Stentless root replacement versus tissue valves in infective endocarditis - a propensity-score matched study

Abstract Introduction: People with aortic/prosthetic valve endocarditis are a high-risk cohort of patients who present a challenge for all medically involved disciplines and who can be treated by various surgical techniques. Methods: We analyzed the results of treatment of root endocarditis with Medtronic Freestyle® in full-root technique over 19 years (1999-2018) and compared them against treatment with other tissue valves. Comparison was made with propensity score matching, using the nearest neighbor method. Various tests were performed as suited for adequate analyses. Results: Fifty-four patients in the Medtronic Freestyle group (FS group) were matched against 54 complex root endocarditis patients treated with other tissue valves (Tissue group). Hospital mortality was 9/54 (16.7%) in the FS group vs. 14/54 (25.6%) in the Tissue group (P=0.24). Cox regression performed for early results demonstrated coronary heart disease (P=0.004, odds ratio 2.3), among others, influencing early mortality. Recurrent infection was low (1.8% for FS and Tissue patients) and freedom from reoperation was 97.2% at a total of 367 patient-years of follow-up (median of 2.7 years). Conclusion: The stentless xenograft is a viable alternative for treatment of valve/root/prosthetic endocarditis, demonstrating a low rate of reinfection. The design of the bioroot allows for complex reconstructive procedures at the outflow tract and the annular level with at an acceptable operative risk. Endocarditis patients can be treated excluding infective tissue from the bloodstream, possibly with benefits, concerning bacteremia and recurrent infection. Furthermore, the use of the stentless bioroot offers varying treatment options in case of future valve degeneration.

Relación entre la enfermedad Periodontal y enfermedad cardiovascular. La necesidad de un protocolo de manejo / Relationship between Periodontal disease and cardiovascular disease. The need for a management protocol

Resumen La enfermedad periodontal y la enfermedad cardiovascular son dos de las enfermedades más prevalentes en la población mundial. Son ambas enfermedades de alto impacto en la salud pública. La enfermedad periodontal se define como una inflamación crónica de los tejidos que dan soporte a los dientes causada por bacterias bacilos gram negativos y espiro quetas que se generan en biofilms alrededor de los dientes. La prevalencia de la periodontitis severa va desde el 1% en pacientes entre 20 y 29 años hasta de 39% en pacientes mayores de 65 años. La presencia de microorganismos genera una respuesta inflamatoria local y sistémica. La producción de reactantes de fase aguda y mediadores proinflamatorios aumenta el riesgo de inflamación en las placas ateroescleróticas haciéndolas propensas a ruptura. Existe además lo po sibilidad de la entrada de bacterias al torrente sanguíneo, dichas bacteremias se han relacionado con la posibilidad de endocarditis infecciosa. Estudios epidemiológicos han demostrado un aumento del riesgo de enfermedad cardiovascular en pacientes con enfermedad periodontal activa, independientemente de otros factores de riesgo que comparten ambas patologías. El riesgo relativo varía entre diferentes autores y trabajos realizados pero está cercano al 19% como lo demos tró Wei-Dong en su metanalisis. El efecto de la periodontitis se ha evidenciado en otros aspectos del espectro clínico de la enfermedad cardiovascular como lo son la alteración de la actividad insulínica, glicogénesis hepática y alteración de la microflora intestinal que lleva a procesos de inflamación sistémica y cambios metabólicos. Por estas razones es aconsejable realizar una revisión exhaustiva de la condición dental de los pacientes en riesgo de enfermedad cardiovascular. En aquellos con datos de enfermedad activa se aconseja la extracción y reparación de piezas dentales. El uso de clorhexidina es aconsejable como parte del tratamiento de la enfermedad así como la prevención de la misma en pacientes de riesgo o que vayan a ser sometidos a procedimientos quirúrgicos. En casos especiales se aconseja profilaxis antibiótica para prevenir la endocarditis infecciosa.

Abstract Relationship between Periodontal disease and cardiovascular disease. The need for a management protocol Periodontal disease and cardiovascular disease are two of the most prevalent diseases in the world population. Both diseases have high impact on public health. Periodontal disease is defined as a chronic inflammation of the tissues that support the teeth caused by gram-negative bacilli bacteria and spirochetes that are generated in biofilms around the teeth. The prevalence of severe periodontitis ranges from 1% in patients between 20 and 29 years old to 39% in patients older than 65 years. The presence of microorganisms generates a local and systemic inflammatory response. The production of acute phase reactants and proinflammatory mediators increases the risk of inflammation in atherosclerotic plaques making them prone to rupture. There is also the possibility of entrance of bacteria into the bloodstream and bacteremias have been linked to the possibility of infective endocarditis. Epidemiological studies have shown an increased risk of cardiovascular disease in patients with active periodontal disease, independently of other risk factors that share both pathologies. The relative risk varies between different authors and works performed but is close to 19% as demonstrated by Wei-Dong in his meta-analysis. The effect of periodontitis has been evidenced in other aspects of the clinical spectrum of cardiovascular disease such as the alteration of insulin activity, hepatic glycogenesis and alteration of the intestinal microflora that leads to processes of systemic inflammation and metabolic changes. For these reasons it is advisable to carry out a comprehensive review of the dental condition of patients at risk for cardiovascular disease. In those with active disease data suggest it is appropriate to remove and repair dental pieces. The use of chlorhexidine is advisable as part of the treatment of the periodontal disease as well as the prevention in patients at risk or who will undergo surgical procedures. In special cases antibiotic prophylaxis is recommended to prevent infective endocarditis.

