Letter to the Editor
Endocarditis by Abiotrophia defectiva
Endocarditis por Abiotrophia defectiva
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Some factors like oral/dental manipulation, immunosuppression and the presence of prosthetic heart valves contribute to facilitate bacterial entrance into blood circulation<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a>. This agent is associated with higher morbidity and mortality (17%)<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> than other types of streptococci (12%). Usually, <span class="elsevierStyleItalic">A. defectiva</span> infects immunocompetent hosts and <span class="elsevierStyleItalic">Granulicatella</span> immunocompromised ones. Because of its slow development, it is very difficult to grow and identify the species under the standard methods. The agent is highly virulent and is associated with a greater prevalence of mortality and complications. These problems can be explained by the production of exopolysacaridases and fibronectin, which facilitate bacterial adherence to the extracellular matrix.</p><p id="par0010" class="elsevierStylePara elsevierViewall">This case concerns a 74 year-old woman, without relevant medical priors. She presented to the Emergency Department of Centro Hospitalar de São João, Oporto, Portugal, with 4-month-old symptoms of fatigue, weight loss, sudoresis and intermittent fever. She denied recent infections, manipulation of the oral cavity or intravenous drug use. At physical examination her mucosal was pale and dehydrated; she was feverish of 38.2<span class="elsevierStyleHsp" style=""></span>°<span class="elsevierStyleSmallCaps">C</span>. The heart auscultation revealed a pan systolic murmur grade <span class="elsevierStyleSmallCaps">V</span>/<span class="elsevierStyleSmallCaps">VI</span>, most audible in the aortic valve area. There were no other relevant alterations to the physical examination, including Janeway lesions, Osler nodes or petechiae. Blood work showed anemia of 9.5<span class="elsevierStyleHsp" style=""></span>g/dL, previously unknown, and a slight increase in inflammatory parameters, with leukocytosis (leukocyte count of 11.32<span class="elsevierStyleHsp" style=""></span>μ/L and C-reactive protein of 52.4<span class="elsevierStyleHsp" style=""></span>mg/dL). The ECG was in sinus rhythm. Thoracic X-ray found no abnormality. She was admitted to the Internal Medicine infirmary. As fever persisted, blood cultures were taken and identified the presence of <span class="elsevierStyleItalic">Abiotrophia defectiva</span>. The transthoracic echocardiogram reported “filiform vegetation with 10<span class="elsevierStyleHsp" style=""></span>mm length adherent to the right coronary cusp – probable endocarditis of the aortic valve”. Intravenous antibiotic therapy with ceftriaxone 2<span class="elsevierStyleHsp" style=""></span>g twice daily and gentamicin 1200<span class="elsevierStyleHsp" style=""></span>mg once daily was started. All blood cultures in the aftermath were negative. Fever recurred after 5 days and antibiotic therapy was changed to intravenous ampicillin 3000<span class="elsevierStyleHsp" style=""></span>mg four times daily, combined with the previous dose of gentamicin, and the patient remained without fever until discharge. Upon re-evaluation was reported “tricuspid aortic valve with marked involvement by bacterial endocarditis involving the 3 leaflets (…). The coronary leaflet presented with multi lobed vegetation, mobile, measuring 13<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>7<span class="elsevierStyleHsp" style=""></span>mm, with great embolic potential; the non-coronary leaflet presents also a large vegetation.” Cardiothoracic surgery was performed and a biologic aortic valve prosthesis <span class="elsevierStyleItalic">perimount magna</span> n° 21 was inserted. The defective valve culture was negative and antibiotic therapy discontinued after 6 weeks. The patient was discharged, medicated with a beta-blocker, diuretic, ACEi, statin and an anticoagulant for 3 months. Upon follow-up, no new problems occurred.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Prescribed treatment varies according to source, but mostly consists of a combination of a beta-lactamic with an aminoglycoside for at least the first 2 weeks, same treatment that is used for other streptococci, depending on minimal inhibitory concentration (MIC)<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">4,5</span></a>. The MIC for different antibiotics in this case were: ceftriaxone 0.25<span class="elsevierStyleHsp" style=""></span>μg/mL; penicillin 0.064<span class="elsevierStyleHsp" style=""></span>μg/mL; ampicillin 0.064<span class="elsevierStyleHsp" style=""></span>μg/mL. Even though, antibiotic therapy, even when adequate, can fail in up to 40% of the cases, reason why 30% of patients usually need surgical valve replacement<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a>. In this case, despite good clinical response to antibiotic therapy, fever persisted, valve destruction occurred and surgical replacement was still required.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Infective endocarditis by <span class="elsevierStyleItalic">Abiotrofia defectiva</span> accounts for less than 1% of all endocarditis. <span class="elsevierStyleItalic">A. defectiva</span> is a recent but known cause of infective endocarditis, associated to a high mortality and complication rate<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a>. As such, its cultural identification is essential to a correct treatment and a premature surgical intervention, factors that can improve prognosis. This microorganism should not be overlooked, given is pathogenic potential, even in the absence of clinical instability, as described earlier. Finally, the authors consider that this case, despite being and isolated and rare case report, is important because it reinforces the significance of correctly identifying microorganisms in culture, as the benefits of narrowed antibiotic therapy and early recognition of warning signs that contribute to a better prognosis and a lower mortality rate.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Infective endocarditis with atypical clinical feature and relapse by <span class="elsevierStyleItalic">Abiotrophia defectiva</span>" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "B. Ilkay" 1 => "C. Metin" 2 => "B.C. Idris" 3 => "G. 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Michael" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/CIRCULATIONAHA.115.019080" "Revista" => array:4 [ "tituloSerie" => "Circulation" "fecha" => "2015" "volumen" => "132" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26700012" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "European Society of Cardiology (ESC) Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "H. Gilbert" 1 => "L. Patrizio" 2 => "J.A. Manuel" 3 => "G.B. Maria" 4 => "C. Jean-Paul" 5 => "D.Z. Francesco" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Eur Heart J" "fecha" => "2015" "volumen" => "44" "paginaInicial" => "3075" "paginaFinal" => "3128" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/00257753/0000015700000005/v1_202108280531/S0025775320305467/v1_202108280531/en/main.assets" "Apartado" => array:4 [ "identificador" => "66430" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Cartas al Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/00257753/0000015700000005/v1_202108280531/S0025775320305467/v1_202108280531/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775320305467?idApp=UINPBA00004N" ]
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