Scientific letter
Infective endocarditis caused by Streptococcus cristatus
Endocarditis infecciosa causada por Streptococcus cristatus
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class="elsevierStyleItalic">Streptococcus cristatus</span>" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "314" "paginaFinal" => "315" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Domingo Fernández Vecilla, José Luis Díaz de Tuesta del Arco" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Domingo" "apellidos" => "Fernández Vecilla" "email" => array:1 [ 0 => "domingofvec@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "José Luis" "apellidos" => "Díaz de Tuesta del Arco" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Microbiología y Parasitología, Hospital Universitario de Basurto, OSI Bilbao-Basurto, Bilbao, Vizcaya, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Biocruces Bizkaia Health Research Institute, Barakaldo, Vizcaya, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Endocarditis infecciosa causada por <span class="elsevierStyleItalic">Streptococcus cristatus</span>" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 694 "Ancho" => 1676 "Tamanyo" => 123781 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Joint CT and PET-CT study performed following endocarditis protocol after inconclusive result by transoesophageal echocardiogram by administration of intravenous contrast and 18-FDG, with imaging from the cervical region up to and including the pelvis. Hypodense lesions of triangular morphology and new appearance in the lower pole of the spleen and interpolar region of the left kidney, compatible with small infarcts (yellow circles). Focal increase in metabolic activity (yellow line) on the prosthetic aortic valve annulus's anterior region makes it impossible to rule out endocarditis without significant morphological findings.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 76-year-old patient presented at our hospital with intermittent fever of up to 40<span class="elsevierStyleHsp" style=""></span>°C lasting three weeks, coinciding with stem cell inoculation in both hips. The patient had required aortic valve replacement six years earlier and, due to liver cirrhosis with hepatocarcinoma in segment 5, had also required partial hepatectomy and cholecystectomy five months earlier. Twenty days before, the patient had a dental filling for which he did not receive antibiotic prophylaxis. On examination, the patient had a fever of 39.1<span class="elsevierStyleHsp" style=""></span>°C with a pansystolic murmur, and a blood test showed 12,900 leukocytes, 90% of which were neutrophils. Suspecting endocarditis, a blood culture was obtained and the patient was admitted for study and antibiotic treatment with vancomycin and cefepime (1 g/12<span class="elsevierStyleHsp" style=""></span>h and 2<span class="elsevierStyleHsp" style=""></span>g/24<span class="elsevierStyleHsp" style=""></span>h intravenously [IV], respectively).</p><p id="par0010" class="elsevierStylePara elsevierViewall">A transthoracic echocardiogram was performed, in which thickened aortic leaflets were observed, and also a transoesophageal echocardiogram, in which no clear images of endocarditis were observed. The blood culture was positive after 20<span class="elsevierStyleHsp" style=""></span>h of incubation, showing Gram-positive cocci in chains in the Gram stain. The blood culture was inoculated on CNA agars (Becton Dickinson, New Jersey, USA), TSA agars with 5% sheep blood (BD™) and chocolate agar. At 24<span class="elsevierStyleHsp" style=""></span>h, growth was observed, with its identification and antibiotic sensitivity provided by means of the SMIC-ID-11 (BD™) panel in the BD Phoenix™ AP system. The strain was identified as <span class="elsevierStyleItalic">Streptococcus cristatus</span> (<span class="elsevierStyleItalic">S. cristatus</span>), which was sensitive to penicillin (MIC ≤0.03<span class="elsevierStyleHsp" style=""></span>mg/l), vancomycin (MIC = 1<span class="elsevierStyleHsp" style=""></span>mg/l), teicoplanin (MIC ≤1<span class="elsevierStyleHsp" style=""></span>mg/l) and clindamycin (MIC ≤0.03<span class="elsevierStyleHsp" style=""></span>mg/l). In a subsequent blood culture, <span class="elsevierStyleItalic">S. cristatus</span> was identified again, changing the antibiotic treatment to ceftriaxone (2<span class="elsevierStyleHsp" style=""></span>g/24<span class="elsevierStyleHsp" style=""></span>h) while waiting to perform CT + PET-CT. After administration of IV contrast and 18-FDG, lesions compatible with small infarcts in the lower pole of the spleen and left kidney were found, as well as increased metabolic activity in the periprosthetic aortic valve, which did not prevent us from ruling out endocarditis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The condition was considered as probable endocarditis (one major criterion and three minor criteria) and the patient completed six weeks of IV treatment. The patient was followed up through outpatient visits, confirming clinical improvement and normality in subsequent echocardiograms. To confirm the identification, the strain was reseeded to sequence the 16S ribosomal RNA gene. A 637<span class="elsevierStyleHsp" style=""></span>bp sequence was obtained that was entered into BLAST<span class="elsevierStyleSup">R</span>, and was identified as <span class="elsevierStyleItalic">S. cristatus</span> with an identification percentage of 99.37% (see sequencing protocol and sequence in <a class="elsevierStyleCrossRef" href="#sec0020">Appendix B: Supplementary material attached</a>).