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"apellidos" => "Sá" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935619301586" "doi" => "10.1016/j.redar.2019.08.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935619301586?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192920300214?idApp=UINPBA00004N" "url" => "/23411929/0000006700000002/v1_202002150624/S2341192920300214/v1_202002150624/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2341192920300172" "issn" => "23411929" "doi" => "10.1016/j.redare.2019.10.005" "estado" => "S300" "fechaPublicacion" => "2020-02-01" "aid" => "1085" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2020;67:99-102" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Lung recruitment maneuvers: Opening the door to a hidden enemy" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "99" "paginaFinal" => "102" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Maniobras de reclutamiento pulmonar: abriendo la puerta a un enemigo oculto" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 787 "Ancho" => 905 "Tamanyo" => 49257 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Endoscopic image of the carcinoid tumour in the left main bronchus.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "R. 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Esnaola Iriarte, S. Telletxea Benguria, K. Intxaurraga Fernández, E. Díez Castillo" "autores" => array:4 [ 0 => array:4 [ "nombre" => "B." "apellidos" => "Esnaola Iriarte" "email" => array:1 [ 0 => "beaesnaola@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "S." "apellidos" => "Telletxea Benguria" ] 2 => array:2 [ "nombre" => "K." "apellidos" => "Intxaurraga Fernández" ] 3 => array:2 [ "nombre" => "E." "apellidos" => "Díez Castillo" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Anestesiología, Reanimación y Tratamiento del dolor, Hospital de Galdakao-Usansolo, Galdakao, Vizcaya, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Endocarditis infecciosa sobre válvula nativa por <span class="elsevierStyleItalic">Escherichia coli</span> resistente a ampicilina en el postoperatorio de una nefrectomía radical derecha por pielonefritis xantogranulomatosa" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 677 "Ancho" => 905 "Tamanyo" => 68812 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Abdominal CT scan showing significant dilation of the pyelocaliceal system and right-sided pyonephrosis.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The spectrum of microorganisms that produce native valve endocarditis is constantly changing. Despite an increase in the incidence of infections caused by gram-negative microorganisms, they are still a rare cause of native valve endocarditis (1.8%).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Specifically, infective endocarditis (IE) due to <span class="elsevierStyleItalic">E. coli</span> represents 0.51% of cases.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Patients currently diagnosed with IE due to <span class="elsevierStyleItalic">E. coli</span> are older than 70 years, often diabetic, and with underlying heart disease (degenerative valve lesions). The proportion of men to women in confirmed cases of IE due to <span class="elsevierStyleItalic">E. coli</span> is 10:26 (72.2% women), although IE is generally is more frequent in older men. The urinary tract appears to be the main source of infection, and the mitral and aortic valves are most frequently involved.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Given the aggressiveness of this microorganism as an extraintestinal pathogen, surgery is often required,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> as in the case reported here. Although the mortality rate of this type of infection has steadily declined since 1950, it is still estimated to be as high as 25%.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 36-year-old man who presented at the emergency department with a 1-week history of right-sided abdominal pain and fever, together with frequent and urgent urination. He also reported an episode of right renal colic in the preceding weeks that had been treated on an outpatient basis with anti-inflammatories. His medical history was significant for smoking, morbid obesity, HTN in pharmacological treatment with ramipril, diabetes mellitus (DM) type 2 in treatment with insulin aspart, glargine and liraglutide, metabolic syndrome, and obesity-hypoventilation syndrome/obstructive sleep apnoea in treatment with non-invasive mechanical ventilation (NMV). His records also included a report of an echocardiogram performed due to signs of heart failure during a previous admission for inguinal cellulitis, which reported preserved global systolic function with no valve disease. We performed an abdominal CT scan, which showed the presence of right-sided pyonephrosis along with multiple renal and subhepatic abscesses (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). On the basis of these findings, the patient was diagnosed with xanthogranulomatous pyelonephritis and underwent urgent open right-sided radical nephrectomy along with drainage of multiple abscesses that same day. Two Penrose drains were placed: one upper drain in the subhepatic region and one lower drain in the surgical site. Surgery lasted 180 min and was performed under balanced general anaesthesia. During surgery, the patient became hemodynamically unstable, and continuous infusion