Gonococcal Endocarditis: The Gift That Stops Giving! An Uncommon Presentation of a Common Disease.

INTRODUCTION: Gonorrhea is the 2nd most common sexually transmitted disease in the US with 800,000 cases of gonorrhea each year. Disseminated gonorrhea infection occurs in 0.5 percent - 3 percent of these patients and is more frequent in woman younger than 40 years of age. CASE: A 36 year old woman with a history of polysubstance abuse presented with 10 day history of feeling generally unwell. At presentation, vitals were remarkable for tachycardia and hypotension. Physical exam was remarkable for conjunctival pallor, bibasilar crackles, and tachycardia with grade III/VI systolic murmur loudest over the 2nd inter-costal space and loudest with expiration. No skin lesions were noted. Labs demonstrated leukocytosis (WBC 20,200 with 84 percent neutrophils);, anemia (Hb 6.7);, thrombocytosis (platelets 423 k/uL);, abnormal liver function tests (alkaline phosphatase 239 IU, AST 151 IU ALT 71 IU, albumin 2.5g/dL);, PT/INR 17.1/1.5. Troponin 0.42, BNP 823, D-dimer 619, and a urine drug screen that was positive for benzodiazepines, opiates, barbiturates, amphetamine, and THC. Hep panel and HIV were negative. Chest radiograph showed mild cardiomegaly and early interstitial edema. The patient was placed on broad spectrum antibiotics and given adequate fluid resuscitation and blood products. Blood cultures grew Neisseria gonorrhoeae. 2D ECHO showed a large pedunculated/mobile echo density adherent to the non-coronary and lefts cusps of the aortic valve. Proximal aortic root and aorto-mitral continuity were thickened, consistent with aortitis and/or abscess formation. Initial EKG on arrival showed junctional tachycardia which progressed into complete heart block. Cardiology was consulted and a pacemaker was placed emergently. However despite all aggressive measures the patient died of cardiac complications. DISCUSSION: Endocarditis is a rare complication of disseminated gonorrhea, occurring in only 1-2 percent of patients with gonoccocemia. The aortic valve is most commonly affected. Valve replacement is warranted in cases with severe dysfunction. Mortality remains around 19-20. Neisseria gonorrhoeae endocarditis should be included in the differential diagnosis in sexually active patients with endocarditis.

Cat Got Your Eye?

Bartonella hensalae (CSD) is a gram negative bacilli causing variety of clinical sequelae. Patients usually develop lymphadenopathy and fever but in rare cases (1%-2%) neuro-retinitis can occur.

Neutrophil uptake of vaccinia virus in vitro.

We studied human neutrophils for uptake of vaccinia virus. Uptake was determined radiometrically and by electron microscopy. Vaccinia virus was labeled with 14C or 3H, incubated with neutrophils, and quantified in neutrophil pellets in a new radiometric phagocytosis assay. Better results were obtained from assays of [3H]thymidine-labeled virus; uptake increased through 1 hr and then plateaued. Phagocytosis of 3H-labeled Staphylococcus aureus was normal. Uptake of virus was serum dependent. Hexose monophosphate shunt activity was measured by two methods. No 14CO2 from [14C]1-glucose accompanied uptake of vaccinia virus, in contrast to the respiratory burst accompanying bacterial phagocytosis. Electron microscopy showed intact to slightly digested intraphagolysosomal vaccinia virus. Pock reduction assay showed a decrease in viral content due to neutrophils until 6 hr of incubation, when a modest but significant increase was observed. Thus, neutrophil uptake of vaccinia virus is distinguished from bacterial phagocytosis.

Pseudomonas putrefaciens and group A beta-hemolytic streptococcus septicemia.

Pseudomonas putrefaciens was isolated twice in blood cultures from which group A beta-hemolytic streptococci were concurrently isolated from a moribund woman. Only once previously has P putrefaciens bacteremia been reported. To our knowledge, we are reporting the first blood isolate of P putrefaciens, albeit with group A beta-hemolytic streptococci, associated with fatal septicemia.

Saccharomyces cerevisiae septicemia.

We report the first known case of septicemia caused by Saccharomyces cerevisiae. It occurred nosocomially in a hyperalimented burned man. It is a rare example of disease caused by S cerevisiae, which, like many saprophytes, can become pathogenic in the debilitated. The case is remarkable for its apparent origin in a bleeding esophageal lesion, for its clinical characteristics, including profound neutropenia, thrombocytopenia, hypothermia, and monocytopenia, and for its cure by amphotericin B.

Clostridium pseudotetanicum bacteremia in a patient with Pasteurella multocida conjunctivitis.

Clostridium pseudotetanicum only once previously has been identified as causing disease. Pasteurella multocida has been identified only three times as the cause of purulent conjunctivitis. A very debilitated patient had C. pseudotetanicum bacteremia and P. multocida conjunctivitis from which she recovered only to die of a nosocomial Staphylococcus epidermidis septicemia, originating in a site for the administration of intravenous fluids.