Corynebacterium jeikeium-induced infective endocarditis and perivalvular abscess diagnosed by 16S ribosomal RNA sequence analysis: A case report.

INTRODUCTION: Corynebacterium jeikeium normally presents on human skin, and it is often judged as contamination when it is cultured from blood. C. jeikeium can cause infective endocarditis, especially, that associated with cardiac surgery and prosthetic valvular endocarditis. CASE REPORT: A 66-year-old Japanese male patient was diagnosed with C. jeikeium-induced infective endocarditis (IE) and perivalvular abscess after a coronary artery bypass grafting and aortic valve replacement with bioprosthesis; pyogenic spondylodiscitis was also observed. Patch repair for aortic valve annulus and re-Bentall procedure with bioprosthesis was performed for IE and perivalvular abscess. The causative bacterium was confirmed as C. jeikeium on 16S ribosomal RNA sequencing of surgical sample and positive blood culture. The patient underwent six weeks of intravenous antibacterial treatment with vancomycin and an additional two weeks of oral treatment with linezolid, following which, his condition improved. Corynebacterium jeikeium can cause infective endocarditis and perivalvular abscess, which is a more severe condition than IE. CONCLUSION: 16S ribosomal RNA sequencing is useful in diagnosing bacterial species that can cause contamination, such as Corynebacterium spp.

Higher incidence of perivalvular abscess determines perioperative clinical outcome in patients undergoing surgery for prosthetic valve endocarditis.

BACKGROUND: Cardiac surgery for prosthetic valve endocarditis (PVE) is associated with substantial mortality. We aimed to analyze 30-day and 1-year outcome in patients undergoing surgery for PVE and sought to identify preoperative risk factors for mortality with special regard to perivalvular infection. METHODS: We retrospectively analyzed data of 418 patients undergoing valve surgery for infective endocarditis between January 2009 and July 2018. After 1:1 propensity matching 158 patients (79 PVE/79 NVE) were analyzed with regard to postoperative 30-day and 1-year outcomes. Univariate and multivariable analyses were performed to identify potential risk factors for mortality. RESULTS: 315 patients (75.4%) underwent surgery for NVE and 103 (24.6%) for PVE. After propensity matching groups were comparable with regard to preoperative characteristics, clinical presentation and microbiological findings, except a higher incidence of perivalvular infection in patients with PVE (51.9%) compared to NVE (26.6%) (p = 0.001), longer cardiopulmonary bypass (166 [76-130] vs. 97 [71-125] min; p < 0.001) and crossclamp time (95 [71-125] vs. 68 [55-85] min; p < 0.001). Matched patients with PVE showed a 4-fold increased 30-day mortality (20.3%) in comparison with NVE patients (5.1%) (p = 0.004) and 2-fold increased 1-year mortality (PVE 29.1% vs. NVE 13.9%; p = 0.020). Multivariable analysis revealed perivalvular abscess, sepsis, preoperative AKI and PVE as independent risk factors for mortality. Patients with perivalvular abscess had a significantly higher 30-day mortality (17.7%) compared to patients without perivalvular abscess (8.0%) (p = 0.003) and a higher rate of perioperative complications (need for postoperative pacemaker implantation, postoperative cerebrovascular events, postoperative AKI). However, perivalvular abscess did not influence 1-year mortality (20.9% vs. 22.3%; p = 0.806), or long-term complications such as readmission rate or relapse of IE. CONCLUSIONS: Patients undergoing surgery for PVE had a significantly higher 30-day and 1-year mortality compared to NVE. After propensity-matching 30-day mortality was still 4-fold increased in PVE compared to NVE. Patients with perivalvular abscess showed a significantly higher 30-day mortality and perioperative complications, whereas perivalvular abscess seems to have no relevant impact on 1-year mortality, the rate of readmission or relapse of IE.

Perivalvular Mitral Abscess Fistulised to the Pericardial Cavity Revealing Staphylococcal Endocarditis.

