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Endocarditis due to Listeria: Description of two cases and review of the literature
European Journal of Internal Medicine 19 (2008) 295 – 296 www.elsevier.com/locate/ejim
Brief report
Endocarditis due to Listeria: Description of two cases and review of the literature J. Antolín ⁎, A. Gutierrez, R. Segoviano, R. López, R. Ciguenza I Internal Medicine Service. Hospital Clínico Universitario San Carlos, Madrid, Spain, C/ Prof. Martín Lagos s/n, 28040 Madrid, Spain Received 27 January 2007; received in revised form 13 May 2007; accepted 29 June 2007 Available online 30 January 2008
Abstract Endocarditis due to Listeria monocytogenes is a very uncommon and very serious disease that may lead to valve dysfunction and cardiac arrest. We report two cases of endocarditis caused by L. monocytogenes and review the papers previously published on the subject. © 2007 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. Keywords: Endocarditis; Listeria; Prosthetic valves
1. Introduction Listeria monocytogenes is a gram-positive aerobic coccobacillus that is able to cause sepsis, meningo-encephalitis, and many focal infections. The disease has high morbidity and mortality rates [1,2]. Endocarditis is a rare complication of bacteremia due to Listeria that has not been reported in recent studies on listeriosis in adults [3,4]. Yet, isolated cases of endocarditis in native and prosthetic valves have been reported – 68 in all – of which only 23 were in patients with prosthetic valves. Five of them were detected in Spain [4,5]. A search was made on Medline using the terms: “bacteremia due to Listeria”; “endocarditis due to Listeria”, and “endocarditis of prosthetic valves by Listeria”. 2. Case reports 2.1. Case 1 The patient was an 80-year-old woman who was admitted to the hospital for hyponatremia, anemia, and deterioration of ⁎ Corresponding author. Hospital Clínico Universitario San Carlos, C/ Prof. Martín Lagos s/n, E-28040 Madrid, Spain. E-mail address: [email protected] (J. Antolín).
higher functions. Biological prostheses had been fitted in the mitral and aortic valves 2 years earlier. One year prior to the year in which she was treated, she had meningitis due to L. monocytogenes. Physical examination revealed a panfocal systolic murmur, as well as cerebrospinal fluid 34 cells, 66% mononuclear and glucose 65 with a negative culture. Blood cultures revealed L. monocytogenes in two cultures that was sensitive to ampicillin, vancomycin, gentamicin, and trimethoprim. A transesophageal echocardiogram showed normal functioning of the biological mitral prosthesis. Several groups of mobile vegetations were observed on the ring of the valve, distributed throughout; the largest was 14 mm and was highly mobile. A thickening of the lateral mitral membrane was observed without the clear presence of mobile growths in it. The biological aortic prosthesis was functioning normally. The left auricle was normal. CSF cultures were negative. With regard to evolution, the patient presented with a slight fever, anemia, hyponatremia, and deterioration of the higher functions. These findings were compatible with endocarditis due to L. monocytogenes and meningeal affectation, both probably of the same etiology. After antibiotic treatment with ampicillin and gentamicin, the blood cultures were negative.
0953-6205/$ - see front matter © 2007 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.ejim.2007.06.020
296
J. Antolín et al. / European Journal of Internal Medicine 19 (2008) 295–296
2.2. Case 2 This case involved a 73-year-old diabetic woman with a metallic prosthetic mitral valve who had been in the intensive care unit because of an acute coronary syndrome that had developed a few months earlier. She presented with a 2month history of high fever and constitutional syndrome with no other symptoms. Physical examination showed only a systolic mitral murmur and 2-cm hepatomegaly. Blood tests revealed a normochromic normocytic anemia, with normal white blood cells and platelets, and schistocytosis in the peripheral blood (suggestive of hemolytic anemia). Her transaminases, alkaline phosphatase, and LDH levels were slightly increased, with a normal serum iron concentration, transferrin saturation, and iron stores. Serological tests and first blood and urine cultures were negative. An abdominal ultrasound study, CT scan (thorax and abdomen), colonoscopy, and initial transesophageal echocardiography failed to shed light on the cause of the fever, which recurred while the patient was in the hospital. High temperatures alternated with afebrile periods despite empirical antibiotic treatment. The last blood culture was positive for Stenotrophomona maltophilia and L. monocytogenes. The decision was made to perform transesophageal echocardiography a second time and the results suggested prosthetic valve endocarditis with important valve dysfunction. Accordingly, after therapy with trimethoprim–sulfamethoxazole and aminoglycoside antibiotics, surgical treatment for valve replacement was recommended.
