID-19 peak in our region (June 2021 to June 2022), with a 25% decrease compared to the usual annual rate. This is in contrast to the expected surge during the pandemic. Compared with group B (398 published IE cases from our database), group A had significantly longer symptoms-to-presentation intervals (60 [31-92] vs. 28 [14-72] days, p = 0.01). Male sex dominated both groups, but group A had significantly less pre-existing structural heart disease. Despite the more liberal use of empirical antibiotics in the COVID-era, group-A had lower rates of culture-negative IE. Compared to group B, group A demonstrated a better response to medical therapy, fewer arterial embolizations, fewer indications for surgery, and fewer overall complications, except for increased acute kidney injury. This can be explained by the abundant use of non-steroidal anti-inflammatory drugs. The data analysis strongly suggests that there might have been a natural selection or selection bias of IE patients with favorable profiles to survive the pandemic to the appropriate diagnosis. Conclusions: The diagnosis of IE and commencing the appropriate workup were significantly undermined during the COVID-19 pandemic. The inexplicable decline in IE referral rate and the favorable outcomes witnessed during the pandemic strongly suggest a referral bias and natural selection of those who survived the pandemic to the appropriate IE diagnosis.

COVID-19-associated MRSA infective endocarditis and mitral valve perforation: a case report

BACKGROUND

Coronavirus disease 2019 (COVID-19) has emerged as a global pandemic, leading to significant morbidity and mortality. The interplay between COVID-19 and other medical conditions can complicate diagnosis and management, necessitating further exploration.

CASE PRESENTATION

This case report presents a patient with COVID-19 who developed infective endocarditis (IE) and mitral valve perforation caused by methicillin-resistant Staphylococcus aureus on a native mitral valve. Notably, the patient did not exhibit typical IE risk factors, such as intravenous drug use. However, he did possess risk factors for bacteremia, including a history of diabetes mellitus and recent steroid use due to the COVID-19 infection. The diagnosis of IE was crucially facilitated by transesophageal echocardiography.

CONCLUSIONS

This case highlights the potential association between COVID-19 and the development of infective endocarditis. Prompt evaluation using transesophageal echocardiography is vital when there is a high suspicion of IE in COVID-19 patients. Further research is required to elucidate the precise relationship between COVID-19 and IE.

Bacterial endocarditis following COVID-19 infection: two case reports

BACKGROUND

COVID-19, an emerging disease raised as a pandemic, urgently needed treatment choices. Some options have been confirmed as lifesaving treatments, but long-term complications must be clearly illustrated. Bacterial endocarditis is a less frequent disease among patients infected with SARS_COV_2 compared to other cardiac comorbidities in these patients. This case report discusses bacterial endocarditis as a potential adverse effect after administering tocilizumab, corticosteroids, and COVID-19 infection.

CASE PRESENTATION

In the first case, a 51-year-old Iranian female housewife was admitted to the hospital with fever, weakness, and monoarthritis symptoms. The second case is a 63-year-old Iranian woman who is a housewife admitted with weakness, shortness of breath, and extreme sweating. Both cases tested positive for Polymerase chain reaction (PCR) less than one month ago and were treated with tocilizumab and corticosteroid. Both patients were suspected of infective endocarditis. Methicillin-resistant Staphylococcus aureus (MRSA) was detected in the blood cultures of both patients. The diagnosis of endocarditis is confirmed for both cases. Cases are subjected to open-heart surgery, a mechanical valve is placed, and they are treated with medication. In subsequent visits, their condition was reported to be improving.

CONCLUSION

Adjacent to cardiovascular inclusion as COVID-19 disease complications, secondary infection taken after the organisation of immunocompromising specialists can result in basic maladies and conditions counting infective endocarditis.