BACKGROUND: Fistula to the pericardial cavity is a very rare complication of perivalvular abscess during infective endocarditis, with Staphylococcus aureus being the most commonly associated microorganism. METHODS: We report a fatal septic shock due to a mitral endocarditis revealed by a myocardial abscess fistulised toward the pericardial cavity. RESULTS: A 66-year-old female without previous valvular disease was admitted to intensive care for severe sepsis. A few hours after admission, an unexpected cardiac arrest occurred. Chest computed tomographic-scan and transoesophageal echocardiography revealed a pericardial effusion due to a perivalvular mitral abscess fistulised toward the pericardial cavity. Despite prompt management including surgical debridement and appropriate antibiotics, death occurred 36hours after intensive care admission. All blood cultures as well as native mitral valve and pericardial fluid grew methicillin-sensitive Staphylococcus aureus. CONCLUSIONS: Intensivists should consider this rare complication in patients with staphylococcal infective endocarditis and perivalvular abscess.

Recent Surgical Results for Active Endocarditis Complicated With Perivalvular Abscess.

BACKGROUND: Surgical treatment for endocarditis patients with a perivalvular abscess is still challenging.Methods and Results:From 2009 to 2016, 470 patients underwent surgery for active endocarditis at 11 hospitals. Of these, 226 patients underwent aortic valve surgery. We compared the clinical results of 162 patients without a perivalvular abscess, 37 patients who required patch reconstruction of the aortic annulus (PR group) and 27 who underwent aortic root replacement (ARR group). Patients with a perivalvular abscess had a greater number ofStaphylococcusspecies and prosthetic valve endocarditis, a greater level of inflammation at diagnosis and symptomatic heart failure before surgery, especially in the ARR group. Nevertheless, the duration between diagnosis and surgery was similar, because of a high prevalence of intracranial hemorrhage in the ARR group. Hospital death occurred in 13 (9%) patients without a perivalvular abscess, in 4 (12%) in the PR and in 7 (32%) in the ARR group. Postoperative inflammation and end-organ function were similar between the groups. Overall survival of patients without a perivalvular abscess and that of the PR group was similar, but was significantly worse in the ARR group (P=0.050, 0.026). Freedom from endocarditis recurrence was similar among all patients. CONCLUSIONS: Patients treated with patch reconstruction showed favorable clinical results. Early surgical intervention is necessary when a refractory invasive infection is suspected.

Transcatheter aortic valve replacement for acute aortic regurgitation due to Staphylococcus aureus infective endocarditis complicated with a perivalvular abscess: a case report.

Background: Infective endocarditis is a life-threatening disease associated with high mortality. Appropriate antimicrobial treatment and cardiac surgery, when indicated, are closely related to prognosis. When cardiac surgery is contraindicated, prognosis worsens dramatically. There is few data concerning the use of transcatheter aortic valve replacement after healed aortic valve endocarditis or during active IE. We present the first case report of a transcatheter aortic valve replacement implanted during antimicrobial therapy for a severely symptomatic acute aortic regurgitation due to an infective endocarditis complicated with a perivalvular abscess. Case summary: A 68-year-old man was admitted due to left hemiparesis and fever. An acute ischaemic stroke with haemorrhagic transformation was diagnosed. Blood cultures were positive for methicillin-susceptible Staphylococcus aureus and a transoesophageal echocardiogram revealed an aortic endocarditis with an acute severe aortic regurgitation and a perivalvular abscess. Urgent cardiac surgery was contraindicated due to intracranial haemorrhage. However, the patient developed refractory pulmonary oedema and haemodynamic instability. Despite the perivalvular abscess, a transcatheter aortic valve replacement was successfully performed 15 days after the diagnosis. Nine months after completing antimicrobial therapy, there were no signs of relapse. Discussion: Transcatheter aortic valve replacement could be considered in selected patients with symptomatic severe aortic regurgitation due to aortic infective endocarditis during antimicrobial therapy when cardiac surgery is contraindicated.

Infective Endocarditis Due to Streptococcus agalactiae Complicated by a Complete Atrioventricular Block.

Infective endocarditis due to Streptococcus (S.) agalactiae is an uncommon but potentially life-threatening condition. We report a case of infective endocarditis due to S. agalactiae in a 79-year-old woman who presented with fatigue and appetite loss. The results of blood cultures and the vegetation detected by transesophageal echocardiography led us to the diagnosis. She was started on prompt and appropriate antibiotic therapy. Despite her favorable clinical course, she suddenly developed a complete atrioventricular block after one week of conservative treatment. She then underwent surgery with abscess drainage along with aortic and mitral valve replacement. Intraoperative findings revealed that the perivalvular inflammation insidiously extended to the cardiac conduction system and caused a complete heart block. Our case highlights the high virulence of S. agalactiae, requiring more vigilance among clinicians.