</p><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">S. cristatus</span> was isolated for the first time from the human oral cavity, belonging to the <span class="elsevierStyleItalic">mitis</span>group.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> A 2014 study showed that <span class="elsevierStyleItalic">S. cristatus, Streptococcus oligofermentans</span> and <span class="elsevierStyleItalic">Streptococcus sinensis</span> are closely related, and a new phylogenetic clade, the “<span class="elsevierStyleItalic">sinensis</span> group”, was proposed to include these three microorganisms.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> The relationship between infections such as endocarditis and dental interventions has been proven, and prophylaxis is recommended in patients with risk factors, such as valve carriers. In addition, poor dental hygiene also seems to be associated with a higher risk of infections by <span class="elsevierStyleItalic">S. cristatus</span>.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> In the case presented here, and in another of those previously reported, the patients had minor dental interventions or a history of poor dental hygiene prior to the infection.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Only nine clinical cases of infections caused by this microorganism have been described: six cases of infective endocarditis, one of septic arthritis and two of bacteraemia.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4-9</span></a> At our institution, we have identified another case of endocarditis by sequencing the 16S rRNA gene from a prosthetic valve sample.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Current treatment guidelines recommend, in patients with <span class="elsevierStyleItalic">viridans</span> group streptococcal prosthetic valve endocarditis, six weeks of penicillin (24 million U/24<span class="elsevierStyleHsp" style=""></span>h IV in continuous infusion or 4-6 doses) or ceftriaxone (2<span class="elsevierStyleHsp" style=""></span>g/24<span class="elsevierStyleHsp" style=""></span>h IV or IM), which can be combined with a 2-6 week regimen of gentamicin (3<span class="elsevierStyleHsp" style=""></span>mg/kg every 24<span class="elsevierStyleHsp" style=""></span>h IV or IM). In highly sensitive strains (MIC of penicillin ≤0.12<span class="elsevierStyleHsp" style=""></span>mg/l), as in our case, the combination with gentamicin has not shown higher cure rates compared to monotherapy.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">This case adds more scientific evidence about the ability of <span class="elsevierStyleItalic">S. cristatus</span> to cause serious infections such as bacteraemia or endocarditis, although more studies are needed to explore its virulence.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0040" class="elsevierStylePara elsevierViewall">No funding was received.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0055" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Annex A" "titulo" => "Additional material" "identificador" => "sec0020" ] ] ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 694 "Ancho" => 1676 "Tamanyo" => 123781 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Joint CT and PET-CT study performed following endocarditis protocol after inconclusive result by transoesophageal echocardiogram by administration of intravenous contrast and 18-FDG, with imaging from the cervical region up to and including the pelvis. Hypodense lesions of triangular morphology and new appearance in the lower pole of the spleen and interpolar region of the left kidney, compatible with small infarcts (yellow circles). Focal increase in metabolic activity (yellow line) on the prosthetic aortic valve annulus's anterior region makes it impossible to rule out endocarditis without significant morphological findings.</p>" ] ] 1 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.doc" "ficheroTamanyo" => 19997 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "<span class="elsevierStyleItalic">Streptococcus cristatus</span> sp. nov., a <span class="elsevierStyleItalic">viridans</span> streptococcus with tufted fibrils, isolated from the human oral cavity and throat" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "P. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 2 | 0 | 2 |
| 2024 October | 37 | 5 | 42 |
| 2024 September | 20 | 3 | 23 |
| 2024 August | 24 | 5 | 29 |
| 2024 July | 46 | 3 | 49 |
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| 2024 May | 20 | 3 | 23 |
| 2024 April | 14 | 4 | 18 |
| 2024 March | 21 | 4 | 25 |
| 2024 February | 10 | 2 | 12 |
| 2024 January | 19 | 3 | 22 |
| 2023 December | 10 | 1 | 11 |
| 2023 November | 9 | 7 | 16 |
| 2023 March | 0 | 4 | 4 |
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