Endocarditis by Abiotrophia defectiva

Oliveira, Diana; Reis, Joana; Ferreira, Pestana

doi:10.1016/j.medcli.2020.06.050

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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">1,2</a>. This agent is associated with higher morbidity and mortality (17%)<a class="elsevierStyleCrossRef" href="#bib0040">3</a> than other types of streptococci (12%). Usually, A. defectiva infects immunocompetent hosts and Granulicatella 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.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°C. The heart auscultation revealed a pan systolic murmur grade V/VI, 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 9.5g/dL, previously unknown, and a slight increase in inflammatory parameters, with leukocytosis (leukocyte count of 11.32μ/L and C-reactive protein of 52.4mg/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 Abiotrophia defectiva. The transthoracic echocardiogram reported “filiform vegetation with 10mm length adherent to the right coronary cusp – probable endocarditis of the aortic valve”. Intravenous antibiotic therapy with ceftriaxone 2g twice daily and gentamicin 1200mg 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 3000mg 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 13×7mm, with great embolic potential; the non-coronary leaflet presents also a large vegetation.” Cardiothoracic surgery was performed and a biologic aortic valve prosthesis perimount magna 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.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">4,5</a>. The MIC for different antibiotics in this case were: ceftriaxone 0.25μg/mL; penicillin 0.064μg/mL; ampicillin 0.064μg/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">3</a>. In this case, despite good clinical response to antibiotic therapy, fever persisted, valve destruction occurred and surgical replacement was still required.Infective endocarditis by Abiotrofia defectiva accounts for less than 1% of all endocarditis. A. defectiva is a recent but known cause of infective endocarditis, associated to a high mortality and complication rate<a class="elsevierStyleCrossRef" href="#bib0035">2</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." "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 Abiotrophia defectiva" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "B. Ilkay" 1 => "C. Metin" 2 => "B.C. Idris" 3 => "G. Okan" 4 => "T. Esra" 5 => "L. 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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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