Unexpected Infective Endocarditis: Towards a New Alert for Clinicians
Abstract
:1. Introduction
2. Infective Endocarditis Pathophysiology
3. The Diagnosis of Infective Endocarditis: The Expected Paradigm
4. The Diagnosis of Infective Endocarditis: The Unexpected Scenario
4.1. Infective Endocarditis in Healthy Subjects
4.1.1. Athletes
4.1.2. Piercing
Clinical Case 1. A 38-year-old woman without pre-existing cardiac disease was admitted for 10-day mild fever associated with progressive epigastric pain and vomit one month following piercing implant. Clinical examination revealed a painful hepato-splenomegaly. Cardiovascular evaluation showed tachycardia (120 beat/min), arterial hypotension (75/45 mm Hg) without any cardiac murmur. Abdomen echo scan confirmed a normally structured hepatosplenomegaly, together with inferior vena cava enlargement suggesting venous congestion. Blood chemistry showed increased white cell count (12,860) and severe anemia (Hb3.9), requiring urgent transfusion. C-reactive protein was moderately high (16.5). Blood culture was positive for methicillin sensitive S. aureus. TT (1) and subsequent TEE (2,3,4) showed a large iso-echogenic vegetation (yellow arrow), which was attached to the atrial surface of the anterior leaflet of the tricuspid valve, prolapsing into the right atrium during the systole and determining related severe valve regurgitation. The patient underwent culture-guided antibiotic therapy with disappearance of the vegetation and reduction in tricuspid regurgitation to a moderate degree at subsequent echocardiographic examination.
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4.2. Comorbidities and Infective Endocarditis
4.2.1. Diabetes
4.2.2. Hemodialysis Patients
4.2.3. Cancer Patients
4.3. Subclinical Valve Disease in the Elderly
5. Unexpected Infective Endocarditis Syndrome: An Intriguing Clinical Challenge
Clinical Case 2. Unexpected endocarditis at opprtunistic echocardiography follow-up. A 60-year-old woman was observed at our heart valve clinic for a scheduled 3-month survey following surgical mitral valve repair of prolapse-related mitral regurgitation. The patient was asymptomatic under medical therapy, including a beta-blocking agent and routine early anticoagulation with dicumarol. Clinical examination was normal. Transthoracic echocardiography showed a small iso-echogenic mass on the atrial side of the posterior mitral leaflet. The subsequent transesophageal echocardiography (1 = 2D-TEE, 2 = 3D-TEE), showed a large iso-echogenic mass with an annular infiltrative appearance suggesting active valve vegetation. Blood cultures and phlogistic indices were normal. A PET examination (3 = PET) showed moderate mitral ring uptake, coherent with the recent surgical procedure. Due to the unexpected findings suggesting IE without clinical and microbiological associated criteria, TEE was re-evaluated following seven-day treatment with iv Heparin and empirical antibiotic therapy (Vancomicin, Gentamicin, Rifampicin). Owing to the persistence of mitral valve mass at high embolic risk, the patient underwent surgery. Surgical inspection (4 = surgical specimen) and histological examination confirmed IE diagnosis with a microbiological tissue culture for Enterobacter Cloacae. Following mitral valve replacement the clinical course was favorable with 1-month focused antibiotic therapy, without IE recurrence at long-term follow-up. This case underscores the importance of a careful and systematic survey following cardiac surgery to exclude silent unexpected endocarditis, especially during the first year after heart valve surgery.
