Isolated pulmonic valve endocarditis caused by group B streprococcus (Streptococcus agalactiae)--a case report and literature review

Pulmonary Valve Endocarditis With Tetralogy of Fallot: A Comprehensive Exploration

Infective endocarditis, a fatal infection with rising morbidity and mortality rates among infants and children, is characterized by microbial infection within the endocardium, the inner lining of the heart including heart valves. The heightened susceptibility to infection in children is attributed to pre-existing pathologies, structural defects, and comorbidities. This report details a case of a one-year-old child with tetralogy of Fallot, showcasing isolated pulmonary valve vegetations as a distinctive manifestation of infective endocarditis.

Case report: isolated pulmonary valve endocarditis in a 39-year-old patient with intravenous drug abuse

Background 

Isolated pulmonary valve endocarditis is a very rare form of right-sided infective endocarditis. Due to the anatomy, in most cases, just the tricuspid valve is involved. Diagnosis can be challenging because of non-specific symptoms (fever, dyspnoea, haemoptysis, and pleuritic chest pain) and difficulty of detection by echocardiography. Risk factors include intravenous drug abuse, congenital heart disorders, alcohol abuse, male sex and central venous catheters, or pacemaker leads.

Case summary 

A 39-year-old homeless male patient, who was a current intravenous drug user, presented with fever, dyspnoea, and haemoptysis. The chest X-ray showed bilateral infiltrates. Empiric antibiotic treatment was initiated. Blood cultures showed the presence of Streptococcus dysgalactiae. Atypical causes of pneumonia were excluded. Systemic embolism was suspected, and a computed tomography scan of brain, thorax, and abdomen was performed. Multiple septic embolic lesions were detected in both lungs. Echocardiography revealed an isolated pulmonary valve endocarditis. Penicillin G and gentamycin were administered intravenously for a duration of 6 and 2 weeks, respectively. The patient was discharged in stable condition but did not return for outpatient clinical appointments.

Discussion 

To detect rare causes of right-sided infective endocarditis, repeated echocardiograms with special focus on the pulmonary valve may be required. Usually, antibiotic treatment alone leads to recovery. In special situations (heart failure, septic shock, or large vegetation size) surgery is required. Due to the high risk of postoperative complications, surgery in intravenous drug users should be avoided if possible.

Delayed diagnosis of right-sided valve endocarditis causing recurrent pulmonary abscesses: a case report

BACKGROUND

Pulmonary valve infective endocarditis is a rare diagnosis that is usually associated with immunocompromised states or structurally abnormal hearts. It is unusual for it to occur in structurally normal hearts or to cause recurrent symptoms after targeted antibiotics. Although guidelines suggest follow-up with repeat echocardiography and inflammatory marker surveillance, this case demonstrates that these are not always useful investigations, and instead imaging of the chest may be more appropriate.

CASE PRESENTATION

We describe a case of a 74-year-old man who presented with respiratory symptoms and was originally misdiagnosed with pneumonia but later found to have a large pulmonary valve vegetation caused by Streptococcus mitis. Despite initially responding to antibiotic therapy, the vegetation continued to cause pulmonary emboli and cavitating lung abscesses months later, necessitating pulmonary valve replacement.

CONCLUSIONS

This case demonstrates that pulmonary valve endocarditis can present atypically with recurrent respiratory symptoms, and in such cases, echocardiography should be considered to investigate for right-sided infective endocarditis. In addition, despite correct treatment, with normalization of inflammatory markers and improvement in vegetation size, infective endocarditis can continue to cause systemic symptoms. Finally, clinicians should consider chest computed tomography routinely as part of right-sided infective endocarditis follow-up.

Isolated pulmonary valve endocarditis masquerading as community-acquired pneumonia

Isolated pulmonary valve endocarditis in intravenous drug users is a rarely reported phenomenon. We present the case of a 25-year-old male with history of intravenous drug use who presented with respiratory symptoms after failing outpatient treatment for community-acquired pneumonia. Further investigations identified multiple lung lesions with early cavitation, concerning for septic pulmonary embolism on computerized tomography scan, positive blood cultures with methicillin-susceptible staphylococcus aureus, and isolated vegetation of the pulmonic valve on transthoracic echocardiography. The patient had a complete recovery after being treated medically with intravenous oxacillin for a total of 6 weeks.