A Rare Presentation of Perivalvular Abscess and Infective Valve Endocarditis as Multiple Cerebral Septic Emboli Mimicking Ischemic Stroke.

The perivalvular cardiac abscess is a severe condition associated with infective endocarditis, leading to significant morbidity and mortality if not diagnosed and managed promptly. Neurological complications, particularly stroke, can occur due to embolic events resulting from cardiac abscesses. A 63-year-old female with end-stage renal disease and multiple comorbidities presented with altered mental status. Imaging revealed acute ischemic infarcts in the frontotemporal lobes, suggesting the embolic phenomenon. Blood cultures grew Enterococcus faecalis, and an echocardiogram showed severe aortic valve destruction with perivalvular abscess. Cardiac abscesses can cause severe complications, including tissue destruction, valve damage, and embolic events. Echocardiography is crucial for diagnosis, detecting vegetation, and assessing associated complications. Transthoracic echocardiography is reliable but has limitations, whereas transesophageal echocardiography is highly sensitive. Prompt antibiotic therapy and surgical intervention are crucial for treatment. Early initiation of appropriate antibiotic therapy and surgical intervention is crucial for positive outcomes. The choice of treatment should be individualized based on the patient's specific condition and the medical team's expertise.

Local administration of the powder minocycline during surgical intervention for active infective endocarditis.

OBJECTIVES: We retrospectively assessed the initial clinical impact of the locally administered bacteriostatic antibiotic, powder minocycline, during surgery for active infective endocarditis (AIE). METHODS: Among 38 surgical AIE patients, 36 patients who underwent surgical intervention for AIE using local administration of powder minocycline between January 2008 and August 2017 in our institute were enrolled. During surgery, the local administration and dispersion of powder minocycline at not only the valvular annulus and perivalvular cavity, but also the prosthetic cuff and ring were performed following the complete resection and aggressive debridement of infectious tissues. Early clinical outcomes, including survival, postoperative co-morbidities, and freedom from re-intervention or significant paravalvular leakage (PVL), were assessed. RESULTS: Early mortality within 30 days was 5.6% and hospital death was 13.9%. There was no reoperation within 30 days and only one patient (3.8%) developed recurrent infection, which improved with additional antibiotic treatments. More than moderate PVL within 30 days was detected in one patient only (3.8%). Over a median follow-up period of 38.3 ± 35.5 months, a Kaplan-Meier analysis revealed that 1- and 5-year survival rates were 75.7 and 66.8%, respectively, and freedom from reoperation was 100% at 5 years. Freedom from significant PVL at 5 years was 91.0%. CONCLUSIONS: The local administration of powder minocycline may be a simple and effective manipulation during surgical intervention for AIE without extensive reconstruction; however, the surgical management of AIE remains challenging.

First-Degree Heart Block: The Guiding Light to Discovering an Aortic Root Abscess.

Minor conduction abnormalities such as first-degree heart blocks are generally overlooked on electrocardiogram (EKG) as their impact on clinical management is usually not substantial. However, they can be an important screening tool for early diagnosis of infective endocarditis (IE) and associated perivalvular complications, especially in patients with surgical valve replacements. This case report describes a 58-year-old male with a past medical history of bicuspid aortic valve status post replacement five years prior to presentation who initially presented with presumed symptoms of a complicated urinary tract infection (UTI) and later developed chest pain and shortness of breath. He showed no initial signs of infection including negative blood and urine cultures. EKG showed new onset prolonged PR interval. He then underwent a transthoracic echocardiogram (TTE) which showed prosthetic valve dysfunction and subsequently underwent transesophageal echocardiogram (TEE) which revealed vegetations on all leaflets and circumferential peri-aortic abscess encompassing both coronary ostia and extending towards the tricuspid and mitral valve leaflets. The patient then underwent redo-sternotomy for dissection of mediastinal adhesions, extraction of the aortic bio-prosthesis, and debridement of the aortic root abscess. The aortic root was replaced with a homograft and the valve cultures were positive for Enterococcus faecium. The patient developed complete heart block afterwards and received a permanent pacemaker; repeat cultures showed no further evidence of infection. This case report is presented to reiterate the importance of early detection of IE-related aortic valve abscess and their rare sequelae. Early screening for conduction abnormalities via EKG and subsequently a TEE can allow prompt identification and management of valvular abnormalities to prevent life-threatening complications and improve patient outcomes.

