Characteristics associated with occurrence of stroke in patients with infective endocarditis - a retrospective cohort study.

BACKGROUND: Stroke is a severe complication of infective endocarditis (IE), associated with high rates of mortality. Data on how IE patients with and without stroke differ may help to improve understanding contributing mechanisms. METHODS: All patients treated for IE between 2019 and 2021 with and without associated stroke were identified from the medical records of three academic tertiary care hospitals in Germany, all part of Charité - Universitätsmedizin Berlin, Germany. Multivariable logistic regression analyses were performed to identify variables associated with the occurrence of stroke. RESULTS: The study population consisted of 353 patients diagnosed with IE. Concomitant stroke occurred in 96/353 (27.2%) patients. Acute stroke was independently associated with co-occurring extracerebral arterial embolism [adjusted Odds ratio (aOR = 2.52; 95% confidence interval (CI) 1.35-4.71)], acute liver failure (aOR = 2.62; 95% CI 1.06-6.50), dental focus of infection (aOR = 3.14; 95% CI 1.21-8.12) and left-sided IE (aOR = 28.26; 95% CI 3.59-222.19). Stroke was found less often in IE patients with congenital heart disease (aOR = 0.20; 95% CI 0.04-0.99) and atypical pathogens isolated from blood culture (aOR = 0.31; 95% CI 0.14-0.72). CONCLUSIONS: Stroke is more likely to occur in individuals with systemic complications affecting other organs, too. Special attention should be addressed to dental status. The low incidence of stroke in patients with congenital heart disease may reflect awareness and prophylactic measures.

Insights into microorganisms, associated factors, and the oral microbiome in infective endocarditis patients.

Introduction: Infective Endocarditis (IE) is a rare, life-threatening infection of the endocardium with multisystem effects. Culprit microorganisms derived from different niches circulate through the bloodstream and attach to the endocardium, particularly the heart valves. This study aimed to investigate culprit microorganisms among a cross-sectional cohort of IE patients, their associated factors, and to explore the potential relationship to the oral microbiome. Methods: In this observational study, we undertook a cross-sectional analysis of 392 medical records from patients diagnosed with IE. The primary outcome of this study was to analyse the association between the IE culprit microorganisms and the underlying anatomical types of IE (native valve (NVE), prosthetic valve (PVE), or cardiac device-related (CDE)). Secondary outcomes encompassed a comparative analysis of additional factors, including: the treatment approaches for IE, and the categorisation of blood cultures, extending to both genus and species levels. Additionally, we cross-referenced and compared the species-level identification of IE bacteraemia outcome measures with data from the expanded Human Oral Microbiome Database (eHOMD). Results: A culprit microorganism was identified in 299 (76.28%) case participants. Staphylococcal infections were the most common (p < 0.001), responsible for 130 (33.16%) hospitalisations. There were 277 (70.66%) cases of NVE, 104 (26.53%) cases of PVE, and 11 (2.81%) cases of CDE. The majority of PVE occurred on prosthetic aortic valves (78/104, 75%), of which 72 (93.5%) were surgical aortic valve replacements (SAVR), 6 (7.8%) were transcatheter aortic valve implants, and one transcatheter pulmonary valve implant. Overall, underlying anatomy (p = 0.042) as well as the treatment approaches for IE (p < 0.001) were significantly associated with IE culprit microorganisms. Cross-reference between IE bacteraemia outcomes with the eHOMD was observed in 267/392 (68.11%) cases. Conclusions: This study demonstrated that IE patients with a history of stroke, smoking, intravenous drug use, or dialysis were more likely to be infected with Staphylococcus aureus. CDE case participants and patients who had previous SAVR were most associated with Staphylococcus epidermidis. IE patients aged 78+ were more likely to develop enterococci IE than other age groups. Oral microorganisms indicated by the eHOMD are significantly observed in the IE population. Further research, through enhanced dental and medical collaboration, is required to correlate the presence of oral microbiota as causative factor for IE.

Nonbacterial thrombotic endocarditis of mitral valve associated with a lymphoproliferative malignancy: case report and literature review.

