Splenic Embolism in Infective Endocarditis: A Systematic Review of the Literature with an Emphasis on Radiological and Histopathological Diagnoses

Infective endocarditis (IE) is characterised by fever, heart murmurs, and emboli. Splenic emboli are frequent in left-sided IE. A systematic review of the literature published on splenic embolism (SE) between 2000 and 2023 was conducted. Search strategies in electronic databases identified 2751 studies published between 1 January 2000 and 4 October 2023, of which 29 were finally included. The results showed that the imaging tests predominantly used to detect embolisms were computed tomography (CT), magnetic resonance imaging, positron emission tomography (PET)/CT, single-photon emission computed tomography/CT, ultrasound, and contrast-enhanced ultrasound. More recent studies typically used 18F-FDG PET-CT. The proportion of SE ranged from 1.4% to 71.7%. Only seven studies performed systematic conventional CT screening for intra-abdominal emboli, and the weighted mean frequency of SE was 22% (range: 8-34.8%). 18F-FDG PET-CT was performed systematically in seven studies, and splenic uptake was found in a weighted mean of 4.5%. There was a lack of uniformity in the published literature regarding the frequency and management of splenic embolisation. CT scans were the most frequently used method, until recently, when 18F-FDG PET-CT scans began to predominate. More data are necessary regarding the frequency of SE, especially focusing on their impact on IE management and prognosis.

Invasive Pneumococcal Disease in People Living with HIV: A Retrospective Case-Control Study in Brazil

HIV-infected patients are at particular risk for invasive pneumococcal disease (IPD). We describe cases of IPD in people living with HIV/AIDS (PLWHA) and find associated risk factors for infection and death.

METHODS

A retrospective case-control study, nested in a cohort, including PLWHA with and without IPD, conducted in Brazil, 2005-2020. Controls were of the same gender/age and seen at the same time/place as cases.

RESULTS

We identified 55 episodes of IPD (cases) in 45 patients and 108 controls. The incidence of IPD was 964/100,000 person-years. A total of 42 of 55 (76.4%) IPD episodes presented with pneumonia and 11 (20%) with bacteremia without a focus and 38/45 (84.4%) were hospitalized. Blood cultures were positive in 54/55 (98.2%). Liver cirrhosis and COPD were the only factors associated with IPD in PLWHA in univariate analysis, although no associated factors were found in multivariate analysis. Penicillin resistance was found in 4/45 (8.9%). Regarding antiretroviral therapy (ART), 40/45 (88.9%) cases vs. 80/102 controls (74.1%) were in use (p = 0.07). Patients with HIV and IPD had a higher CD4 count of 267 cells/mm³ compared with the control group, in which it was 140 cells/mm³ (p = 0.027). Pneumococcal vaccination was documented in 19%. Alcoholism (p = 0.018), hepatic cirrhosis (p = 0.003), and lower nadir CD4 count (p = 0.033) were associated with the risk of death in patients with IPD. In-hospital mortality among PLWHA and IPD was 21.1%, and it was associated with thrombocytopenia and hypoalbuminemia, elevated band forms, creatinine, and aspartate aminotransferase (AST).

CONCLUSIONS

The incidence of IPD in PLWHA remained high despite ART. The vaccination rate was low. Liver cirrhosis was associated with IPD and death.

Infective Endocarditis due to Non-HACEK Gram-Negative Bacilli: Clinical Characteristics and Risk Factors from a Prospective Multicenter Brazilian Cohort