Usefulness of 18F-fluorodeoxyglucose positron emission tomography/computed tomography angiography in a patient with blood culture-negative prosthetic valve endocarditis complicated with perivalvular abscess: a case report.

BACKGROUND: Prosthetic valve endocarditis (PVE) is a life-threatening systemic infection involving a high mortality rate and severe complications, including perivalvular abscess. Early diagnosis and detection of PVE continue to be challenging in clinical settings. CASE SUMMARY: A 64-year-old man with a history of mechanical aortic valve implantation 12 years prior was referred to our hospital with a major complaint of high fever and was admitted. Although results of three blood culture tests at admission were negative, transthoracic echocardiography, and transoesophageal echocardiography (TOE) were performed to exclude the possibility of PVE; both, however, were inconclusive. Subsequently, 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) was performed; revealing intense hyper-metabolism above the aortic valve prosthesis with a greater intensity at the posterior end, confirming a diagnosis of aortic PVE complicated with perivalvular abscess. DISCUSSION: Considering the intermediate suspicion of PVE despite negative TOE and negative blood culture tests, 18F-FDG PET/CT can play a central role in diagnosing PVE. However, this new imaging modality often fails to differentiate thrombi, soft atherosclerotic plaques, or foreign body reactions on the surface of prosthetic valves. In this report, we have successfully enhanced the diagnostic accuracy of 18F-FDG PET/CT by focusing on perivalvular involvement, which could be a key finding, because intense 18F-FDG uptake surrounding the aortic annulus was consistent with the thickened area within the aortic annular region observed in the TOE examinations.

Salmonella infective endocarditis.

OBJECTIVE: Salmonella endocarditis is so rarely reported that its clinical features, prognosis, and optimal treatment remain unclear. In this paper, we report a female with nontyphoid Salmonella endocarditis complicated with perivalvular abscess. We also review and summarize other cases reported in the English literature. METHODS: Using the key words "Salmonella", "infective endocarditis", and "mural endocarditis" to search the PubMed database, we reviewed case reports on Salmonella endocarditis published between 1976 and 2014 and case series of infective endocarditis that included at least 500 cases. RESULTS: Salmonella species were rare infective endocarditis pathogens. Among 16 large case series, they accounted for less than 0.01% and up to 2.9% of bacterial endocarditis cases. From 1976 to 2014, a total of 87 cases of typhoid and nontyphoid Salmonella endocarditis were reported, which included 42 cases in 1976-1984, 30 cases in 1986-2002, and 15 cases in 2003-2014. Men predominated among the cases (58.6%), and the mean age was approximately 50-60 years. The major affected valves were the mitral valves (33.3%). Mural endocarditis was common (26.4%). Perivalvular abscess was only reported in 10.5% (6 cases) of 57 cases. The overall mortality rate was 42.5% and decreased over time from 69.0% to 13.3% during the three study periods. CONCLUSION: Salmonella endocarditis, although rare, may cause purulent infections in the perivalvular area or myocardium and lead to substantial mortality.

Fatal rupture of aortic root abscess following native aortic valve enterococcal endocarditis.

We describe the case of a 66-year-old male, who was referred to our cardiology department with suspected endocarditis, following an enterococcal bacteremia. Transesophageal echocardiography showed vegetations on a native trileaflet aortic valve. Having been prescribed intravenous amoxicillin and gentamicin, to which he initially responded, the patient became increasingly breathless during the third week of treatment. Although lung fields were clear and there were no changes to a pre-existing heart murmur on physical examination, transthoracic echocardiography and Doppler color flow imaging revealed that an aortic root abscess had ruptured and formed a left-to-right shunt. The patient was transferred to a specialist cardiac center, but was unsuitable for major surgery and died a week later. We discuss this rare and devastating complication of infective endocarditis.