Splenic abscess and infective endocarditis.

OBJECTIVE: To determine the background, bacteriological, clinical and radiological findings, associated lesions, treatment and outcome of splenic abscesses (SAs) in infective endocarditis (IE). METHODS: Retrospective study (2005-2021) of 474 patients with definite IE. The diagnosis of SA was made in 36 (7.6%) patients (31, 86.1%, males, mean age = 51.3) on abdominal CT. RESULTS: The main implicated organisms were Streptococcus spp (36.1%), Enterococcus faecalis (27.7%), Staphyloccus spp (19.4%). Rare agents were present in 10 patients (27.8%). Pre-existing conditions included a prosthetic valve (19.4%), previous IE (13.9%), intravenous drug use (8.4%), diabetes (25%) alcohol abuse (13.9%), liver disease (5.5%). Vegetations ≥ 15 mm were present in 36.1%. Common presentations were abdominal pain (19.4%) and left-sided pleural effusion (16.5%). SA were more often small (50%; 7 multiple) than large (36.1%; 1 multiple) or microabscesses (13.9%, 3 multiple). Associated complications were extrasplenic abscesses (brain, 11.1%; lung, 5.5%; liver, 2.8%), infectious aneurysms (16.7%: 3 intracranial, 1 splenic, 1 hepatic, 1 popliteal), emboli (brain, 52.8%; spleen, 44.4%, 5 evolving to SA; kidney, 22.2%; aorta, 2.8%), osteoarticular infections (25%). Twenty-eight (77.8%) patients only received antimicrobials, 7 (19.4%) underwent splenectomy, after cardiac surgery in 5. One had percutaneous drainage. The outcome was uneventful (follow-up 3 months-14 years; mean: 17.2 months). CONCLUSION: In SA-IE patients, the prevalence of vegetation size, Enterococcus faecalis, rare germs, diabetes, osteo-arthritic involvement and cancer was higher than in non-SA patients. Some SAs developed from splenic infarcts. IE-patients with evidence of splenic emboli should be evaluated for a possible abcedation. Cardiac surgery before splenectomy was safe.

Hepatic Artery Aneurysms in Infective Endocarditis: Report of 10 Cases and Literature Review.

BACKGROUND: Hepatic artery aneurysms (HAAs), albeit rare in infective endocarditis (IE), are associated with a life-threatening morbidity. METHODS: Retrospective review of 10 HAA-IE patients based on a total of 623 IE patients managed in 2 institutions (2008-2020) versus 35 literature cases. RESULTS: In our patient population, HAAs (10 males, mean age 48) were incidentally found during IE workup. All were asymptomatic. IE involved mitral (n = 6), aortic (n = 3), or mitral-aortic valve (n = 1). Predisposing factors for IE were as follows: prosthetic valve (n = 6), previous IE (n = 2), IV drug user (n = 1). Streptococcus species (spp.) were predominant (n = 4), then staphylococcus spp (n = 2) and E. faecalis (n = 2). All patients presented associated lesions: infectious aneurysms (n = 5), emboli (n = 9), abscesses (n = 5), and spondylitis/spondylodiscitis (n = 2). HAA patterns on abdominal CT angiography (CTA) were solitary (70%), mean diameter 11.7 mm (range 2-30), intrahepatic location (100%) involving the right HA in 9 out of 10 (90%) patients. In 2 patients, HAAs were complicated (rectorragia and hemobilia in 1, cholestasis in the other). Six patients underwent endovascular hepatic embolization (2 with multiple HAAs). Three HAA-IEs <15 mm resolved under antibiotherapy on abdominal CTA follow-up. All patients underwent cardiac surgery. Late outcome was favorable in all followed patients (5/10). Literature review showed the preponderance of Streptococcus spp., of right lobe and intrahepatic HAA localization. Complications revealed HAAs in patients under antibiotic therapy and/or after cardiac surgery in 17 literature cases of delayed diagnosis. CONCLUSIONS: Abdominal CTA was pivotal in the initial IE workup. Small aneurysms (≤15 mm) resolved under antibiotherapy. The usual treatment modality was HAA embolization and endovascular embolization before valve surgery was safe.