fallen to 12% since then, probably because of an increase in indications for surgery and the improved results of it. Fortyone patients only received antibiotics and 18 received antibiotics plus valve replacement; of these, 16 (39%) and 4 (22%), respectively, died. Of the 23 patients with L. monocytogenes prosthetic valve endocarditis described in the literature, 16 (69%) had a valve dysfunction and 15 (65%) had heart failure. Four of the 23 patients (17%) died in the hospital [1–6]. The antibiotic treatment of choice was ampicillin plus gentamicin, or vancomycin plus gentamicin as an alternative. Fifty percent of the patients required valve replacement owing to valve insufficiency with heart failure, large vegetations, or local complications. Mortality is not as high as first thought; in recent decades, it has decreased appreciably and is lower than in other cases of endocarditis involving prostheses, whose mean mortality is 25% [1–6]. 4. Learning points • Endocarditis due to L. monocytogenes is a rare and severe disease that often causes valve dysfunction and heart failure. • Treatment with penicillin or ampicillin plus gentamicin seems to be the most effective, but vancomycin plus gentamicin may offer a good alternative treatment. • Antibiotic treatment alone may be efficient, even in cases of endocarditis on prosthetic valves. Valve replacement should be reserved for complications with valve dehiscence, heart failure, or myocardial abscess. • Mortality has fallen considerably in recent decades.
3. Discussion References Since it was first described in 1955, 68 cases of endocarditis due to L. monocytogenes have been published [1–6]. Sixty percent of the patients had some type of valve alteration and 23 (33%) had a prosthetic valve; this percentage was 18% in 1955–1984 and 53% in 1985–2000. Rheumatic valve disease, hypertrophic myocardiopathy, mitral valve prolapse, and ischemia were other alterations predisposing patients to L. monocytogenes endocarditis [1–6]. Meningitis, a frequent manifestation in listeriosis, is very rare in patients with L. monocytogenes endocarditis. L. monocytogenes is sensitive to penicillin, vancomycin, trimethoprim–sulfamethoxazole, and some quinolones. Penicillin and ampicillin are the drugs most frequently used, although their action against L. monocytogenes is not completely bactericidal. The combination of penicillin and gentamicin has a synergic activity in vitro and in vivo and has thus been considered the treatment of choice. Twenty-four (35%) of the patients with L. monocytogenes endocarditis died, most of them before 1985; mortality has
[1] Goulet V, Marchetti P. Listeriosis in 225 non-pregnant patients in 1992: Clinical aspects and outcome in relation to predisposing conditions. Scand J Infec Dis 1996;28:367–74. [2] Julián A, Jiménez A, Górgolas M, Fernández Roblas R, Fernández Guerrero ML. Infecciones por Listeria monocytogenes en el adulto. Aspectos clínicos y microbiológicos de una enfermedad cambiante. Enferm Infecc Microbiol Clin 2001;19:297–303. [3] Spyrou N, Anderson M, Foale R. Listeria endocarditis: current management and patient outcome world literature review. Heart 1997;77:380–3. [4] Fernandez-Guerrero ML, Rivas P, Rábago R, Núñez A, Gárgolas M, Martinell J. Prosthetic valve endocarditis due to Listeria monocytogenes. Report of two cases and reviews. Int J Infect Dis 2004;8:97–102. [5] De Miguel-Yanes JM, González-Ramallo VJ, Pastor L. Outcome of Listeria monocytogenes prosthetic valve endocarditis: As bad as it looks? Scand J Infect Dis 2004;36:709–11. [6] Akowuah EF, Davies W, Oliver S, Stephens J, Riaz I, Zadik P, et al. Prosthetic valve endocarditis: early and late outcome following medical or surgical treatment. Heart 2003;89:269–72.