Correção endovascular de pseudoaneurisma de tronco tibiofibular secundário a endocardite ­ relato de caso / Endocarditis-related tibioperoneal trunk pseudoaneurysm managed with endovascular treatment ­ case report

Os aneurismas do tronco tibiofibular são raros e consistem principalmente em pseudoaneurismas. Os autores descrevem um caso incomum de pseudoaneurisma do tronco tibiofibular secundário a endocardite bacteriana diagnosticada e tratada vários anos antes. Após a exclusão de um processo infeccioso ativo, o paciente foi tratado com sucesso através do implante percutâneo de um stent recoberto. O tratamento endovascular, neste contexto, apresentou uma alternativa segura e eficaz

ibioperoneal trunk aneurysms are rare and the majority of them are pseudoaneurysms This report describes an unusual case of a pseudoaneurysm secondary to bacterial endocarditis diagnosed and treated several years previously. After ruling out ongoing infection, the patient was successfully treated by percutaneous covered stent implantation. In this scenario, the use of endovascular techniques offered a safe and effective alternative treatment

Endocarditis por Lactococcus garvieae en un paciente sometido a hemodialisis crónica. Primer caso reportado en Chile y revisión de la literatura / Lactococcus garvieae endocarditis in a patient undergoing chronic hemodialysis. First case report in Chile and review of the literature

Resumen Los casos reportados de infección por Lactococcus garvieae son escasos y sólo uno asociado a hemodiálisis. Comunicamos el caso de endocarditis infecciosa de curso fatal por L. garvieae en un paciente con una enfermedad renal crónica sometido a hemodiálisis y portador de diverticulosis colónica no complicada. Se realiza una revisión de los casos publicados y se discuten los actuales desafíos diagnósticos y terapéuticos de este patógeno, capaz de producir infecciones graves y potencialmente fatales en pacientes susceptibles. Este sería el segundo caso de infección asociada a hemodiálisis y el primero reportado en Chile.

Reports of Lactococcus garvieae infections in humans are scarce, and only one of them in a patient under-going hemodialysis. We report the first case of Lactococcus garvieae infection in Chile, presenting as an infective endocarditis, ultimately fatal, in a patient with uncomplicated colonic diverticulosis and end stage renal failure undergoing chronic hemodialysis. We review the published cases and discuss the diagnostic and therapeutic challenges associated with this new, increasingly diagnosed pathogen, capable of producing serious infections in susceptible patients.

Endocarditis infecciosa: ¿afectan su pronóstico las complicaciones neurológicas? / Neurologic complications of infective endocarditis: do they have an impact on prognosis?

De acuerdo a la literatura, en un 20 a 40% de las endocarditis infecciosas se producen complicaciones neurológicas. Nuestro objetivo fue determinar la frecuencia de compromiso neurológico en pacientes con endocarditis infecciosa de válvulas izquierdas, considerando la presentación clínica, tipo de lesión en las imágenes y su influencia en la evolución. Se incluyeron en forma prospectiva 98 pacientes con endocarditis infecciosa de válvulas izquierdas. El 47% (46 casos) presentó compromiso neurológico. En 28 casos (61%) el síntoma fue el déficit focal, en 9 (20%) la alteración de estado de conciencia; el 17% (8) fue asintomático y 2% (1 caso) presentó convulsiones. En las imágenes, la isquemia cerebral (76%) fue la lesión más frecuente. El tamaño de la vegetación mayor a 1 cm se asoció a compromiso neurológico (57% vs. 31%, p = 0.01). Aquellos pacientes con compromiso neurológico tuvieron mayor frecuencia de reemplazo valvular (70% vs. 44%, p = 0.01) y la mortalidad hospitalaria también fue mayor (20% vs. 15%, p = 0.5). El tiempo total de internación fue significativamente más prolongado en sujetos con compromiso neurológico (32 ± 27 vs. 21 ± 15 días, p = 0.01) y la discapacidad fue mayor en los que tenían manifestaciones neurológicas (74% vs. 36% p = 0.0001). En nuestra serie, el síntoma más frecuente fue el déficit focal, y en las imágenes la isquemia cerebral fue el patrón más común. Los casos con lesión neurológica presentaron mayor tiempo de internación y grado de discapacidad al alta, pero no mayor mortalidad hospitalaria.