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5.1. Clinical Phenotypes of Unexpected Infective Endocarditis Syndrome
5.1.1. Hidden Subtle Clinical Phenotype
Clinical Case 3. Unexpected IE in at-risk patient. Female, 80 years old, who underwent previous breast cancer treatment (surgery, chemotherapy, radio therapy). Due to symptomatic severe mitral regurgitation, the patient underwent surgical mitral valve replacement with a biological prosthesis. A 3-month follow-up transthoracic echocardiogram (TTE) showed a normally functioning bioprosthesis. Six months after surgery, the patient was hospitalized for pulmonary edema coincident with high-ventricular rate atrial fibrillation responsive to medical treatment. During the subsequent month, the patient showed transient low-grade fever with a mild increase in PCR and leucocytes together with X-ray evidence of pulmonary infiltrate suggesting pneumonia. Thus, empirical antibiotic therapy was started in addition to cardiac medications (beta-blocking agent, angiotensin II inhibitor, edoxaban). A subsequent 3-day TTE (picture A) showed an unexpected iso-echogenic mass on the atrial surface of the mitral bioprosthesis. Due to concomitant anticoagulant therapy, IE was suspected instead of valve thrombosis with admission to our hospital. On admission the patient showed a stable clinical condition without fever or symptoms. Clinical examination showed a normal clinical condition with sinusal rhythm. Despite a low clinical probability of IE, due to echo-imaging, blood culture was carried out showing S. epidermidis. Focused antibiotic therapy, including Tazocin and Daptomicin, was started. Subsequent 6 h fasting Transesophageal Echocardiography (picture A = 2D-TEE; pictures 1–3 = 3D-TEE) showed a large iso-echogenic mass with bifurcated morphology (maximum diameter 25 × 10 mm). The mass was inserted on the atrial surface of the posterior prosthetic leaflet with annular infiltration and diastolic prolapse in the valvular ostium. Due to the high risk of embolism, the patient underwent a total body CT scan to exclude systemic embolization and subsequent emergency surgery. Surgical inspection (4, yellow arrow) and histological examination together with S. epidermidis isolation confirmed IE diagnosis. The clinical course was uneventful. This clinical case underscores the importance of clinical alert for unexpected at-risk IE requiring emergency surgery, despite a subtle and atypical clinical presentation. |
5.1.2. Long-Term Extracardiac Symptoms
5.1.3. Infective Endocarditis with Dominant Spondylodiscitis
5.1.4. Healthy Subjects
5.1.5. Deceptive Acute Clinical Context
Clinical Case 5. Streptococcus pneumoniae infection with meningitis, pneumonia, and fulminant endocarditis (“Austrian syndrome”). A 72-year-old female was admitted after 3 days of fever, shortness of breath, and abrupt headache with nausea and vomiting. On admission, the patient appeared confused and troubled. Clinical examination revealed nuchal rigidity without focal neurologic signs. Her temperature was 39 °C, arterial blood pressure 115/60 mm Hg. The clinical diagnosis was initially addressed toward bacterial or viral meningitis vs. COVID-19 with meningoencephalitis phenotype. Lumbar puncture was carried out; cerebrospinal fluid analysis showed hypoglycorrhachia and hyperproteinorrhachia, supporting a diagnosis of probable bacterial meningitis. Empirical antibiotic therapy with intravenous Ceftriaxone, Vancomycin and Dexametasone, was promptly started. A brain CT was negative for intracranial lesions. Baseline and contrast CT showed normal pulmonary findings without parenchymal consolidation or signs of thromboembolism. Pneumococcal antigen in urine was positive and blood culture (BC) showed Gram-positive cocci. Nasopharyngeal Swab (NS) was negative for COVID-19. The final BC result confirms S. pneuomoniae bacteremia, supporting a bacterial meningitis etiology. Targeted antibiotic therapy was introduced, including levofloxacin. After 12 h, the patient showed abrupt cognitive impairment with arterial blood hypotension (80/50 mm Hg) and severe hypoxemia requiring endotracheal intubation. The patient was admitted to the intensive care unit with a diagnosis of pneumococcal meningitis and septic shock. After two days, due to significant clinical improvement, endotracheal intubation was removed. However, during the subsequent two hours the patient showed atrial fibrillation with a high ventricular rate that was reverted with iv amiodarone. Clinical examination revealed a new diastolic regurgitant murmur at cardiac auscultation. Temperature