Topical use of antithrombotics: review of literature

While antithrombotics are usually administered intravenously, subcutaneously or orally, there are a number of publications reporting topical application of anticoagulation therapy. This paper aims to review the available literature regarding clinical conditions, the details of the topical antithrombotic treatment, as well as positive or adverse effects in an attempt to ascertain the safety and efficacy of this form of treatment. Published literature was searched to identify publications reporting the use of antithrombotic treatments administered via topical application between 1st January 1990 and 1st January 2013. There were 43 studies reported in 10 different clinical conditions. Majority of the studies were randomized controlled trials (51.2%), prospective studies (18.6%) or case reports (11.6%). The clinical conditions in which topical antithrombotics were administered included: microangiopathy, acute haemorrhoids, periodontitis, dermatitis, burns, ocular conditions and surgery, blunt force impact, scars, as well as clinical conditions associated with superficial venous thrombosis (SVT). The most commonly used topical antithrombotic was heparin (79.1% of studies). The respective dosage of different antithrombotics varied depending on specific clinical conditions. While most studies reported mean improvements or resolution of symptoms/condition in patients, the patient outcomes were variable. This review demonstrates that topical antithrombotic treatment is used according to a wide variety of protocols, with a subsequent variability in patient outcomes. Specific guidelines for the use of topical antithrombotics should be developed to standardize this form of treatment and ensure the best possible outcomes for patients.

Bias due to lack of patient blinding in clinical trials. A systematic review of trials randomizing patients to blind and nonblind sub-studies

BACKGROUND

Blinding patients in clinical trials is a key methodological procedure, but the expected degree of bias due to nonblinded patients on estimated treatment effects is unknown.

METHODS

Systematic review of randomized clinical trials with one sub-study (i.e. experimental vs control) involving blinded patients and another, otherwise identical, sub-study involving nonblinded patients. Within each trial, we compared the difference in effect sizes (i.e. standardized mean differences) between the sub-studies. A difference <0 indicates that nonblinded patients generated a more optimistic effect estimate. We pooled the differences with random-effects inverse variance meta-analysis, and explored reasons for heterogeneity.

RESULTS

Our main analysis included 12 trials (3869 patients). The average difference in effect size for patient-reported outcomes was -0.56 (95% confidence interval -0.71 to -0.41), (I(2)=60%, P=0.004), i.e. nonblinded patients exaggerated the effect size by an average of 0.56 standard deviation, but with considerable variation. Two of the 12 trials also used observer-reported outcomes, showing no indication of exaggerated effects due lack of patient blinding. There was a larger effect size difference in 10 acupuncture trials [-0.63 (-0.77 to -0.49)], than in the two non-acupuncture trials [-0.17 (-0.41 to 0.07)]. Lack of patient blinding also increased attrition and use of co-interventions: ratio of control group attrition risk 1.79 (1.18 to 2.70), and ratio of control group co-intervention risk 1.55 (0.99 to 2.43).

CONCLUSIONS

This study provides empirical evidence of pronounced bias due to lack of patient blinding in complementary/alternative randomized clinical trials with patient-reported outcomes.

Isolated Pulmonary Valve Endocarditis Complicated With Septic Emboli to the Lung Causing Pneumothorax, Pneumonia, and Sepsis in an Intravenous Drug Abuser

Intravenous drug users are at increased risk for developing right-sided infective endocarditis involving the tricuspid and pulmonary valves. Isolated pulmonary valve endocarditis in intravenous drug users is very rare, and these patients often have more complications, such as pulmonary embolism, sepsis, and pneumonia. We report a case with pulmonary valve endocarditis and extensive pulmonary complications, including sepsis, septic emboli, pneumonia, and pneumothorax. Early identification of pulmonic valve endocarditis and treatment with appropriate antibiotics with or without surgical management should provide better outcomes, and clinicians need to think about pulmonary valve endocarditis in patients with complex respiratory presentations.

Native valve right sided infective endocarditis

Right-sided infective endocarditis (RSIE) accounts for 5-10% of all cases of infective endocarditis (IE), and is predominantly encountered in the injecting drug user (IDU) population, where HIV and HCV coinfections often coexist. Staphylococcus aureus is the most common pathogen. The pathogenesis of RSIE is still not well understood. RSIE usually presents as a persistent fever with respiratory symptoms whilst signs of systemic embolisation as seen in left-sided IE are notably absent. The prompt diagnosis of RSIE thus requires a high index of suspicion. Transthoracic echocardiography (TTE) can detect the majority of RSIE, whilst transoesophageal echocardiography (TOE) can increase sensitivity. Virulence of the causative organism and vegetation size are the major determinants of prognosis. Most cases of RSIE resolve with appropriate antibiotic administration.

[Streptococcus agalactiae endocarditis]

Streptococcus agalactiae endocarditis is a rare clinical entity that is generally characterized by acute onset, the presence of large vegetations, rapid valvular destruction and frequent complications, particularly embolization. Mortality is high with medical therapy alone. The authors present a case report of Streptococcus agalactiae endocarditis in a young patient treated by prompt surgery. The literature is reviewed.

