Risk factors for systemic emboli in infective endocarditis

A retrospective study was undertaken to analyse the risk factors for systemic emboli in infective endocarditis. Patients (n = 80; 70% males; mean age 65 years; range 20-91 years) with infective endocarditis, as defined by the Duke criteria and diagnosed using transoesophageal echocardiography during the period January 1995 to March 2001, were included. The average time between the start of the illness and the beginning of antibiotic treatment was 55 days (range 0-405 days). The pathogens identified were streptococci (n = 47), staphylococci (n = 11), enterococci (n = 9), and others (n = 4). In nine cases, blood cultures were sterile. Thirty patients with at least one embolic episode were compared with 50 control patients. According to univariate analysis, the main risk factor for systemic emboli was the size of the vegetation (12.4 mm vs. 7.8 mm; p = 0.0005). The risk of emboli was 57% when the vegetation measured > 10 mm and only 22% when it was < 10 mm (p = 0.003). The mobility of the vegetation was also a risk factor: 48% if the vegetation was mobile; and 9% if fixed (p = 0.003). Sex, age, pathogen, antibiotic treatment, type of valve and the number and position of the vegetations were not found to be risk factors. With multivariate analysis, only mobility was identified as a risk factor. Overall, mobile vegetations > 10 mm in size were associated with an increased risk of embolic episodes in infective endocarditis.

[Propionibacterium acnes infectious endocarditis]

BACKGROUND

Propionibacterium acnes, a Gram positive microaerophilic bacteria is considered to have a low level of virulence. Nevertheless, it can be associated with infective endocarditis. We report 2 cases and a review of the literature.

CASE REPORTS

The first man developed an acute prosthetic valve infective endocarditis and died. The second case was also a prosthetic valve infective endocarditis in a patient who developed infectious spondylitis.

DISCUSSION

P. acnes is an uncommon causal agent in infective endocarditis and appears to have a predilectio for prosthetic valves. A prior history of skin infection is rare. P. acnes grow quite slowly, often requiring 7 to 14 days for identification. All isolates of P. acnes from blood or valve do not necessarily mean contamination.

Malignant boutonneuse fever and polymyalgia rheumatica: a coincidental association?

Mediterranean spotted fever is a tick-borne disease that is endemic in the Mediterranean basin from spring to autumn. Usually mild, the disease can be severe in some cases, especially when risk factors are encountered in patients or when treatment is delayed. The correlation between these malignant forms and patients' immunological disorders remains unclear, while the pathophysiology of the disease seems well known. A case of a malignant form of Mediterranean spotted fever is reported which occurred 2 months prior to the diagnosis of polymyalgia rheumatica. Evidence of immunological disorders consisted only in an antiphospholipid antibody associated with a transient lupus anticoagulant. No underlying risk factors other than the primary undiagnosed phase of polymyalgia rheumatica has been observed.

[Actinomyces meyeri disseminated actinomycosis disclosing pulmonary carcinoma]

The diagnosis of severe actinomycosis parallel to that of neoplasia leads to speculation of a possible fortuitous association. Because underlying conditions such as immuno-suppression are suspected in such disease, and to strengthen this hypothesis, we report one more case of disseminated actinomycosis associated with a malignant disease, namely an epidermoid pulmonary carcinoma. The diagnosis was made by thoracotomy a few months after the infectious episode. Two years later the patient recovered. The analysis of the literature data is in favor of a fortuitous association between both diagnoses.

New serotype of Bartonella henselae in endocarditis and cat-scratch disease

BACKGROUND

The fastidious nature of Bartonella henselae is such that demonstration of clinical infection relies mainly on serological or molecular biological methods. Only five isolates have been obtained from patients with cat-scratch disease (CSD) and none from endocarditis.

METHODS

We isolated B henselae from a CSD patient and, for the first time, from a patient with endocarditis. The isolates were characterised on the basis of morphology, biochemistry, cell-wall fatty-acid analysis, PCR-restriction fragment length polymorphism analysis of the 16-23S intragenic spacer region, and 16S rRNA gene sequences. Characterisation of these isolates indicated them to belong to a new serogroup, which we have called "Marseille", and to a new genotype based on the 16S rRNA gene sequence. The new variant was incorporated into an immuno-fluorescence antibody test (IFAT), which was used to reassess serum samples from 113 CSD patients who were seronegative with the conventional IFAT.

FINDINGS

18 (16%) of these apparently seronegative patients yielded significantly raised titres. 20 CSD patients who were seropositive as judged by the conventional IFAT remained seropositive with the new IFAT.

INTERPRETATION

Antigenic variability within the species is one possible reason for inconsistent results in the serological diagnosis of CSD.

Recurrent bilateral anterior uveitis with hypopyon and rifabutin therapy

Rifabutin is used in patients with human immunodeficiency virus infection to prevent and treat Mycobacterium avium complex infection. We report a case of recurrent bilateral anterior uveitis with hypopyon in a patient who was taking 600 mg of rifabutin daily. The rate of recurrence with the continuation of rifabutin seems to be high, especially in the opposite eye (alternate uveitis with hypopyon); rifabutin should be discontinued if uveitis recurs.

[Heel involvement in rheumatoid polyarthritis]

Calcaneus involvement during the course of RA is poorly known. A clinical and radiological study of 408 consecutive rheumatoid feet are then reported. If talalgia was seldomly noted (3.7 p. cent), plantar calcaneitis was found in 29.7 p. cent as plantar spur. Similarly, posterior exostosis was displayed in 30.5 p. cent of patients. These radiological abnormalities are increased in RA but appeared more as a consequence of the statical modification of the foot secondary to RA process than as a direct involvement. Logical orthopedic therapeutics are then proposed.