Neurologic complications of infective endocarditis have been observed in 20-40% of cases. Our aim was to determine the frequency of neurologic involvement, clinical manifestations, lesional patterns and evolution in patients with infective endocarditis. This was a prospective cohort study. We included 98 patients with left-sided infective endocarditis. Forty seven percent presented neurologic involvement at some time of the disease. The frequency of symptoms was: focal deficit 61%, sensory disturbance 17% and seizures 2%, while 20% remain asymptomatic. The most prevailing lesion was cerebral ischemia (76%). Vegetations larger than 1 cm were associated to neurologic involvement (57% vs. 31%, p = 0.01). Valvular replacement was more common among patients with neurologic involvement (70% vs. 44%, p = 0.01). Hospital mortality was 20% in patients with neurologic manifestation versus 15% of those without it (p = 0.5). The length of stay was significantly prolonged in patients with neurologic affection (32 ± 27 vs. 21 ± 15 days, p = 0.01) and a favorable Rankin assessment at the discharge was less likely in patients with neurologic involvement (36% vs. 74%, p = 0.0001). In this cohort, the most frequent clinical manifestation was focal deficit and the most prevalent pattern of lesion was cerebral ischemia. Those with neurologic involvement presented an increased length of stay and more disability at the discharge but not statistical significant difference in hospital mortality.

Endocardite aórtica e tricúspide em pacientes de hemodiálise com embolia sistêmica e pulmonar / Aortic and tricuspid endocarditis in hemodialysis patient with systemic and pulmonary embolism

RESUMO Este artigo relata o caso de um homem caucasiano de 43 anos de idade com nefropatia terminal em tratamento com hemodiálise e apresentando endocardite infecciosa das válvulas aórtica e tricúspide. O quadro clínico foi dominado pelo comprometimento neurológico, devido à embolia cerebral e a componentes hemorrágicos. Uma tomografia computadorizada tóraco-abdominal revelou um êmbolo séptico pulmonar. O paciente foi submetido à antibioticoterapia empírica utilizando ceftriaxona, gentamicina e vancomicina, sendo o tratamento modificado para flucloxacilina e gentamicina após o isolamento de S. aureus nas hemoculturas. A equipe multidisciplinar determinou que o paciente deveria ser submetido à substituição de válvulas após estabilização da hemorragia intracraniana; contudo, no oitavo dia após a hospitalização, o paciente entrou em parada cardíaca causada por embolia séptica pulmonar maciça, vindo a falecer. Apesar do risco de agravamento da lesão hemorrágica cerebral, em pacientes de alto risco deveria ser considerado realizar precocemente uma intervenção cirúrgica.

ABSTRACT This is a case report of a 43-year-old Caucasian male with end-stage renal disease being treated with hemodialysis and infective endocarditis in the aortic and tricuspid valves. The clinical presentation was dominated by neurologic impairment with cerebral embolism and hemorrhagic components. A thoracoabdominal computerized tomography scan revealed septic pulmonary embolus. The patient underwent empirical antibiotherapy with ceftriaxone, gentamicin and vancomycin, and the therapy was changed to flucloxacilin and gentamicin after the isolation of S. aureus in blood cultures. The multidisciplinary team determined that the patient should undergo valve replacement after the stabilization of the intracranial hemorrhage; however, on the 8th day of hospitalization, the patient entered cardiac arrest due to a massive septic pulmonary embolism and died. Despite the risk of aggravation of the hemorrhagic cerebral lesion, early surgical intervention should be considered in high-risk patients.

Endocarditis infecciosa por Rhizobium radiobacter: Reporte de un caso / Infective endocarditis by Rhizobium radiobacter: A case report