Background: Non-HACEK Gram-negative bacilli (NGNB) infective endocarditis (IE) has a growing frequency. We aimed to describe cases of NGNB IE and find associated risk factors. Methods: We conducted a prospective observational study of consecutive patients with definitive IE according to the modified Duke criteria in four institutions in Brazil. Results: Of 1154 adult patients enrolled, 38 (3.29%) had IE due to NGNB. Median age was 57 years, males predominated, accounting for 25/38 (65.8%). Most common etiologies were Pseudomonas aeruginosa and Klebsiella spp. (8 episodes, 21% each). Worsening heart failure occurred in 18/38 (47.4%). Higher prevalence of embolic events was found (55,3%), mostly to the central nervous system 7/38 (18.4%). Vegetations were most commonly on aortic valves 17/38 (44.7%). Recent healthcare exposure was found in 52.6% and a central venous catheter (CVC) in 13/38 (34.2%). Overall mortality was 19/38 (50%). Indwelling CVC (OR 5.93; 95% CI, 1.29 to 27.3; p = 0.017), hemodialysis (OR 16.2; 95% CI, 1.78 to 147; p = 0.008) and chronic kidney disease (OR 4.8; 95% IC, 1.2 to 19.1, p = 0.049) were identified as risk factors for mortality. Conclusions: The rate of IE due to NGNB was similar to that in previous studies. Enterobacterales and P. aeruginosa were the most common etiologies. NGNB IE was associated with central venous catheters, prosthetic valves, intracardiac devices and hemodialysis and had a high mortality rate.

Histoplasmosis at a Reference Center for Infectious Diseases in Southeast Brazil: Comparison between HIV-Positive and HIV-Negative Individuals

Objectives: Histoplasmosis is a systemic mycosis, present globally. We aimed to describe cases of histoplasmosis (Hc) and to establish a risk profile associated with Hc in HIV-infected patients (HIV+). Methods: This was a retrospective study of patients with a clinical laboratory diagnosis of Hc. Data were fed into REDCap, and statistical analysis was performed with R. Results: We included 99 records, 65 HIV+ and 34 HIV-. Average age was 39 years. Median time from onset to diagnosis was 8 weeks in HIV- and 22 weeks in HIV+. Disseminated histoplasmosis occurred in 79.4% of HIV+, vs. 36.4% of HIV- patients. Median CD4 count was 70. Co-infection with tuberculosis was present in 20% of HIV+ patients. Blood cultures were positive in 32.3% of HIV+ vs. 11.8% of HIV- (p = 0.025) patients; bone marrow culture was positive in 36.9% vs. 8.8% (p = 0.003). Most HIV+ patients (71.4%) were hospitalized. On univariate analysis, anemia, leukopenia, intensive care, use of vasopressors and mechanical ventilation were associated with death in HIV+ patients. Conclusions: Most of our patients with histoplasmosis were HIV+, presenting advanced AIDS. Diagnosis was late in HIV+ patients, and they frequently presented disseminated Hc, required hospitalization, and died. Early screening for Hc in HIV+ and drug-induced immunosuppressed patients is crucial.

Evaluation of Five Non-Culture-Based Methods for the Diagnosis of Meningeal Sporotrichosis

Sporotrichosis is the main subcutaneous mycosis worldwide. Several complications, including meningeal forms, can be observed in immunocompromised individuals. The sporotrichosis diagnosis is time-consuming due to the culture's limitations. The low fungal burden in cerebrospinal fluid (CSF) samples is another important drawback in the diagnosis of meningeal sporotrichosis. Molecular and immunological tests can improve the detection of Sporothrix spp. in clinical specimens. Therefore, the following five non-culture-based methods were evaluated for the detection of Sporothrix spp. in 30 CSF samples: (i) species-specific polymerase chain reaction (PCR); (ii) nested PCR; (iii) quantitative PCR; (iv) enzyme-linked immunosorbent assay (ELISA) for IgG detection; and (v) ELISA for IgM detection. The species-specific PCR was unsuccessful in the diagnosis of the meningeal sporotrichosis. The other four methods presented substantial levels of sensitivity (78.6% to 92.9%) and specificity (75% to 100%) for the indirect detection of Sporothrix spp. Both DNA-based methods presented similar accuracy (84.6%). Both ELISA methods were concomitantly positive only for patients with sporotrichosis and clinical signs of meningitis. We suggest that these methods should be implemented in clinical practice to detect Sporothrix spp. in CSF early, which may optimize treatment, augment the chances of a cure, and improve the prognosis of affected individuals.

Infective endocarditis in pregnant women without intravenous drug use: a multicentre retrospective case series

OBJECTIVES

To describe the clinical features and outcomes of infective endocarditis (IE) in pregnant women who do not inject drugs.

METHODS

A multinational retrospective study was performed at 14 hospitals. All definite IE episodes between January 2000 and April 2021 were included. The main outcomes were maternal mortality and pregnancy-related complications.