BACKGROUND: Non-bacterial thrombotic endocarditis (NBTE) is a rare condition marked by sterile vegetations on cardiac valves, often linked to rheumatologic diseases, autoimmune disorders, and advanced solid malignancies. An early diagnosis and treatment of the associated clinical condition are mandatory, although they do not usually eliminate valvular vegetations, making anticoagulation essential to prevent embolic events. Despite variability, the prognosis of NBTE is usually unfavorable due to recurrent embolic events and the severity of the primary condition, typically advanced cancer. CASE PRESENTATION: We present a case of a 57 years-old male who presented to the emergency department with a 5-day history of painful bilateral digital edema and color change episodes (from pallor to cyanosis). Physical examination revealed erythrocyanosis in the distal extremities, prompting consideration of secondary Raynaud syndrome. Despite medical therapy, progressive digital ischemia led to multiple finger amputations. During etiological investigation, anticoagulation tests and autoimmune analysis yielded negative results. A transesophageal echocardiogram was performed, revealing an irregular hyperechogenic mass on the anterior leaflet of the mitral valve without valve dysfunction, and a thoracic computed tomography scan with contrast showed an enlarged right paratracheal lymph node. Histopathological analysis from a transthoracic needle biopsy of the paratracheal lymph node revealed diffuse large B-cell lymphoma. The patient underwent aggressive R-CHOP chemotherapy, achieving a favorable complete response. CONCLUSION: This is a particular case involving the occurrence of NBTE and Raynaud phenomenon as the initial paraneoplastic manifestations in a previously healthy young man. Reports of NBTE associated with lymphoproliferative conditions are quite rare, with fewer than ten cases described in the literature. To our knowledge, this is the first case of NBTE specifically associated with diffuse large B-cell lymphoma.

Impact of postoperative cerebral complications in acute infective endocarditis: a retrospective single-center study.

BACKGROUND: The treatment of patients with infective endocarditis (IE) who have preoperative cerebral complications remains less understood. Therefore, this study aimed to retrospectively evaluate the clinical outcomes of patients with acute IE based on preoperative intracranial findings. METHODS: Of 32 patients with acute IE treated at our hospital between August 2015 and March 2022, 31 patients of whom preoperative intracranial imaging evaluation was available were included in our analysis and compared with those with and without intracranial findings. We controlled the mean arterial blood pressure and activated clotting time (ACT) to prevent abnormally high perfusion pressures and ACTs during cardiopulmonary bypass (CPB). The preoperative background, and postoperative courses focusing on postoperative brain complications were reviewed. RESULTS: Among the 31 patients, 20 (65%) had preoperative imaging findings. The group with intracranial findings was significantly older, with more embolisms in other organs, positive intraoperative pathology findings, and longer CPB times. A new cerebral hemorrhage developed postoperatively in one patient without intracranial findings. There were no early deaths; two patients had recurrent infections in each group, and one died because of sepsis in the late phase in the group with intracranial findings. CONCLUSIONS: Positive intracranial findings indicated significantly active infectious conditions preoperatively but did not affect the postoperative course. Patients without preoperative cerebral complications can develop serious cerebral hemorrhage. Although meticulous examination of preoperative cerebral complications in all patients with IE is essential, a strategy should be adopted to prevent cerebral hemorrhage, even in patients without intracranial findings.

D-Transposition of Great Arteries With Infective Endocarditis and Congestive Cardiac Failure: A Case Report.

Embryological misalignment between the aorta and pulmonary trunk gives rise to the congenital anomaly of the heart known as transposition of the great arteries (TGA). TGA is a type of parallel circulation, where the heart pumps oxygenated blood from the left ventricle into the pulmonary trunk. The deoxygenated blood from the right ventricle is circulated into the body as it pumps blood into the aorta. This type of parallel circulation is not compatible with life unless there is communication between oxygenated and deoxygenated blood. The presence of a ventricular septal defect (VSD) or patent ductus arteriosus (PDA) in TGA patients serves as this communication. Cyanosis in the first month of life is the most common presenting feature. We had a five-and-a-half-year-old male child presenting with cyanosis and congestive cardiac failure (CCF), along with infective endocarditis with mitral valve regurgitation, which is an unusual complication of dextro-TGA (d-TGA) with pulmonary stenosis (PS) with VSD.

Abiotrophia defectiva Endocarditis Complicated by Stroke and Spinal Osteomyelitis.

A 67-year-old male with coronary artery disease and aortic stenosis after coronary artery bypass graft (CABG) and aortic valve replacement (AVR) presented after a two-day history of dizziness and frequent falls. Initially, he was found to have a subacute infarct of the left temporal lobe, osteomyelitis of the lumbar spine, and an aortic valve vegetation. Further investigations demonstrated gram-positive bacteremia, and, eventually, the causative organism was identified as Abiotrophia defectiva. He was treated with penicillin and gentamicin in the inpatient setting and then discharged with outpatient intravenous (IV) ceftriaxone for the remainder of the four-week antibiotic course. He did not suffer complications after initiating therapy and recovered. We wish to raise awareness of the existence and complications that can result from A. defectiva endocarditis and encourage further research into effective antibiotic treatment. A. defectiva endocarditis may lead to neurological and orthopedic infective sequelae; understanding and awareness of Abiotrophia spp. infections are important to ensure effective treatment of endocarditis.