Rhizobium radiobacter es una bacteria Gram-negativa, fijadora de nitrógeno que se encuentra principalmente en el suelo. Rara vez causa infecciones en humanos. Ha sido asociada a bacteriemia secundaria a colonización de catéteres intravasculares en pacientes inmunocomprometidos. El objetivo de este trabajo es informar un caso de endocarditis infecciosa por R. radiobacter. Se trata de paciente masculino, de 47 años de edad, con diagnóstico de enfermedad renal crónica estadio 5 en tratamiento sustitutivo con hemodiálisis, quien acude a centro asistencial por presentar fiebre de dos semanas de evolución. Es hospitalizado, se toman muestras de sangre periférica para hemocultivo y se inicia antibioticoterapia empírica con cefotaxime más vancomicina. El ecocardiograma transtorácico revelo vegetación fusiforme en válvula tricúspide con regurgitación grado III-IV/IV. Al séptimo día del inicio de la antibioterapia el paciente presenta mejoría clínica y paraclínica. La bacteria identificada por hemocultivo es Rhizobium radiobacter resistente a ceftriaxona y sensible a imipenem, amikacina, ampicilina y ampicilina/sulbactam. Debido a la mejoría clínica se decide continuar tratamiento con vancomicina y se anexa imipenem. A los 14 días de iniciada la antibioterapia el paciente es dado de alta con tratamiento ambulatorio con imipenen hasta cumplir seis semanas de tratamiento. En el ecocardiograma control se evidencio ausencia de la vegetación en la válvula tricúspide. Este caso sugiere que R. radiobacter puede ser una causa de endocarditis en pacientes portadores de catéteres intravasculares.

Rhizobium radiobacter is a Gram-negative, nitrogen-fixing bacterium, which is found mainly on the ground. It rarely causes infections in humans. It has been associated with bacteremia, secondary to colonization of intravascular catheters, in immunocompromised patients. The aim of this paper was to report the case of an infective endocarditis caused by R. radiobacter, in a 47-year-old male, diagnosed with chronic kidney disease stage 5, on replacement therapy with hemodialysis and who attended the medical center with fever of two weeks duration. The patient was hospitalized and samples of peripheral blood were taken for culture. Empirical antibiotic therapy was started with cefotaxime plus vancomycin. The transthoracic echocardiogram revealed fusiform vegetation on the tricuspid valve, with grade III-IV/IV regurgitation. On the seventh day after the start of antibiotic therapy, the patient had a clinical and paraclinical improvement. The bacterium identified by blood culture was Rhizobium radiobacter, ceftriaxone-resistant and sensitive to imipenem, amikacin, ampicillin and ampicillin/ sulbactam. Because of the clinical improvement, it was decided to continue treatment with vancomycin and additionally, with imipenem. At 14 days after the start of antibiotic therapy, the patient was discharged with outpatient treatment with imipenem up to six weeks of treatment. The control echocardiogram showed the absence of vegetation on the tricuspid valve. This case suggests that R. radiobacter can cause endocarditis in patients with intravascular catheters.

Alterações sistêmicas detectadas em pacientes em tratamento periodontal / Systemic alterations detected in patients with periodontal treatment

Introdução: Periodontite é a alteração patológica crônica dos tecidos periodontais, sendo que sua etiologia inclui a interação entre fatores de risco, defesa do hospedeiro e biofilme bacteriano. Em décadas mais recentes foi levantada a possibilidade da associação entre doença periodontal e alterações sistêmicas. Objetivo: avaliar a prevalência de algumas alterações sistêmicas em indivíduos com diagnóstico de periodontite. Métodos: foram selecionados 200 pacientes, divididos em dois grupos: com doença periodontal e sem doença periodontal, com idade entre 18 e 60 anos, e no mínimo, 20 dentes presentes, atendidos nas clínicas de odontologia da Universidade do Sagrado Coração, Bauru. Dados sobre hemorragia, alergia, reumatismo infeccioso, doenças cardiovasculares, gastrite/úlcera, diabetes e ansiedade/depressão, obtidos por meio de anamnese, foram confrontados com a presença ou ausência de doença periodontal. Foi realizada análise descritiva e o teste de Chi-quadrado, para verificar a significância entre amostras. Resultados: a diferença entre os grupos com relação à presença de alergia, reumatismo infeccioso, gastrite e diabetes não foi significante. Episódios hemorrágicos, relato de ansiedade/depressão e presença de alterações cardíacas, incluindo hipertensão, apresentaram diferença significante entre os grupos, predominando nos pacientes com doença periodontal. O número de pacientes com 3 ou mais alterações sistêmicas foi duas vezes maior neste grupo. Conclusões: verificamos que alterações sistêmicas estiveram presentes com maior frequência naqueles pacientes que apresentavam doença periodontal. Com isto, evidencia-se a importância do conhecimento da história médica do paciente para estabelecimento de um plano de tratamento.