RESULTS

Twenty-five episodes of IE were included. Median age at IE diagnosis was 33.2 years (IQR 28.3-36.6) and median gestational age was 30 weeks (IQR 16-32). Thirteen (52%) patients had no previously known heart disease. Sixteen (64%) were native IE, 7 (28%) prosthetic and 2 (8%) cardiac implantable electronic device IE. The most common aetiologies were streptococci (n = 10, 40%), staphylococci (n = 5, 20%), HACEK group (n = 3, 12%) and Enterococcus faecalis (n = 3, 12%). Twenty (80%) patients presented at least one IE complication; the most common were heart failure (n = 13, 52%) and symptomatic embolism other than stroke (n = 4, 16%). Twenty-one (84%) patients had surgery indication and surgery was performed when indicated in 19 (90%). There was one maternal death and 16 (64%) patients presented pregnancy-related complications (11 patients ≥1 complication): 3 pregnancy losses, 9 urgent Caesarean sections, 2 emergency Caesarean sections, 1 fetal death, and 11 preterm births. Two patients presented a relapse during a median follow-up of 3.1 years (IQR 0.6-7.4).

CONCLUSIONS

Strict medical surveillance of pregnant women with IE is required and must involve a multidisciplinary team including obstetricians and neonatologists. Furthermore, the potential risk of IE during pregnancy should never be underestimated in women with previously known underlying heart disease.

Secondary infections in a cohort of patients with COVID-19 admitted to an intensive care unit: impact of gram-negative bacterial resistance

Some studies have shown that secondary infections during the COVID-19 pandemic may have contributed to the high mortality. Our objective was to identify the frequency, types and etiology of bacterial infections in patients with COVID-19 admitted to an intensive care unit (ICU) and to evaluate the results of ICU stay, duration of mechanical ventilation (MV) and in-hospital mortality. It was a single-center study with a retrospective cohort of patients admitted consecutively to the ICU for more than 48 h between March and May 2020. Comparisons of groups with and without ICU- acquired infection were performed. A total of 191 patients with laboratory-confirmed COVID-19 were included and 57 patients had 97 secondary infectious events. The most frequent agents were Acinetobacter baumannii (28.9%), Pseudomonas aeruginosa (22.7%) and Klebsiella pneumoniae (14.4%); multi-drug resistance was present in 96% of A. baumannii and in 57% of K. pneumoniae. The most prevalent infection was ventilator-associated pneumonia in 57.9% of patients with bacterial infections, or 17.3% of all COVID-19 patients admitted to the ICU, followed by tracheobronchitis (26.3%). Patients with secondary infections had a longer ICU stay (40.0 vs. 17 days; p < 0.001), as well as a longer duration of MV (24.0 vs 9.0 days; p= 0.003). There were 68 (35.6%) deaths overall, of which 27 (39.7%) patients had bacterial infections. Among the 123 survivors, 30 (24.4%) had a secondary infections (OR 2.041; 95% CI 1.080 - 3.859). A high incidence of secondary infections, mainly caused by gram-negative bacteria has been observed. Secondary infections were associated with longer ICU stay, MV use and higher mortality.

COVID-19 in patients with cardiac disease: Impact and variables associated with mortality in a cardiology center in Brazil

BACKGROUND

Cardiovascular disease is associated with severe COVID-19. Our aim was to describe clinical and laboratory features (including electrocardiographic and echocardiographic ones) and outcomes of patients with cardiac disease hospitalized with COVID-19.

METHODS

This is an observational retrospective study of consecutive adult patients admitted, between March and September of 2020, with confirmed SARSCoV-2 infection. Data were collected as per the ISARIC case report form and complemented with variables related to heart disease.

RESULTS

One hundred twenty-one patients were included. Mean age was 60 SD 15.2 years and 80/121(66.1%) were male. Two-thirds of the patients (80/121, 66.1%) had COVID-19 at the time of hospital admission and COVID-19 was the reason for hospitalization in 42 (34.7%). Other reasons for hospital admission were acute coronary syndrome (26%) and decompensated heart failure (14.8%). Chronic cardiac diseases were found in 106/121 (87.6%), mostly coronary artery disease (62%) or valve disease (33.9%). A transthoracic echocardiogram was performed in 93/121(76.8%) and enlarged cardiac chambers were found in 71% (66/93); admission ECG was done in 93 cases (93/121, 76.8%), and 89.2% (83/93) were abnormal. Hospital-acquisition of COVID-19 occurred in 20 (16.5%) of patients and their mortality was 50%. On bivariate analysis for mortality, BNP levels and troponin levels were NOT associated with mortality. On multivariate analysis, only C reactive protein levels and creatinine levels were significant.