was 37.5°, blood pressure 155/50 mm Hg. Large vegetation with severe AR was shown by TTE. Subsequent TEE confirmed AR due to extensive damage of three valve leaflets with large iso-echogenic (like myocardium echogenicity) vegetation, inserted at the level of the ventricular surface of the right coronary cusps (dimension 20 × 7 mm) and prolapsing in the left ventricular outflow tract. There was moderate MR, pulmonary artery hypertension (sPAP 70 mm Hg), and severe TR. Left ventricular dimension and ejection fraction were normal. A fresh thrombus was found in the left atrial appendage. Inotropic support, with furosemide and heparin infusion, was started. Due to high systemic embolic risk (large aortic valve vegetations and left atrial appendage thrombosis), total body CT was performed. Brain CT was normal, while the thoracic scan revealed bilateral parenchymal consolidation and large pleural effusion with parenchymal edema (Figure 1). Additional NPS and BAL excluded COVID-19. Final diagnosis was “Austrian syndrome” (6), including meningitis, with subsequent pneumoniae and endocarditis due to S. pneumoniae. Although clinically indicated, cardiac surgery was postponed due to the unavailability of an operating room during the COVID-19 outbreak. The next day, hemodynamics remained stable under inotropic, diuretic, and mechanical ventilation support. A new TEE showed unchanged findings, apart from the disappearance of the thrombus in the left atrial appendage. The following day, the patient underwent contrast CT, showing significant improvement of pulmonary findings, a normal coronary anatomy, and double bulging of the aortic root below the coronary artery ostium. Immediate TEE was performed showing, in addition to the previous findings, an intimal tear with a new cavity of the anterior wall of the aortic root at the site of systolic contact of vegetation, suggesting a “kissing” mycotic pseudoaneurysm. In addition, TEE revealed normalization of sPAP and related TR. The patient, due to the added risk of impending root rupture, underwent emergency cardiac surgery. Anatomical inspection confirmed large vegetation and extensive leaflet damage of the tricuspid aortic valve, with a large paravalvular mycotic pseudoaneurysm (Figure 1). The operating strategy involved drainage of purulent material and pseudoaneurysm patch repair, followed by biological valve prosthesis implantation. The leaflet aortic culture was positive for S. Pneumoniae. The postoperative clinical course was uneventful, with complete recovery of the clinical condition. Comment. This case outlines the importance of careful daily clinical examination to target the appropriate pathway for the identification and management of unexpected fulminant IE, which can be superimposed in the deceptive context of meningitis and pneumonia due to S. pneumoniae infection (so-called Austrian syndrome).
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Transesophageal echocardiography and computed tomography of fulminant aortic endocarditis. TEE images: (A) two-dimensional; (B) three-dimensional; (C): photorealistic three-dimensional showing large vegetation (arrow) on the aortic valve prolapsing during diastole into LVOT, increasing at 24 h TEE images (D–F) together with an intimal tear communicating with a neocavity (star) on the aortic anterior wall at the site of vegetation contact (dotted arrow), suggesting a mycotic pseudoaneurysm; (I): three-dimensional computed tomography showing double bulging of the anterior aortic wall (dotted circle) overlapping photorealistic 3D images (G,H) and surgical specimen findings (AS). Computed tomography showing bilateral pulmonary parenchymal consolidation and large pleural effusion (CT1), which improved following thoracentesis and intensive medical therapy (CT2). |
6. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Acknowledgments
Conflicts of Interest
References
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La Canna, G.; Torracca, L.; Barbone, A.; Scarfò, I. Unexpected Infective Endocarditis: Towards a New Alert for Clinicians. J. Clin. Med. 2024, 13, 5058. https://doi.org/10.3390/jcm13175058
La Canna G, Torracca L, Barbone A, Scarfò I. Unexpected Infective Endocarditis: Towards a New Alert for Clinicians. Journal of Clinical Medicine. 2024; 13(17):5058. https://doi.org/10.3390/jcm13175058
Chicago/Turabian StyleLa Canna, Giovanni, Lucia Torracca, Alessandro Barbone, and Iside Scarfò. 2024. "Unexpected Infective Endocarditis: Towards a New Alert for Clinicians" Journal of Clinical Medicine 13, no. 17: 5058. https://doi.org/10.3390/jcm13175058