Introduction: periodontitis is a chronic pathological alteration of periodontal tissues, and its etiology includes the interaction between risk factors, host defense and bacterial biofilm. In more recent decades has raised the possibility of the association between periodontitis and systemic diseases. Objective: the purpose of this assay was to verify the prevalence of systemic alterations in patients with and without periodontitis. Methods: 200 patients between 18 and 60 years were selected, with a minimum of 20 teeth present, admitted in the clinics of odontology of the University of Sacred Heart, Bauru. Data on hemorrhage, allergy, infectious rheumatism, cardiovascular diseases, gastritis/ulcer, diabetes and anxiety/depression, were compared with the presence or absence of periodontal disease. Statistical analysis included descriptive statistic and the Chi-square test, to verify the significance between samples. Results: the difference enters the groups with regard to the allergy presence, infectious rheumatism, gastritis and diabetes was not significant. Hemorrhagic episodes, story of anxiety/depression and presence of cardiac alterations, including hypertension, had presented significant difference between the groups, predominating in the patients with periodontal disease. The number of patients with 3 or more systemic alterations was two times in this group. Conclusions: we found that in patients with periodontal disease, systemic alterations were present more frequently. With this, it is evident the value of knowledge of the patient's medical history to establish a treatment plan, and also the importance of periodontal treatment on general health.

Endocarditis infecciosa: características clínicas, complicaciones y mortalidad en 506 pacientes y factores pronósticos de sobrevida a 10 años (1998-2008). Estudio cooperativo nacional en endocarditis infecciosa en Chile (ECNEI-2) / Clinical characteristics, complications and mortality in 506 patients with infective endocarditis and determinants of survival rate at 10 years

Background: Rates ofmorbidity and mortality in Infective Endocarditis (IE) remain high and prognosis in this disease is still difficult and uncertain. Aim: To study IE in Chile in its active phase during inpatient hospital stay and long term survival rates. Material and Methods: Observational prospective national cohort study of 506 consecutive patients included between June 1,1998 and July 31, 2008, from 37 Chilean hospitals (secondary and tertiary centers) nationwide. Results: The main findings were the presence of Rheumatic valve disease in 22.1 % of patients, a history of intravenous drug abuse (IVDA) only in 0.7%, the presence of Staphylo-coccus aureus in 29.2% of blood cultures, negative blood cultures in 33.2%, heart failure in 51.7% and native valve involvement in 86% ofpatients. Echocardiographic diagnosis was achieved in 94% of patients. Hospital mortality was 26.1% and its prognostics factors were persisting infection (Odds ratio (OR) 6.43, Confidence Interval (CI) 1.45-28.33%), failure of medical treatment and no surgical intervention (OR 48.8; CI 6.67-349.9). Five and 10 years survival rates were 75.6 and 48.6%, respectively. The significant prognostic factors for long term mortality, determined by multivariate analysis were the presence of diabetes, Staphylococcus aureus infection, sepsis, heart failure, renal failure and lack of surgical treatment during the IE episode. Conclusions: The microbiologic diagnosis of IE must be urgently improved in Chile. Mortality rates are still high (26.1%) partly because of a high incidence of negative blood cultures and the need for more surgical valve interventions during in-hospital period. Long term prognostic factors for mortality should be identified early to improve outcome.

Perfil clínico-epidemiológico de pacientes con endocarditis infecciosa, período 2003-2010 en el hospital de Temuco, Chile / Profile of patients with infective endocarditis admitted to a Chilean regional hospital

Background: Mortality due to infective endocarditis (IE) in Chile is close to 30%. Aim: To report the experience with patients admitted with the diagnosis of IE in a regional tertiary hospital. Material and Methods: Retrospective study of 107 patients aged 50 ± 16years (75% males) discharged with a definitive diagnosis of IE according to modified DUKE criteria, between years 2003 and 2010. Demographic variables, severity scores, clinical characteristics, bacteriology and hospital evolution were recorded. Results: Fifty nine percent of patients had concomitant cardiovascular problems. APACHE II and Sequential Organ Failure Assessment (SOFA) scores on admission were 8.4 ± 4.7 and 2.7 ± 2.8 respectively. Native valves were affected in 91% of cases (aortic and mitral valves in 62% and 50% of cases respectively). Prosthetic valves were affected in 9.3% of cases. Rheumatic heart disease was the predominant primary lesion in 10% of patients. Antibiotics were used in 45.1% before blood cultures were performed. In 68% of patients blood cultures were positive. S. viridans (30.8%), S.aureus (18.6%) and coagulase negative Streptocicci (5.6%) were the identified microorganisms. Intensive care unit admission was required in 48% of patients. Renal, heart and neurological deterioration was observed in 53, 34 and 14% of patients, respectively. Twenty percent of patients developed systemic embolism and 37% required heart surgery. Mean hospital stay was 28.3 ± 19.1 days and 27% of patients died. Conclusions: In this series of patients, IE has a high mortality. Most patients studied were admitted in bad conditions.