Unusual endocarditis: "rare bug, rare site"

A 27-year-old man was diagnosed with infective endocarditis due to Streptococcus agalactiae. Large vegetations were seen on the anterior mitral valve leaflet and also on the right ventricular side of a membranous ventricular septal defect. Streptococcus agalactiae is a rare cause of endocarditis, and it is very rare to find large vegetations around ventricular septal defect. The authors present this interesting case of unusual endocarditis with vegetations in both the right and left heart. This case is the first reported case of infective endocarditis involving the left and the right sides of the heart at the same time in a nonintravenous drug user.

Pulmonary valve infective endocarditis in an adult patient with severe congenital pulmonary stenosis and ostium secundum atrial septal defect

A hypertensive 76-year-old man with severe pulmonary valve stenosis (PVS) and recent initiation of haemodialysis was referred with fever, chills, and asthenia. One month prior, he had been admitted with similar symptoms. Transthoracic echocardiography (TTE) had shown a PVS and no valve vegetations were observed. Following discharge, he was readmitted with fever and blood cultures positive for Staphylococcus haemolyticus. A new TTE revealed two pulmonary valve vegetations and a previously undetected ostium secundum-type atrial septal defect (ASD), confirmed by transesophageal echocardiography. The clinical course was uneventful with intravenous antibiotic treatment and the patient was safely discharged. This is a case of pulmonary valve infective endocarditis (IE). The incidence of right-sided IE is on the rise due to the increased number of patients using central venous lines, pacing, haemodialysis and other intravascular devices. Pulmonary valve IE is extremely rare, especially in structurally normal hearts. The case reported here, presents a combination of predisposing factors, such as severe congenital PVS, the presence of a central venous catheter, and haemodialysis. The fact that it was an older patient with severe congenital PVS and associated with a previously undiagnosed ASD, is also an unusual feature of this case, making it even more interesting.

Effect of a plaster containing DHEP and heparin in acute ankle sprains with oedema: a randomized, double-blind, placebo-controlled, clinical study

OBJECTIVE

Ankle sprains are the most frequent injuries in sport and daily life, and are usually treated with anti-inflammatory drugs or compounds that have an effect on microcirculation. The efficacy and tolerability of a novel plaster containing both diclofenac epolamine (DHEP) and heparin in the treatment of acute painful ankle sprains with oedema was investigated in a randomized, double-blind, placebo-controlled study.

RESEARCH DESIGN AND METHODS

This study, carried out in 32 French medical centres, enrolled 233 patients (148 male and 86 female, aged 18-65 years) with an ankle sprain that had occurred within the previous 48 hours. Patients were treated once daily with DHEP heparin or placebo plaster for 7 days.

MAIN OUTCOME MEASURES

Reduction in ankle joint swelling measured by submalleolar circumference was the primary efficacy endpoint; secondary endpoints were pain (at rest, in active mobilization, by passive stretch and by pressure), functional disability and global judgement of efficacy and tolerability.

RESULTS

DHEP heparin-treated patients experienced a significantly greater reduction in joint swelling compared with placebo (p = 0.005). The reduction in pain was also in favour of DHEP heparin patients, with significantly lower pain in DHEP heparin-treated than placebo-treated patients within 3 hours of the first application (p < 0.05). Only two patients in the DHEP heparin plaster group and six in the placebo group experienced minor adverse events, all of which resolved spontaneously. By design, the study was limited to a placebo-controlled comparison, and there was no test for possible selection bias (subsequently ruled out by choice of efficacy parameters and measures) that may have resulted in a baseline imbalance between patient groups.

CONCLUSIONS

Results confirm the efficacy of DHEP heparin plaster compared with placebo for the treatment of painful ankle sprain with oedema. Prompt control of pain and oedema may shorten the time to initiation of a rehabilitation programme, thus reducing the risk of ankle disability recurrence and the development of chronic injury.

Candida albicans tricuspid and pulmonic valve endocarditis: Challenge of relapsing risk and role of combined medical treatment and surgery

Candida albicans endocarditis involves infrequently the tricuspid valve and involvement of the pulmonic valve is rare. We report our experience with an immunosuppressed liver-transplanted female who developed both tricuspid and pulmonic valve endocarditis, review the literature and discuss the importance of effective antimycotic therapy combined with surgical replacement of the affected valve.