Cardiac Surgery for Treatment of COVID-19-Associated Infectious Endocarditis

BACKGROUND

Significant uncertainty exists about the optimal timing of surgery for infectious endocarditis (IE) surgery in patients with active SARS-CoV-2 infection. This case series and a systematic review of the literature were carried out to evaluate the timing of surgery and postsurgical outcomes for patients with COVID-19-associated IE.

METHODS

The PubMed database was searched for reports published from June 20, 2020, to June 24, 2021, that contained the terms infective endocarditis and COVID-19. A case series of 8 patients from the authors' facility was also added.

RESULTS

A total of 12 cases were included, including 4 case reports that met inclusion criteria in addition to a case series of 8 patients from the authors' facility. Mean (SD) patient age was 61.9 (17.1) years, and patients were predominantly male (91.7%). Being overweight was the main comorbidity among patients studied (7/8 [87.5%]). Among all patients evaluated in this study, dyspnea (n = 8 [66.7%]) was the leading symptom, followed by fever (n = 7 [58.3%]). Enterococcus faecalis and Staphylococcus aureus caused 75.0% of COVID-19-associated IE. The mean (SD) time to surgery was 14.5 (15.6) days (median, 13 days). In-hospital and 30-day mortality for all evaluated patients was 16.7% (n = 2).

CONCLUSION

Clinicians must carefully assess patients diagnosed with COVID-19 to prevent missing underlying diseases such as IE. If IE is suspected, clinicians should avoid postponement of crucial diagnostic and treatment steps.

Infective Endocarditis Revealed after Resolution of COVID-19 Infection

A 34-year-old previously healthy Japanese woman was diagnosed with COVID-19 and treated with remdesivir and dexamethasone. She was discharge but returned the next day due to acute myocardial infarction. Conservative treatment was selected because of an embolic occlusion in the distal portion. Contrast-enhanced computed tomography and brain magnetic resonance imaging revealed a right renal infarction and multiple cerebral embolisms, respectively; she had a fever of 38.9°C that night. Blood culture was positive for methicillin-susceptible Staphylococcus aureus. Transthoracic echocardiography revealed an 11-mm vegetation on the posterior mitral valve leaflet. Native mitral valve infective endocarditis causing multiple embolizations was diagnosed. She underwent surgical mitral valve replacement.

Bentall Endocarditis by C. Lusitaniae After COVID-19: The Finger Covers The Moon

We report a case of endocarditis months after a Bentall procedure. This was caused by Candida Lusitaniae, in an immunocompetent patient with a recent SARS-CoV-2 infection. The patient underwent a new Bentall procedure. SARS-CoV-2 has been associated with co-infection by Candida species since the beginning of the pandemic, nevertheless, Candida Lusitaniae remains a very uncommon causative agent of prosthetic endocarditis. We suggest a possible role of the SARS-CoV-2, which may have delayed the diagnosis of endocarditis and the appropriate therapy.

TEA Clinical Profile of Infective Endocarditis in Patients with Recent COVID-19: A Systematic Review

Background

Coronavirus disease 2019 (COVID-19) can progress to cardiovascular complications which are linked to higher in-hospital mortality rates. Infective endocarditis (IE) can develop in patients with recent COVID-19 infections, however, characterization of IE following COVID-19 infection has been lacking. To better characterize this disease, we performed a systematic review with descriptive analysis of the clinical features and outcomes of these patients.

Methods

Our search was conducted in 8 databases for all published reports of probable or definite IE in patients with a prior COVID-19 confirmed diagnosis. After ensuring an appropriate inclusion of the articles, we extracted data related to clinical characteristics, modified duke criteria, microbiology, outcomes, and procedures.

Results

Searches generated a total of 323 published reports, and 20 articles met our inclusion criteria. The mean age of patients was 52.2 ± 16.9 years and 76.2% were males. Staphylococcus aureus was isolated in 8 (38.1%) patients, Enterococcus faecalis in 3 patients (14.3%) and Streptococcus mitis/oralis in 2 (9.5%) patients. The mean time interval between COVID-19 and IE diagnoses was 16.7 ± 15 days. Six (28.6%) patients required critical care due to IE, 7 patients (33.3%) underwent IE-related cardiac surgery and 5 patients (23.8%) died during their IE hospitalization.