of 0.1 µg/kg/min noradrenaline (NA) was started to maintain a mean arterial pressure of 75 mmHg. After surgery, he was transferred, intubated, to the post-anaesthesia care unit and connected to mechanical ventilation for postoperative control. After admission he required vasopressor support with increasing doses of NA, and was extubated within a few hours of the intervention, maintaining adequate oxygenation with high flow oxygen therapy. We also started broad-spectrum empirical antibiotic therapy with meropenem and IV amikacin. Lab parameters at admission were: creatinine 2.1 mg/dl, potassium 5.2 mmol/l, procalcitonin 4.16 ng/ml, PCO<span class="elsevierStyleInf">2</span> 54 mmol/l, lactate 1 4 mmol/l, leukocytes 32,000 (neutrophils 90%, band neutrophils 4%), INR 1.56, PI 53%, and aPTT 30 s. He initially presented oliguria, which responded well to continuous perfusion of diuretics. His condition worsened progressively over the next few days, presenting septic shock and purulent discharge, so a surgical revision of the abdomen was performed, finding abundant pus between folds, without collections. The peritoneal cavity was washed with physiological serum and a vacuum-assisted closure (VAC) system was placed due to the impossibility of closing the abdominal wall. Ampicillin-resistant <span class="elsevierStyleItalic">E. Coli</span> was grown in blood and abdominal drainage cultures, so the original antibiotic therapy was maintained. However, the patient’s condition continued to deteriorate, with haemodynamic instability that required high-dose vasopressor support, mechanical ventilation and persistent fever of up to 41 °C that did not respond to physical or pharmacological measures. Given the situation, continuous venovenous hemodiafiltration via the femoral vein was started to control body temperature, and linezolid and caspofungin were added empirically to the treatment. Temperature was controlled after a few days, and the patient improved both clinically and hemodynamically, with a decrease in infectious parameters. The patient was disconnected from haemofiltration and mechanical ventilation, and vasopressor support was discontinued. Despite clinical improvement, both sepsis and abnormal infectious parameters persisted, and given the finding of a panfocal systolic murmur not present in the previous studies, we ordered a transthoracic echocardiogram (TTE), which showed moderate mitral insufficiency and moderate-severe aortic insufficiency. Since the patient did not present a good window for echocardiography, we decided to complete the study with a transoesophageal echocardiogram (TOE), which showed severe aortic and mitral insufficiency secondary to leaflet rupture with endocarditis vegetation, as well as a pseudoaneurysm in the left aortic sinus that affected aortic mitral continuity and fistulized to the left atrium with a jet parallel to the mitral annulus that encircled the atrium (<a class="elsevierStyleCrossRefs" href="#fig0010">Figs. 2 and 3</a>). After the patient had been evaluated by the cardiology department and the case had been discussed with the infectious diseases department, and given the current finding and the growth of <span class="elsevierStyleItalic">Staphilococcus epidermidis</span> resistant to linezolid and sensitive to daptomycin from abdominal fluid culture taken from the VAC, we decided to switch the antibiotic regimen to ceftriaxone, ciprofloxacin and daptomycin. We discussed the case with the cardiac surgery service of the reference hospital, and a full body CT scan was performed to rule out the presence of possible septic embolisms. These data showed that the patient met 2 of Duke's modified criteria (echocardiographic finding of endocarditis vegetation and blood culture positive for a microorganism compatible with IE) for the definitive clinical diagnosis of endocarditis. The patient was immediately transferred to cardiac surgery where aortic and mitral valve replacement was performed with mechanical prostheses, together with reconstruction of the mitral-aortic junction, the roof of the left atrium, and the aortic root with double pericardium patch. Culture of samples taken from both valves was negative, probably due to the antibiotic therapy started previously. The patient presented multiple postoperative complications, including cardiac tamponade that required reoperation for drainage. Treatment was changed several times due to growth of different bacteria in blood cultures, including multi-resistant <span class="elsevierStyleItalic">S. epidermidis</span> 1 week after of the diagnosis of IE, which was treated with tigecycline and daptomycin for 4 weeks; <span class="elsevierStyleItalic">Stenotrophomonas maltophilia</span> 15 days after the diagnosis of IE, which was treated with cotrimoxazole for 10 days; and echinocandin-resistant <span class="elsevierStyleItalic">Candida parapsilosis</span> 15 days after the diagnosis of IE, which was treated with fluconazole for 4 weeks. Antibiotic therapy for IE was finally suspended after 6 weeks, once the last blood cultures were negative. Finally, 70 days after admission to the unit, the was discharged to the ward and subsequently to his home, with outpatient cardiological controls.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">IE due to <span class="elsevierStyleItalic">E. coli</span> is uncommon, and is observed especially in older women, particularly those with diabetes mellitus,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> although it has also been reported in younger patients. Fayyaz et al.