Cryptogenic Stroke Complicated by Infective Endocarditis: Exploring the Multidisciplinary Interplay.

Infective endocarditis (IE) poses a significant clinical challenge due to its non-specific symptoms and variety of complications. Complications can include ischaemic stroke, valve dysfunction, discitis, and osteomyelitis, highlighting the complexity of IE management. We present a case of a male in his 40s, admitted with an ischaemic stroke, eventually being found to have underlying IE with a plethora of complications. This case highlights the importance of collaboration among specialists to form a multidisciplinary team, which is essential for the effective delivery of care. Furthermore, there is a critical need to explore the psychological impact of IE on patient outcomes, advocating for a holistic approach that considers psychological well-being alongside medical management. Future research should address these underexplored facets to improve patient care and outcomes in IE.

Streptococcus oralis meningitis in pregnancy.

While pregnancy is a time of relative immunosuppression, infective endocarditis and bacterial meningitis remain rare. We present a case of a pregnant woman with Streptococcus oralis endocarditis and meningitis. This is the first reported case of Streptococcus oralis meningitis in a patient without predisposing risk factors. This case highlights the importance of collecting blood cultures in febrile illness during pregnancy and illustrates that effective management plans can be formulated without performing invasive diagnostic tests such as transesophageal echocardiography.

Echocardiographic findings in cancer-associated non-bacterial thrombotic endocarditis. Clinical series of 111 patients from single institution.

AIMS: Echocardiographic assessment of cancer-associated non-bacterial thrombotic endocarditis (Ca-NBTE) is limited to cases reports and small clinical series. Identifying heart valves abnormalities and its relation to embolic complications and cancer types. METHODS AND RESULTS: Manual review of echocardiographic images and medical records of Mayo Clinic patients (03/31/2002-06/30/2022) was performed. Ca-NBTE in 111 patients (mean age 63.2±9.7 years, 66.7% female) predominantly affected mitral valves (MV) (69), 56 aortic (AV), 8 tricuspid (TV) and rarely pulmonic (PV) (1). In 18 patients 2 valves were involved, 3 and 4 valves involvement in only a single patient each. Embolic complications were prevalent (n=102, 91.9%). Ca-NBTE affected MV more frequently the on upstream (atrial) (90% vs 49.3%) and TV downstream (ventricular) side (75% vs 37.5%). NBTE size (cm) varied significantly among valves, with TV hosting the largest masses (0.63-2.40 x 0.39-1.77), compared to MV [(0.11-1.81 x 0.11-1.62), (length p=0.001; width p=0.03)], and to AV [(0.20-2.70 x 0.11-1.51), (length p=0.001; width p=0.056)]; MV masses were borderline longer in systemic compared to cerebral emboli (p=0.057). Majority of MV (79.6%) and AV (69.6%) had thickened leaflets. NBTE lesions commonly affected closing margins (73.9%MV, 85.7% AV, and 62.5% of TV), but rarely commissures of MV (8.7%), yet fairly frequently of AV (41.1%). Five patients had severe regurgitation of MV and 5 AV. CONCLUSION: Ca-NBTE manifests mainly as thrombotic mobile masses attached to thickened MV and AV, with distinct variations in size based on valve type. Embolic destination but not cancer type is associated with NBTE mass size, and location.

Percutaneous Debulking of a Large Mobile Mitral Valve Vegetation Using the Angiovac.

The Angiovac aspiration system has been used successfully for the removal of intravascular material or thrombus in the right-sided heart structures, vena cava, implantable cardiac defibrillator, or other devices. For infective endocarditis, it is reserved for the patients who warrant but are not good candidates for the surgery. The evidence regarding Angiovac aspiration of the infective endocarditis of the left-sided heart valves is scarce. The risk of complications, including thrombi fragmentation leading to systemic embolization, damage to the cardiac structures and tissue, and hemodynamic instability, precludes the widespread use of this procedure, especially for the left-sided lesions. We report a case of successful removal of the mitral valve endocarditis using the Angiovac aspiration technique under the TEE guidance. A SENTINEL™ cerebral protection system was used to prevent embolus migration and a venous rather than an arterial access was used for reperfusion.