Reemplazo de válvula mitral consecutivo a endocarditis micótica / Mitral valve replacement due to mycotic endocarditis

Se presenta el caso clí­nico de un niño de 15 meses de edad, el cual experimentó varias infecciones en la etapa neonatal (entre ellas por Candida albicans) y otras complicaciones; sin embargo, no pudo recibir el esquema terapéutico completo contra la candidiasis sistémica por habérsele diagnosticado un daño funcional hepático. Posteriormente, al detectársele una endocarditis micótica, se le reemplazó la válvula mitral. En su último ingreso padecía, además, broncoespasmo asociado a neumonía bacteriana, anemia carencial, deshidratación isotónica moderada, acidosis metabólica e inmunodeficiencia mixta, causantes de una insuficiencia multiorgánica que le produjo la muerte al dí­a siguiente de su admisión hospitalaria.

A case report of a child aged 15 months who underwent several infections (i.e. due to Candida albicans) and other complications during the neonatal stage is presented. However, he could not receive the complete treatment against systemic candidiasis because of an impairment of liver function. Subsequently, mitral valve was replaced when detecting mycotic endocarditis. In addition, while being hospitalized for the last time, he underwent bronchial spasm associated with bacterial pneumonia, deficiency anemia, mild isotonic dehydration, non-respiratory acidosis, and mixed immunodeficiency which caused multiple organ failure and death the day after his hospital admisión.

Espondilodiscite e endocardite bacteriana: relato de caso / Spondylodiscytis and bacterial endocarditis: case report

JUSTIFICATIVA E OBJETIVOS: A espondilodiscite é uma entidade clínica de difícil diagnóstico devido à clínica inespecífica e sinais radiológicos tardios. O objetivo deste estudo foi relatar um caso de espondilodiscite secundária à endocardite bacteriana por Staphylococcus aureus, adquirido na comunidade. RELATO DO CASO: Paciente do sexo feminino, 79 anos, branca, casada, procedente de Santa Cruz do Sul, RS, em tratamento regular de diabetes mellitus tipo 2 e hipertensão arterial sistêmica. Iniciou com piora de dor lombar crônica e dificuldade para deambular. Os exames de imagem demonstravam lesão lítica de vértebras lombares que após investigação foi definida como espondilodiscite decorrente de endocardite bacteriana. CONCLUSÃO: A endocardite infecciosa, em consequência da gravidade, deverá fazer parte do diagnóstico diferencial de doenças causadas por provável disseminação hematogênica, especialmente, em pacientes que apresentam condições que aumentam o risco de endocardite, como prolapso de valva mitral, doença valvar degenerativa e uso de fármacos por via venosa.

BACKGROUND AND OBJECTIVES: Spondylodiscitis is a clinical entity difficult to diagnose because of nonspecific clinical and radiologics signs late. The aim was to report a case of spondylodiscitis secondary to bacterial endocarditis caused by Staphylococcus aureus, community-acquired. CASE REPORT: Female patient, 79 years old, white, married, resident of Santa Cruz do Sul, RS, regular treatment of type 2 diabetes mellitus and hypertension. Began with worsening of chronicback pain and difficulty in walking. Imaging tests showed osteolytic lesion of the lumbar vertebrae that after investigation it was defined to be due to complication of bacterial endocarditis. CONCLUSION: Infective endocarditis should be part of the differential diagnosis of disease caused by probable hematogenous dissemination, especially in patients who have conditions increase the risk of endocarditis, such as mitral valve prolapsed,valve heart disease degenerative and intravenous drug use.

Endocarditis infecciosa sobre electrodo de marcapasos permanente / Infectious Endocarditis on electrode of permanent pacemaker

Se presenta el caso clínico de un anciano de 84 años, con antecedentes de cardiopatía isquémica crónica, que fue remitido a la consulta de cardiología (para atender a los pacientes con marcapasos y arritmias) del Hospital Provincial Docente Saturnino Lora de Santiago de Cuba, donde se le diagnosticó una disfunción sinusal y se le colocó un marcapasos permanente. Un mes después comenzó a presentar fiebre y otras manifestaciones clínicas de modo que reingresó por sospecha de endocarditis infecciosa aguda en la cavidad derecha, relacionada con la implantación del dispositivo intracardíaco, lo cual fue confirmado con los resultados de los hemocultivos y ecocardiogramas efectuados. El paciente evolucionó desfavorablemente y falleció

The case report of a 84 year-old elderly is presented, with history of chronic ischemic heart disease that was referred to the cardiology visit (to assist the patients with pacemakers and arrhythmias) of Saturnino Lora Teaching Provincial Hospital in Santiago de Cuba, where he was diagnosed a sinusal dysfuntion and he was inserted a permanent pacemaker. One month later he began to present fever and other clinical manifestations so that he was readmitted due to suspicion of acute infectious endocarditis in the right cavity, related to the placing of the intracardiac device, which was confirmed with the results of the hemoculture and echocardiograms. The clinical course of the patient was unfavorable and he died

Tratamiento de ortodoncia en pacientes con trastornos sistémicos / Orthodontic treatment of patients with systemic diseases