Group B streptococcal endocarditis after elective abortion in an adolescent

We describe a case of group B streptococcal endocarditis in a 15-year-old girl after an elective abortion. There are only 6 reports of group B streptococcal endocarditis in older children. It is a well described but rare complication of surgical abortions, and tends to have an aggressive course.

Pulmonary embolism and fever: an indication for urgent echocardiography not reported in clinical guidelines?

We report the case of a 39-year-old woman who developed worsening dyspnea and abdominal pain 4 days after subtotal gastroresection. She underwent thoracic computed tomography scan and lung scintigraphy and was diagnosed with pulmonary embolism. Despite the fact that she was feverish, she was treated by the insertion of a vena cava filter and transferred to our Emergency Department. Twelve hours later, a beta-haemolytic Streptococcus agalactiae was reported to be growing in both bottles of blood cultures that had been taken. The patient underwent transthoracic two- and three-dimensional echocardiography, which showed a large pulmonary valve vegetation prolapsing into the main and right pulmonary artery during systole.

Streptococcal Septic Shock after Inguinal Lymphadenectomy

BACKGROUND

Group B Streptococcus is an uncommon cause of sepsis in the non-pregnant adult.

METHODS

Case report and review of the pertinent English-language literature.

RESULTS

A woman who developed confusion and slurred speech five days after aspiration of a postoperative wound seroma is presented. The patient had hypotension and fever and required emergency drainage of an infected seroma of the groin. Wound culture identified Streptococcus agalactiae as the infecting agent.

CONCLUSION

Life-threatening sepsis caused by group B streptococci in adults is rare, but the organism must be considered as a potential pathogen in fulminating surgical site infection.

Infective endocarditis of bicuspid pulmonary valve

Infective endocarditis of the cardiac valves mainly involves the aortic mitral valves and less frequently the tricuspid valve. Isolated pulmonary valve involvement is extremely rare with few cases reported in literature. We present a case of a 34-year-old female who presented with sudden onset breathlessness and cardiac failure. A complete autopsy showed an uncommon congenital bicuspid pulmonary valve, which was also affected by infective endocarditis.

Staphylococcus aureus infective endocarditis and septic pulmonary embolism after septic abortion

We report a case of a 26-year-old female who after septic abortion developed tricuspid valve endocarditis with large vegetations, which subsequently resulted in embolism to right main pulmonary artery. Patient was treated with intravenous antibiotics and had a good recovery.

Clinical profile of Streptococcus agalactiae native valve endocarditis

BACKGROUND

Streptococcus agalactiae is an unusual pathogen in adults who are not pregnant. S agalactiae endocarditis is a poorly defined entity because it is uncommon; in contrast to other streptococcal endocarditis, it bears a high mortality rate. The aim of this study was to define its clinical, prognostic, and therapeutic profile on the basis of a series of 9 consecutive patients.

METHODS

We conducted a prospective and multicenter study of patients with infectious endocarditis in which 310 episodes were included.

RESULTS

S agalactiae grew in 9 patients (3%) who had no valve prosthesis. All patients except 1 had underlying diseases, and all patients had serious complications; the most common complications were major emboli, heart failure, and shock. The valve affected was the mitral valve in 4 patients, the aortic valve in 2 patients, both the mitral and aortic valves in 2 patients, and the tricuspid valve in 1 patient. All episodes were on native valves. Vegetations tended to be large (maximal diameter >10 mm in all patients), very mobile, and pedunculated. An abscess was found in 2 patients, and a perforation of the valve developed in 3 patients. Five patients died (mortality rate, 56%), 3 of whom had received antibiotic therapy alone. The 4 patients who survived underwent combined medical-surgical therapy.

CONCLUSION

S agalactiae native valve endocarditis is very aggressive, and early surgery should be considered to prevent the destruction of valves and development of serious complications.

Clinical, bacteriologic and echocardiographic evaluation of infective endocarditis in Ankara, Turkey

This study consists of a retrospective evaluation of microbiologic, echocardiographic, and clinical characteristics of patients with infective endocarditis seen at Türkiye Yüksek Ihtisas and SSK Ihtisas Hospitals during the previous 5 years to provide a basis for comparison with other series. The study was performed retrospectively. The mean age of the patient population, which consisted of 74 cases, was considerably low (24.6+/-12.3 yr). The majority of the patients were male (male/female = 1.96). Rheumatic valvular disease was the underlying cardiac pathosis in 66% of the cases. Congestive heart failure, embolic episodes, and mortality were more frequent among those with echocardiographically demonstrable cardiac vegetations. The microbiologic profile was considerably different from that of other series. In addition, this population showed a higher rate of congestive heart failure compared to other series. The patients with infective endocarditis in this series in the previous 5 years were found to be different from series reported from western countries.