CONCLUSIONS

COVID-19 impacted the profile of hospital admissions in cardiac patients. BNP and troponin levels were not associated with mortality and may not be good prognostic discriminators in cardiac patients.

Mitral Valve Mass in a Patient Suspected of Systemic Lupus: Tumor, Endocarditis or Both?

Apresentamos o relato de caso de uma paciente com mixoma valvar mitral infectado e uma revisão da literatura sobre o assunto. Uma mulher de 33 anos apresentou histórico de febre e dispneia com evolução de alguns dias. Na hospitalização, ela apresentava uma síndrome semelhante ao lúpus, com hemoculturas positivas para Haemophilus spp . O ecocardiograma revelou uma massa gigante envolvendo ambos os folhetos mitrais associada à regurgitação grave, necessitando de troca valvar mitral biológica. A microscopia revelou mixoma infectado e a paciente recebeu alta assintomática após o término da antibioticoterapia. Ela apresentou bons resultados no seguimento. Este é o sexto caso de mixoma valvar mitral infectado relatado na literatura e o terceiro caso de mixoma cardíaco infectado pelo grupo HACEK. Devido à alta incidência de eventos embólicos, a antibioticoterapia precoce aliada à pronta intervenção cirúrgica são decisivos para a redução da morbimortalidade. O tempo para o diagnóstico foi muito mais breve do que o geralmente relatado em casos de endocardite por HACEK. A troca valvar foi a intervenção mais comum e todos os pacientes em relatos de caso anteriores apresentaram bons resultados no seguimento.

Functional capacity and rehabilitation strategies in Covid-19 patients: current knowledge and challenges

Covid-19 is a novel infectious disease whose spectrum of presentation ranges from absence of symptoms to widespread interstitial pneumonia associated with severe acute respiratory syndrome (SARS), leading to significant mortality. Given the systemic pattern of Covid-19, there are many factors that can influence patient's functional capacity after acute infection and the identification of such factors can contribute to the development of specific rehabilitation strategies. Pulmonary impairment is the primary cause of hospitalization due to Covid-19, and can progress to SARS as well as increase length of hospitalization. Moreover, cardiac involvement is observed in approximately 30% of hospitalized patients, with an increased risk of acute myocarditis, myocardial injury, and heart failure, which may compromise functional capacity in the long-term. Thromboembolic complications have also been reported in some patients with Covid-19 and are associated with a poor prognosis. Musculoskeletal complications may result from long periods of hospitalization and immobility, and can include fatigue, muscle weakness and polyneuropathy. Studies that address the functional capacity of patients after Covid-19 infection are still scarce. However, based on knowledge from the multiple systemic complications associated with Covid-19, it is reasonable to suggest that most patients, especially those who underwent prolonged hospitalization, will need a multiprofessional rehabilitation program. Further studies are needed to evaluate the functional impact and the rehabilitation strategies for patients affected by Covid-19.

"Metabolically Healthy" Obesity: Fact or Threat?

INTRODUCTION

Obesity is a serious, worldwide and growing problem, with associated complications ranging from cardiovascular disease to cancer. It has been suggested that a subgroup of obese patients- the "metabolically healthy" (MH)- would constitute a phenotype whose cardiovascular risk would be closer to that of normal weight individuals and lower than that of obese patients with other risk factors. The definitions of MH obesity are heterogeneous, what makes the estimation of its prevalence quite difficult. Besides that, data are still controversial about the risk of incident cardiovascular disease in these patients and therefore this remains an unresolved matter. In parallel, the possibly lower risk of MH obesity may raise questions about the need for weight loss in MH obese patients.

CONCLUSION

This issue should be carefully addressed, and evidence for a "benign" profile of MH obesity critically evaluated, as obesity is a risk factor for numerous health outcomes, and weight loss in obese people additionally offers protection against these nonmetabolic diseases.