Los pacientes que padecen alguna enfermedad sistémica orgánica generan durante el tratamiento ortodóncico ciertos riesgos, limitaciones y complicaciones no habituales en un tratamiento convencional. Cada vez más personas están sobreviviendo a enfermedades que antiguamente hubieran sido fatales. Se estima que entre un 10 a 15 por ciento de individuos menores de 16 años son afectados por enfermedades crónicas a largo plazo. La enfermedad crónica presenta desafíos a la persona afectada y a su familia, con implicancias prácticas, sociales y emocionales. Los cambios en el remodelamiento óseo inducidos por factores sistémicos tales como los factores nutricionales, las enfermedades óseas metabólicas, la edad o el uso de ciertas drogas, van a afectar y modificar el movimiento dentario y, en consecuencia, un posible tratamiento ortodóncico. El objetivo de este trabajo es enumerar, describir y desarrollar las enfermedades sistémicas que con más frecuencia podemos encontrar y sus implicancias durante un tratamiento odontológico y ortodóncico. Las enfermedades investigadas fueron: Endocarditis bacteriana. Trastornos de la hemostasia. Leucemia. Diabetes Mellitus. Fibrosis Cística. Artritis reumatoidea juvenil. Insuficiencia renal crónica. Enfermedades que afectan el metabolismo óseo. La búsqueda bibliográfica ha sido realizada sobre trabajos desde 1975 hasta 2009. El trabajo es abarcativo a individuos sin límite de edad.

Tratamento ambulatorial da endocardite bacteriana estreptocócica / Ambulatory treatment of streptococcal bacterial endocarditis

A endocardite bacteriana é uma grave doença infecciosa cujo tratamento é tradicionalmente feito com o paciente internado. recebendo medicação intravenosa. A possibilidade de tratamento domiciliar ou ambulatorial. em casos estritamente selecionados. é atraente tanto do ponto de vista social quanto do econômico. Apresentamos o relato de 6 pacientes com diagnóstico de endocardite bacteriana por Streptococcus. tratados parcial ou integralmente em regime ambulatorial. Todos evoluíram sem complicações e com resolução completa do quadro infeccioso.

Bacterial endocarditis is a severe infectious disease. of which treatment is traditionally carried out in hospitalized patients through intravenous medication. The possibility of at-home or ambulatory treatment. for stringently selected cases. is attractive from the social as well as from the economic point of view. We report 6 patients with a diagnosis of bacterial endocarditis caused by Streptococcus. treated partially or completely on an outpatient basis. All of them evolved without complications and presented complete resolution of the infection.

Incidence of bloodstream infection among patients on hemodialysis by central venous catheter / Incidência de infecção da corrente sanguínea nos pacientes submetidos à hemodiálise por cateter venoso central / Incidencia de infección de la corriente sanguínea em los pacientes sometidos a hemodiálisis por catéter venoso central

This study evaluated the incidence and risk factors of bloodstream infection (BSI) among patients with a double-lumen central venous catheter (CVC) for hemodialysis (HD) and identified the microorganisms isolated from the bloodstream. A follow-up included all patients (n=156) who underwent hemodialysis by double-lumen CVC at the Federal University of São Paulo - UNIFESP, Brazil, over a one-year period. From the group of patients, 94 presented BSI, of whom 39 had positive cultures at the central venous catheter insertion location. Of the 128 microorganisms isolated from the bloodstream, 53 were S. aureus, 30 were methicillin-sensitive and 23 were methicillin-resistant. Complications related to BSI included 35 cases of septicemia and 27 cases of endocarditis, of which 15 cases progressed to death. The incidence of BSI among these patients was shown to be very high, and this BSI progressed rapidly to the condition of severe infection with a high mortality rate.

O objetivo deste estudo foi avaliar a incidência e os fatores de risco de infecção da corrente sanguínea (ICS) em pacientes com cateter venoso central (CVC) duplo lúmen, para hemodiálise (HD) e identificar os micro-organismos isolados na corrente sanguínea. Como método, usou-se o follow up, realizado no período de um ano, incluindo todos os 156 pacientes que estavam em tratamento de HD por CVC duplo lúmen, na Universidade Federal de São Paulo - UNIFESP. Os resultados mostraram que dos 156 pacientes estudados, 94 apresentaram ICS, desses, 39 tiveram culturas positivas no local de inserção do cateter. Dos 128 micro-organismos isolados da corrente sanguínea, 53 eram S.aureus, dos quais 30 eram sensíveis à metilcilina e 23 resistentes. Entre as complicações relacionadas à ICS, houve 35 casos de septicemia e 27 casos de endocardite, dos quais 15 progrediram a óbito. A incidência de ICS neste grupo de pacientes mostrou-se bastante elevada bem como sua progressão para quadros infecciosos de grande magnitude e óbito.