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> detected <span class="elsevierStyleItalic">E. coli</span> in 8.4% of patients with IE aged 20 to 40 years. Other studies have shown that <span class="elsevierStyleItalic">E. coli</span> represents one third of cases of EI caused by gram-negative bacilli of the non-HACEK group, and that it is the most common gram-negative bacillus that causes IE.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> These findings suggest that the incidence of IE due to <span class="elsevierStyleItalic">E. coli</span> may be higher than previously believed.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Most the 33 cases of native valve IE due to <span class="elsevierStyleItalic">E. coli</span> published in the PubMed database in the last 31 years<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> presented predominant mitral valve involvement, followed by aortic valve involvement. Only 1 patient presented bivalvular mitral-aortic involvement of the type found in our patient. The baseline comorbidities in the patients reviewed included diabetes, malignancy and haemodialysis, suggestive of underlying immunosuppression. Excessive alcohol consumption and cirrhosis were also associated with an increased incidence of EI due to non-HACEK gram-negative bacilli, as they destroy the intestinal mucosa and therefore increase the risk of transmural migration of <span class="elsevierStyleItalic">E. coli</span> into the circulation and the gastrointestinal tract. Our patient only presented 1 of the aforementioned risk factors, i.e., diabetes mellitus.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Strains of extraintestinal pathogenic <span class="elsevierStyleItalic">E. coli</span> (ExPEC) are phylogenetic and epidemiologically different from commensal and intestinal pathogenic strains. Like commensal strains, they appear to be incapable of causing enteric disease, but can stably colonize the host intestinal tract.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Despite their low adherence to heart tissue, which explains the low incidence of IE due to <span class="elsevierStyleItalic">E. coli</span>,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> ExPECs have a number of extraintestinal virulence factors, such as adhesins, toxins, invasins, iron uptake systems (siderophores), and host defence evasion mechanisms that make them very virulent pathogens once they enter a normally sterile extraintestinal territory, such as the urinary tract. The urinary tract is known to be a source of pathogen acquisition in patients with IE due to non-HACEK gram-negative bacteria.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,10</span></a> A history of recent urinary tract infection was present in 52% of the cases 33 cases of native valve IE due to <span class="elsevierStyleItalic">E. coli</span> published in PubMed, and in 36% urine cultures were positive for <span class="elsevierStyleItalic">E. coli</span>.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Of these, 70% also had positive blood cultures for <span class="elsevierStyleItalic">E. coli</span>.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In the case reported here, the primary event was probably xanthogranulomatous pyelonephritis along with multiple renal abscesses, since there was an underlying predisposing factor for urinary tract infection (the history of right-sided renal colic in the preceding weeks) and no predisposition for IE in the form of heart disease (an earlier echocardiogram had shown normal valves) or parenteral drug use. In addition, ampicillin-resistant <span class="elsevierStyleItalic">E. coli</span> was isolated in 2 consecutive blood cultures as well as in urine culture. Therefore, although <span class="elsevierStyleItalic">S. epidermidis</span> was initially suspected to be the causative germ of IE, after analysing the clinical context and blood cultures we believe that the pathogen responsible was more likely to be <span class="elsevierStyleItalic">E. coli</span>, since it was not isolated in the valve tissue culture, possibly due to antibiotics initiated prior to surgery.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Complications of IE due to gram-negative bacteria include the formation of paravalvular abscesses, peripheral embolisms, and the development of congestive heart failure, especially when fever persists for more than 7 days despite adequate antibiotic treatment.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Our patient developed a pseudoaneurysm in the left aortic sinus that affected mitral aortic continuity, causing severe mitral and aortic insufficiency that triggered the onset of congestive heart failure.</p><p id="par0040" class="elsevierStylePara elsevierViewall">As far as treatment is concerned, although most of the evidence regarding the management of IE by gram-negative bacilli shows the benefit of early surgery in combination with prolonged cycles (at least 6 weeks) of combined antibiotic therapy, particularly in left-sided IE,<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,13</span></a> a literature search of the ICE-PCS (International Collaboration on Endocarditis-Prospective Cohort Study) database showed no survival benefits in patients undergoing cardiac surgery compared to those who received combined antibiotic treatment.