Conclusions

Our systematic review provides a profile of clinical features and outcomes of patients with a prior COVID-19 infection diagnosis who subsequently developed IE. Due to the ongoing COVID-19 pandemic, it is essential that clinicians appreciate the possibility of IE as a unique complication of COVID-19 infection.

Epidemiology of infective endocarditis: novel aspects in the twenty-first century

INTRODUCTION

The epidemiology of infective endocarditis (IE) in this millennium has changed with emergence of new risk factors and reemergence of others. This, coupled with modifications in national guidelines in the setting of a pandemic, prompted an address of the topic.

AREAS COVERED

Our goal is to provide a contemporary review of IE epidemiology considering changing incidence of rheumatic heart disease (RHD), cardiac device implantation, and injection drug use (IDU), with SARS-CoV-2 pandemic as the backdrop.

METHODS

PubMed and Google Scholar were used to identify studies of interest.

EXPERT OPINION

Our experience over the past two decades verifies the notion that there is not one 'textbook' profile of IE. Multiple factors have dramatically impacted IE epidemiology, and these factors differ, based, in part on geography. RHD has declined in many areas of the world, whereas implanted cardiovascular devices-related IE has grown exponentially. Perhaps the most influential, at least in areas of the United States, is injection drug use complicating the opioid epidemic. Healthy younger individuals contracting a potentially life-threatening infection has been tragic. In the past year, epidemiological changes due to the COVID-19 pandemic have also occurred. No doubt, changes will characterize IE in the future and serial review of the topic is warranted.

Recurrent fever and anemia as manifestations of infective endocarditis in a 13-year-old girl with bicuspid aortic valve

Introduction Infective endocarditis is relatively rare in pediatric population, but can result in significant morbidity and mortality. Children with bicuspid aortic valve are at higher risk of developing infective endocarditis as compared to general population. Our objective is to emphasize the importance of rapid diagnosis and proper treatment of infective endocarditis in patients with bicuspid aortic valve with aim to prevent serious adverse events. Case outline We report a case of a 13-year-old girl with newly diagnosed bicuspid aortic valve who developed infective endocarditis with severe complications and underwent cardiac surgery. Recurrent fever and anemia, as well as cardiac murmur were present for six months prior to diagnosing infective endocarditis. During the course of illness, only one of many blood cultures taken was positive for Streptococus sanguinis. Conclusion Patients with bicuspid aortic valve require careful evaluation for infective endocarditis, especially if anemia is associated with recurrent fever. Delayed diagnosis of infective endocarditis in patients with bicuspid aortic valve is associated with severe complications.

Two cases of acute endocarditis misdiagnosed as COVID-19 infection

The COVID‐19 pandemic has presented countless new challenges for healthcare providers including the challenge of differentiating COVID‐19 infection from other diseases. COVID‐19 infection and acute endocarditis may present similarly, both with shortness of breath and vital sign abnormalities, yet they require very different treatments. Here, we present two cases in which life‐threatening acute endocarditis was initially misdiagnosed as COVID‐19 infection during the height of the pandemic in New York City. The first was a case of Klebsiella pneumoniae mitral valve endocarditis leading to papillary muscle rupture and severe mitral regurgitation, and the second a case of Streptococcus mitis aortic valve endocarditis with heart failure due to severe aortic regurgitation. These cases highlight the importance of careful clinical reasoning and demonstrate how cognitive errors may impact clinical reasoning. They also underscore the limitations of real‐time reverse transcription‐polymerase chain reaction (RT‐PCR) for SARS‐CoV‐2 testing and illustrate the ways in which difficulty interpreting results may also influence clinical reasoning. Accurate diagnosis of acute endocarditis is critical given that surgical intervention can be lifesaving in unstable patients.