Brain abscesses in infective endocarditis: contemporary profile and neuroradiological findings.

BACKGROUND: Brain abscesses (BA) are severe lesions in the course of infective endocarditis (IE). We compare the bacteriological, clinical data, background, associated lesions, and outcome of IE patients with and without BAs, and assess the MRI characteristics of BAs. METHODS: Retrospective study of 351 consecutive patients with definite IE (2005-2020) and at least one brain MRI. Patients with and without BAs were compared. RESULTS: Twenty patients (5.7%) had BA (80% men; median age: 44.9 ± 11.5). They were younger (p = 0.035) and had a higher rate of predisposing factors (previous IE 20% vs 2.2%, p = 0.03), intravenous drug use [25% vs 2.2%; p < 0.0001]), underlying conditions (HIV infection, 20% vs 2.2%, p < 0.0001; alcohol abuse, 20% vs 2.2% p < 0.0001]; liver disease p = 0.04; hemodialysis, p = 0.001; type 2 diabetes, p = 0.001), bacterial meningitis (p = 0.0029), rare species involvement (35% vs 7%, p < 0.0006) and extra-cerebral abscesses (p = 0.0001) compared to patients without BA. Valve vegetations were larger in Group 1 (p = 0.046). Clinical presentation could suggest the diagnosis of BA in only 7/20 (35%) patients. MR identified 58 BAs (mean/patient 2.9; range 2-12): often multiple (80%), bilateral (55%) and ≤ 10 mm (72%). The presence of BA did not modify cardiac surgery indication and timing. Favorable outcome was observed in 85% of patients. CONCLUSION: Rates of predisposing, underlying conditions, rare IE agents, meningitis and metastatic abscesses are significantly higher in BA-IE patients. As BAs can develop in asymptomatic IE patients, the impact of brain MRI on their management needs thoroughly to be further investigated.

Impact of Systematic Whole-body 18F-Fluorodeoxyglucose PET/CT on the Management of Patients Suspected of Infective Endocarditis: The Prospective Multicenter TEPvENDO Study.

BACKGROUND: Diagnostic and patients' management modifications induced by whole-body 18F-FDG-PET/CT had not been evaluated so far in prosthetic valve (PV) or native valve (NV) infective endocarditis (IE)-suspected patients. METHODS: In sum, 140 consecutive patients in 8 tertiary care hospitals underwent 18F-FDG-PET/CT. ESC-2015-modified Duke criteria and patients' management plan were established jointly by 2 experts before 18F-FDG-PET/CT. The same experts reestablished Duke classification and patients' management plan immediately after qualitative interpretation of 18F-FDG-PET/CT. A 6-month final Duke classification was established. RESULTS: Among the 70 PV and 70 NV patients, 34 and 46 were classified as definite IE before 18F-FDG-PET/CT. Abnormal perivalvular 18F-FDG uptake was recorded in 67.2% PV and 24.3% NV patients respectively (P < .001) and extracardiac uptake in 44.3% PV and 51.4% NV patients. IE classification was modified in 24.3% and 5.7% patients (P = .005) (net reclassification index 20% and 4.3%). Patients' managements were modified in 21.4% PV and 31.4% NV patients (P = .25). It was mainly due to perivalvular uptake in PV patients and to extra-cardiac uptake in NV patients and consisted in surgery plan modifications in 7 patients, antibiotic plan modifications in 22 patients and both in 5 patients. Altogether, 18F-FDG-PET/CT modified classification and/or care in 40% of the patients (95% confidence interval: 32-48), which was most likely to occur in those with a noncontributing echocardiography (P < .001) or IE classified as possible at baseline (P = .04), while there was no difference between NV and PV. CONCLUSIONS: Systematic 18F-FDG-PET/CT did significantly and appropriately impact diagnostic classification and/or IE management in PV and NV-IE suspected patients. CLINICAL TRIALS REGISTRATION: NCT02287792.