Real-World Dalbavancin Use for Serious Gram-Positive Infections: Comparing Outcomes Between People Who Use and Do Not Use Drugs.

Background: Dalbavancin has been used off-label to treat invasive bacterial infections in vulnerable populations like people who use drugs (PWUD) because of its broad gram-positive coverage and unique pharmacological properties. This retrospective, multisite study examined clinical outcomes at 90 days in PWUD versus non-PWUD after secondary treatment with dalbavancin for bacteremia, endocarditis, osteomyelitis, septic arthritis, and epidural abscesses. Methods: Patients at 3 teaching hospitals who received dalbavancin for an invasive infection between March 2016 and May 2022 were included. Characteristics of PWUD and non-PWUD, infection highlights, hospital stay and treatment, and outcomes were compared using χ2 for categorical variables, t test for continuous variables, and nonparametric tests where appropriate. Results: There were a total of 176 patients; 78 were PWUD and 98 were non-PWUD. PWUD were more likely to have a patient-directed discharge (26.9% vs 3.1%; P < .001) and be lost to follow-up (20.5% vs 7.14%; P < .01). Assuming loss to follow-up did not achieve clinical cure, 73.1% of PWUD and 74.5% of non-PWUD achieved clinical cure at 90 days (P = .08). Conclusions: Dalbavancin was an effective treatment option for invasive gram-positive infections in our patient population. Despite higher rates of patient-directed discharge and loss to follow-up, PWUD had similar rates of clinical cure at 90 days compared to non-PWUD.

Impact of the SARS-CoV-2 Pandemic on the Management and Prognosis of Infective Endocarditis.

BACKGROUND: Infective endocarditis (IE) is a serious condition which is difficult to diagnose and to treat, both medically and surgically. OBJECTIVES: The objective of this study was to evaluate the impact of the SARS-CoV-2 pandemic on the management of patients with IE. METHODS: We conducted a single-centre retrospective study including patients hospitalized for IE during the pandemic (Group 2) compared with the same period the year before (Group 1). We compared clinical, laboratory, imagery, therapeutic, and patient outcomes between the two groups. RESULTS: A total of 283 patients were managed for possible or definite IE (164 in Group 1 and 119 in Group 2). There were more intravenous drug-related IE patients in Group 2 (p = 0.009). There was no significant difference in surgery including intra-cardiac device extraction (p = 0.412) or time to surgery (p = 0.894). The one-year mortality was similar in both groups (16% versus 17.7%, p = 0.704). The recurrence rate was not significantly different between the two groups (5.9% in Group 2 versus 9.1% in Group 1, p = 0.311). CONCLUSIONS: The SARS-CoV-2 pandemic did not appear to have had a negative impact on the management of patients with IE. Maintenance of the activities of the endocarditis team within the referral centre probably contributed to this result. Nevertheless, the high proportion of intravenous drug-addicted patients in the pandemic cohort suggests that the SARS-CoV-2 pandemic had a major psychosocial impact.

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.

Pseudomonas aeruginosa: An Unusual Culprit of Left-Sided Native Valve Infective Endocarditis.

Endocarditis refers to infection or inflammation of the endocardium, and various pathogens can be involved in infective endocarditis (IE). Endocarditis is usually caused by bacteremia in patients with risk factors, including IV drug abuse, indwelling central venous or urinary catheters, recent dental infections, and implantable cardiac devices. Pseudomonas aeruginosa (P. aeruginosa) is an extremely rare causative organism in IE, predominantly among IV drug users and involving right-sided valves. Left-sided native valve P. aeruginosa IE without established risk factors is uncommon. We present a case of a 68-year-old male with no traditional IE risk factors who presented with intermittent fevers. Blood cultures grew P. aeruginosa, and transesophageal echocardiography revealed posterior mitral valve vegetation. The patient received broad-spectrum IV antibiotics, which were eventually narrowed down to IV cefepime, guided by culture antimicrobial sensitivities. Although the literature describes various risks for P. aeruginosa IE, it can still occur in the absence of traditional predisposing factors. Due to this organism's rapid resistance acquisition and the complication of septic emboli, an expeditious diagnosis and treatment with antibiotics and/or valve surgery are vital to reducing mortality associated with this entity.

Association between Causative Pathogen and Occurrence of Infection-Related Glomerulonephritis in Infective Endocarditis.