El objetivo de este estudio fue evaluar la incidencia y los factores de riesgo de infección de la corriente sanguínea (ICS) en pacientes con catéter venoso central (CVC) doble lumen, para hemodiálisis (HD) e identificar los microorganismos aislados en la corriente sanguínea. Como método, se uso el acompañamiento, realizado en el período de un año, incluyendo todos los 156 pacientes que estaban en tratamiento de HD por CVC doble lumen, en la Universidad Federal de Sao Paulo - UNIFESP. Los resultados mostraron que de los 156 pacientes estudiados, 94 presentaron ICS, de estos, 39 tuvieron culturas positivas en el local de inserción del catéter. De los 128 microorganismos aislados de la corriente sanguínea, 53 eran S.aureus, de los cuales 30 eran sensibles a la metilcilina y 23 resistentes. Entre las complicaciones relacionadas a la ICS, hubo 35 casos de septicemia y 27 casos de endocarditis, de los cuales 15 resultaron en muerte. La incidencia de ICS en este grupo de pacientes se mostró bastante elevada así como su progresión para cuadros infecciosos de gran magnitud y de muerte.

Endocardite infecciosa em câmaras direitas: discrepância entre evolução clínica e ecocardiográfica: relato de caso / Right-side infective endocarditis: discrepancy between clinical and echocardiographic evolution: case report

A endocardite infecciosa é uma patologia relativamente rara na prática clínica, e, apesar dos avanços em seu diagnóstico e tratamento, sua morbi-mortalidade ainda é significativa. Muitas vezes é difícil a identificação de suas complicações e a conduta frente a elas, ocorrendo com freqüência a dissociação entre a evolução clínica e os achados de exames complementares - principalmente ecocardiográficos. A decisão clínica torna-se ainda mais difícil frente às manifestações atípicas da doença, como a endocardite de câmaras direitas. Este é o relato de um caso raro de endocardite de câmaras direitas em uma paciente renal crônica, cuja piora dos achados ecocardiográficos se opunha à evolução clínica favorável. Esta situação pode suscitar dificuldade quanto aos critérios para indicação cirúrgica e a segurança do tratamento conservador.

Infective endocarditis is a relatively rare disease in clinical practice, with significant morbidity and mortality despite the improvements on its diagnosis and treatment. It is often difficult to identify its complications and define strategies for them. Dissociation between the clinical evolution and the findings from complementary tests (especially echocardiographic tests) is common. Clinical decisions become even more difficult when there are atypical manifestations of the disease, such as right-side endocarditis. This report is about a rare case of right-side endocarditis in a patient with chronic renal disease, in which there was a contradiction between worsening of the echocardiographic findings and clinical improvement. This situation may lead to difficulties regarding the criteria for indicating surgery and the safety of conservative clinical treatment.

Endocarditis infecciosa en pacientes con daño hepático crónico: Serie de 4 casos clínicos / Infective endocarditis in patients with chronic hepatic failure: A four cases series

Infective endocarditis and liver cirrhosis is an infrequent association. A retrospective study was performed in order to characterize predisposing factors, microbial causes and evolution. Medical records between 1995 and 2008 (June) were searched. Four cases were identified. In three cases liver cirrhosis was in stage Child A, and in all 4 there was a predisposing cardiac disease. Clinical manifestations were classical in 3 cases and in one presented as hepatic failure. Only in one case a typical agent was recovered. Other cases were associated to a nosocomial agent or Corynebacterium diphtheriae, and in one no agent was identified. One patient required valve replacement. Three patients recovered satisfactorily, all of them in Child A stage. One died of non-infectious causes (Child C). Infective endocarditis and liver cirrhosis is an infrequent association in clinical practice, it can be associated to unusual agents or clinical manifestations.

La asociación entre daño hepático y endocarditis infecciosa es infrecuente. Para analizar los factores predisponentes de esta asociación, la etiología microbiana y evolución clínica, se efectuó un análisis retrospectivo de los egresos por endocarditis infecciosa en pacientes con cirrosis hepática desde 1995 a junio de 2008. Se identificaron cuatro casos, asociados a categoría Child A en tres y en todos había una cardiopatía predisponente. Las manifestaciones clínicas fueron clásicas excepto en un caso que se presentó como descompensación hepática. Sólo un caso se asoció a un agente típico, otros a un agente nosocomial y Corynebacterium diphtheriae. En un caso no se identificó la etiología. Uno de los pacientes requirió cirugía de reemplazo valvular. Tres pacientes se recuperaron (Child A) y el paciente en categoría Child C falleció. Aunque infrecuente, la asociación cirrosis y endocarditis ocurre en la práctica clínica, se puede asociar a agentes inhabituales y tener manifestaciones encubiertas.