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The antibiotic regimen recommended by the AHA (American Heart Association) in these patients is the combination of a β-lactam (penicillin, cephalosporin or carbapenem) with an aminoglycoside or fluoroquinolone for 6 weeks.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> In our case, although broad-spectrum empirical antibiotic therapy was initiated early, IE was already very advanced when it was detected so urgent valve replacement surgery was needed. The aggressiveness of extraintestinal pathogenic <span class="elsevierStyleItalic">E. coli</span>, together with the delay in diagnosis due to the low level of suspicion, could be the reason for the torpid evolution of our patient.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="par0045" class="elsevierStylePara elsevierViewall">EI due to <span class="elsevierStyleItalic">E. coli</span> is a rare, but increasingly prevalent, pathology. The virulence of extraintestinal <span class="elsevierStyleItalic">E. coli</span> strains increases the risk of adhesion to endocardial tissue, and as a result IE is more common on left-sided native valves. Persistent <span class="elsevierStyleItalic">E. coli</span> colonisation in a patient with no cardiac risk factors could be a manifestation of native valve endocarditis, and should prompt clinicians to order an echocardiographic study.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> This clinical case illustrates the need to consider the differential diagnosis of IE in any patient with sepsis of urological origin and persistent fever, despite appropriate antibiotic treatment. Intensive antibiotic and surgical treatment of these patients is vital to improve survival.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1308766" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1208270" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1308767" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1208271" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-05-27" "fechaAceptado" => "2019-09-25" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1208270" "palabras" => array:3 [ 0 => "Postoperative infective endocarditis" 1 => "<span class="elsevierStyleItalic">Escherichia coli</span>" 2 => "Urologic sepsis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1208271" "palabras" => array:3 [ 0 => "Endocarditis infecciosa postoperatoria" 1 => "<span class="elsevierStyleItalic">Escherichia coli</span>" 2 => "Sepsis urológica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Infective endocarditis (IE) due to <span class="elsevierStyleItalic">Escherichia coli</span> is a rare disease, although increasingly frequent. Persistent fever in septic patients despite adequate treatment raises the need to consider IE as a differential diagnosis. We present the case of a 36-year-old male patient who underwent a radical right nephrectomy as a result of diagnosis of xanthogranulomatous pyelonephritis, presenting in the postoperative period a state of septic shock with persistent fever of 41 °C. Given the finding of a new-onset murmur, he was diagnosed with a mitroaortic IE by means of a transesophageal echocardiogram (TEE), having to undergo cardiac surgery for valve replacement. After multiple postoperative complications, he is successfully discharged.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La endocarditis infecciosa (EI) debida a <span class="elsevierStyleItalic">Escherichia coli</span> es una enfermedad rara, aunque cada vez más frecuente. La fiebre persistente en pacientes sépticos a pesar de un tratamiento adecuado plantea la necesidad de considerar la EI como diagnostico diferencial. Presentamos el caso de un paciente varón de 36 años al que se le practica una nefrectomía radical derecha por diagnóstico de pielonefritis xantogranulomatosa, presentando en el postoperatorio un estado de shock séptico con fiebre persistente de hasta 41 °C. Ante el hallazgo de un soplo de nueva aparición se le diagnostica de EI mitroaórtica mediante Ecocardiograma transesofágico (ETE) teniendo que someterse a cirugía cardiaca para sustitución valvular. Tras múltiples complicaciones postoperatorias es dado de alta exitosamente.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Esnaola Iriarte B, Telletxea Benguria S, Intxaurraga Fernández K, Díez Castillo E. Endocarditis infecciosa sobre válvula nativa por <span class="elsevierStyleItalic">Escherichia coli</span> resistente a ampicilina en el postoperatorio de una nefrectomía radical derecha por pielonefritis xantogranulomatosa. Rev Esp Anestesiol Reanim. 2020;67:103–107.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 677 "Ancho" => 905 "Tamanyo" => 68812 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Abdominal CT scan showing significant dilation of the pyelocaliceal system and right-sided pyonephrosis.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 550 "Ancho" => 905 "Tamanyo" => 60586 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Pseudoaneurysm fistula - left atrium.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 579 "Ancho" => 905 "Tamanyo" => 43465 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Ruptures aortic valve with pseudoaneurysm.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "International collaboration on endocarditis prospective cohort study (ICE- PCS) investigators. 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