Periodontal Conditions in Human Immunodeficiency Virus-Positive Patients Under Highly Active Antiretroviral Therapy From a Metropolitan Area of Rio De Janeiro

BACKGROUND

The aim of this study is to evaluate the periodontal status and the presence of opportunistic oral lesions in human immunodeficiency virus-positive (HIV+) patients under highly active antiretroviral therapy (HAART) and their association with cluster of differentiation (CD)4+ and CD4+ nadir T-cell counts and viral load levels.

METHODS

Clinical periodontal parameters and the presence of opportunistic oral lesions along with records of CD4+ counts and viral load levels were evaluated in 29 individuals (16 females; mean age: 42.7 years) with previous serologic diagnosis of HIV, from the acquired immunodeficiency syndrome program of the Health Center of Duque de Caxias, Rio de Janeiro, Brazil.

RESULTS

All individuals presented gingivitis or periodontitis. A higher non-significant prevalence of periodontitis was found in smokers (93.8%) compared with non-smokers (76.9%). A significant weak positive correlation was observed between CD4+ counts and missing teeth (ρ = 0.380, P <0.05), CD4+ nadir and periodontal diagnosis (ρ = 0.418, P <0.005), and CD4+ nadir and moderate probing depth (PD) (ρ = 0.424, P <0.05). When only non-smokers were analyzed, a significant moderate positive association was found between viral load and moderate clinical attachment level (CAL) (ρ = 0.638, P <0.05), CD4+ nadir and diagnosis (ρ = 0.586, P <0.05), and CD4+ nadir and moderate CAL (ρ = 0.680, P <0.05). Analysis considering only smokers found no correlations between serologic parameters and demographic or clinical parameters.

CONCLUSIONS

The current investigation demonstrates that HIV+ individuals under HAART presents a high prevalence of mild to moderate periodontal disease. Viral load levels, CD4+ nadir, and CD4+ counts may present a weak to moderate correlation to the number of missing teeth, periodontal diagnosis, moderate PD, and moderate CAL, which may also reflect some effect of these systemic conditions on the periodontal status.

The difficult management of disseminated Sporothrix brasiliensis in a patient with advanced AIDS

Sporotrichosis is an infection caused by a dimorphic fungus of the Sporothrix schenckii complex. Host immunity is an important factor in the clinical manifestations of the disease. Deeply immunocompromised individuals, especially those infected with the Human Immunodeficiency Virus (HIV) and T CD4 counts < 350 cells/ul lymphocytes, may present with the systemic form of sporotrichosis. This report describes a case of disseminated sporotrichosis caused by S. brasiliensis in a patient with advanced AIDS. The skin, lungs, bones and central nervous system were affected. Medical treatment involved the administration of amphotericin B, terbinafine, itraconazole and posaconazole. Posaconazole was associated with the best clinical response and clearing of the fungus from the central nervous system.

Healthcare-associated infective endocarditis: a case series in a referral hospital from 2006 to 2011

Background

Healthcare-associated infective endocarditis (HCA-IE), a severe complication of medical care, shows a growing incidence in literature.

Objective

To evaluate epidemiology, etiology, risk factors for acquisition, complications, surgical treatment, and outcome of HCA-IE.

Methods

Observational prospective case series study (2006-2011) in a public hospital in Rio de Janeiro.

Results

Fifty-three patients with HCA-IE from a total of 151 cases of infective endocarditis (IE) were included. There were 26 (49%) males (mean age of 47 ± 18.7 years), 27 (51%) females (mean age of 42 ± 20.1 years). IE was acute in 37 (70%) cases and subacute in 16 (30%) cases. The mitral valve was affected in 19 (36%) patients and the aortic valve in 12 (36%); prosthetic valves were affected in 23 (43%) patients and native valves in 30 (57%). Deep intravenous access was used in 43 (81%) cases. Negative blood cultures were observed in 11 (21%) patients, Enterococcus faecalis in 10 (19%), Staphylococcus aureus in 9 (17%), and Candida sp. in 7 (13%). Fever was present in 49 (92%) patients, splenomegaly in 12 (23%), new regurgitation murmur in 31 (58%), and elevated C-reactive protein in 44/53 (83%). Echocardiograms showed major criteria in 46 (87%) patients, and 34 (64%) patients were submitted to cardiac surgery. Overall mortality was 17/53 (32%).