Among patients with pathologically-proven infective endocarditis, the association of pathogen with occurrence of infection-related glomerulonephritis (IRGN) was examined in 48 cases of IRGN and 192 propensity score-matched controls. Bartonella was very strongly associated with IRGN (OR 38.2, 95% C.I. 6.7-718.8, p-value <.001); other microorganisms were not.

Outpatient parenteral antibiotic treatment for infective endocarditis: A retrospective observational evaluation.

BACKGROUND: Infective endocarditis (IE) requires long courses of intravenous (IV) antibiotics. Outpatient parenteral antibiotic therapy (OPAT) saves resources, improves the patient experience and allows care in their preferred place; however, questions remain about safety when treating IE patients. This study evaluates OPAT management of IE patients in our region between 2006 and 2019. METHODS: This is a retrospective observational evaluation and description of outcomes and adherence to suitability criteria, according to British Society for Antimicrobial Chemotherapy (BSAC) guidelines. RESULTS: We identified five models of OPAT delivery. The number of patients treated expanded significantly over time. Of 101 patients, 6 (6%) suffered poor outcomes, but each patient had contributing factors outside of the primary infection. Median OPAT duration was 12 days and 1489 hospital bed days were saved. CONCLUSIONS: In a setting where there was good adherence to BSAC criteria, treating IE patients using OPAT services was safe. Complications observed were likely independent of treatment location. Significant bed days were saved.

Streptococcus agalactiae Infective Endocarditis in a Young Immunocompetent Male.

Group B Streptococcus endocarditis is a rare but serious condition, characterized by the infection of heart valves and associated with a high mortality rate. The emergence of antibiotic-resistant strains adds complexity to therapeutic strategies, emphasizing the importance of tailored antibiotic regimens and surgical interventions when indicated. Early diagnosis and multidisciplinary care are essential in improving patient outcomes. A 22-year-old male patient with no comorbidities was admitted with a thromboembolic stroke. MRI brain showed bilateral cerebral and cerebellar multifocal acute nonhemorrhagic infarcts. He was found to have Streptococcus agalactiae bacteremia, and infective mitral valve endocarditis. He underwent mitral valve replacement and IV antibiotic treatment with a successful outcome.

Enterococcus faecalis Infective Endocarditis Associated With Colorectal Cancer.

Enterococcus faecalis (E. faecalis) is considered the third most common source of infective endocarditis. Some of the published reports linked its origin to colorectal cancer. We report a 70-year-old male patient diagnosed with E. faecalis infective endocarditis complicated by myocardial infarction. The patient also experienced symptoms of melena and anemia, prompting a colonoscopy. A colon mass was found and a biopsy revealed adenocarcinoma. The patient underwent a left hemicolectomy. In addition to that, he was treated for his cardiac issues. Many studies suggest screening for colonoscopy in patients with E. faecalis infective endocarditis to investigate its origin and potential association with colorectal cancer.

Native Aortic Valve Infective Endocarditis Secondary to Community-Acquired Methicillin-Resistant Staphylococcus aureus: A Case Report and Literature Review.

Infective endocarditis (IE) refers to a microbial infection affecting either a heart valve or endocardium, resulting in tissue damage and the formation of vegetation. Native aortic valve endocarditis in children is rare and is associated with serious complications related to valvular insufficiency and systemic embolizations. As reports about community-acquired methicillin-resistant Staphylococcus aureus (MRSA) native aortic valve endocarditis in children are very scarce, we report this case along with a literature review about its complications and management. Here, we report the case of a seven-month-old infant who was previously healthy and presented with signs and symptoms of shock and systemic embolizations secondary to native aortic valve IE. His blood culture showed MRSA. He developed aortic valve insufficiency heart failure and multiorgan septic emboli that progressed to fatal refractory multiorgan failure. The management of complicated aortic valve endocarditis in children is challenging and needs a multidisciplinary team approach and prompt intervention.

Percutaneous aspiration of aortic valve vegetation in a patient with aortic valve endocarditis.

Key Clinical Message: Percutaneous aspiration for debulking of vegetations in right-sided infective endocarditis has been well-described, however, this technique can be employed successfully for left-sided vegetations in select high-risk patients. Abstract: We report a case of percutaneous aspiration of an aortic valve vegetation in a patient with prosthetic valve endocarditis. This novel approach was selected after patient declined surgical intervention for an enlarging vegetation despite antibiotic therapy. The procedure was successful, resulting in the complete removal of solid vegetation without complications.