Conclusion

In Brazil HCA-IE affected young subjects. Patients with prosthetic and native valves were affected in a similar proportion, and non-cardiac surgery was an infrequent predisposing factor, whereas intravenous access was a common one. S. aureus was significantly frequent in native valve HCA-IE, and overall mortality was high.

Adverse events related to intravenous antibiotic therapy: a prospective observational study in the treatment of infective endocarditis

OBJECTIVE

The goal of this prospective observational study was to identify adverse events (AEs) related to the use of intravenous access sites used for infective endocarditis (IE) treatment in a tertiary care hospital.

DESIGN

This is an observational, analytical and prospective study on AEs resulting from the use of intravenous access sites in patients under antimicrobial treatment for IE. Patients enrolled in the International Collaboration on Endocarditis (ICE) study had their peripheral, short-term central catheters (CVC) and peripherally inserted central catheters (PICC) monitored for AEs.

SETTING

Tertiary care hospital for cardiac surgery in Rio de Janeiro, Brazil.

PATIENTS

Patients over 14 years of age, hospitalised in 2009 and 2010 with possible or definite criteria for IE by the modified Duke criteria were included.

MAIN OUTCOME MEASURES

AEs related to intravenous catheters: erythema and infiltration, fever, obstruction, externalisation and blood stream infection.

RESULTS

Thirty-seven episodes of IE in 35 patients were studied. Mean patient age was 44.32±15.2 years; 22 (63%) were men. The number of vascular catheters studied were 253, 148 of which were peripheral, 85 CVC (21 of which for haemodialysis) and 20 PICC. The most frequent AEs were 'erythema' and 'infiltration' for peripheral catheters, 'fever' for CVCs and 'obstruction' and 'externalisation' for PICCs. The number of catheter-days was 360 for peripheral catheters, 1.156 for CVC and 420 for PICC. Kaplan-Meier curves for CVC and PICC showed statistical difference for obstruction (p<0.001) in PICCs. More bacteraemia occurred in CVC compared with PICC.

CONCLUSIONS

The choice of intravenous access sites is critical in the treatment of IE. Close observation for AEs and stricter implementation of infection control measures and better manipulation of catheters are suggested.

β-lactamase producing enterobacteria isolated from surveillance swabs of patients in a cardiac intensive care unit in Rio de Janeiro, Brazil

There is a high incidence of infections caused by betalactamase-producing Gram-negative microorganisms in Brazil. These organisms are of clinical and epidemiological importance, since their mobile genetic elements facilitate cross-infection. The present study was conducted in sentinel rectal swabs from patients admitted to a cardiac surgery hospital in Rio de Janeiro, from January through December 2007, in a consecutive manner. The aim of the study was to characterize the genotype and phenotype of these isolates from colonized patients. Biochemical tests, antimicrobial susceptibility tests, a confirmatory test for the expression of extended spectrum betalactamase (ESBL) production and polymerase chain reaction for the blaTEM, blaSHV, CTX-M1, Toho-1 and AmpC genes were performed at the University Hospital of Universidade do Estado do Rio de Janeiro (UERJ). The most frequently isolated bacteria were Escherichia coli 9/41 (21.95%) and Klebsiella pneumoniae 14/41 (34.1%). In 24/41 (58%), the ESBL genotype was confirmed. The most prevalent genes in samples that expressed ESBL were blaTEM 13/24 (54%), AmpC 12/24 (50%), blaSHV 6/24 (25%), CTX-M1 7/24 (29%), and Toho-1 6/24 (25%). Of these, 14/24 (58%) presented more than one genotype for the tested primers. In nine (37%) samples other than E. coli, K. pneumoniae or Proteus spp., the phenotype for ESBL was found and confirmed by PCR. The most sensitive substrate in the approximation test in ESBL positive samples was ceftriaxone (83%). Fifty percent of the samples expressed AmpC were associated with other genes. Intermediate susceptibility to ertapenem was found in 2/41 (5%).