Brief report
Endocarditis due to Listeria: Description of two cases and review of the literature J. Antolín ⁎, A. Gutierrez, R. Segoviano, R. López, R. Ciguenza I Internal Medicine Service. Hospital Clínico Universitario San Carlos, Madrid, Spain, C/ Prof. Martín Lagos s/n, 28040 Madrid, Spain Received 27 January 2007; received in revised form 13 May 2007; accepted 29 June 2007 Available online 30 January 2008
Abstract Endocarditis due to Listeria monocytogenes is a very uncommon and very serious disease that may lead to valve dysfunction and cardiac arrest. We report two cases of endocarditis caused by L. monocytogenes and review the papers previously published on the subject. © 2007 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. Keywords: Endocarditis; Listeria; Prosthetic valves
1. Introduction Listeria monocytogenes is a gram-positive aerobic coccobacillus that is able to cause sepsis, meningo-encephalitis, and many focal infections. The disease has high morbidity and mortality rates [1,2]. Endocarditis is a rare complication of bacteremia due to Listeria that has not been reported in recent studies on listeriosis in adults [3,4]. Yet, isolated cases of endocarditis in native and prosthetic valves have been reported – 68 in all – of which only 23 were in patients with prosthetic valves. Five of them were detected in Spain [4,5]. A search was made on Medline using the terms: “bacteremia due to Listeria”; “endocarditis due to Listeria”, and “endocarditis of prosthetic valves by Listeria”. 2. Case reports 2.1. Case 1 The patient was an 80-year-old woman who was admitted to the hospital for hyponatremia, anemia, and deterioration of ⁎ Corresponding author. Hospital Clínico Universitario San Carlos, C/ Prof. Martín Lagos s/n, E-28040 Madrid, Spain. E-mail address: [email protected] (J. Antolín).
higher functions. Biological prostheses had been fitted in the mitral and aortic valves 2 years earlier. One year prior to the year in which she was treated, she had meningitis due to L. monocytogenes. Physical examination revealed a panfocal systolic murmur, as well as cerebrospinal fluid 34 cells, 66% mononuclear and glucose 65 with a negative culture. Blood cultures revealed L. monocytogenes in two cultures that was sensitive to ampicillin, vancomycin, gentamicin, and trimethoprim. A transesophageal echocardiogram showed normal functioning of the biological mitral prosthesis. Several groups of mobile vegetations were observed on the ring of the valve, distributed throughout; the largest was 14 mm and was highly mobile. A thickening of the lateral mitral membrane was observed without the clear presence of mobile growths in it. The biological aortic prosthesis was functioning normally. The left auricle was normal. CSF cultures were negative. With regard to evolution, the patient presented with a slight fever, anemia, hyponatremia, and deterioration of the higher functions. These findings were compatible with endocarditis due to L. monocytogenes and meningeal affectation, both probably of the same etiology. After antibiotic treatment with ampicillin and gentamicin, the blood cultures were negative.
0953-6205/$ - see front matter © 2007 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.ejim.2007.06.020
296
J. Antolín et al. / European Journal of Internal Medicine 19 (2008) 295–296
2.2. Case 2 This case involved a 73-year-old diabetic woman with a metallic prosthetic mitral valve who had been in the intensive care unit because of an acute coronary syndrome that had developed a few months earlier. She presented with a 2month history of high fever and constitutional syndrome with no other symptoms. Physical examination showed only a systolic mitral murmur and 2-cm hepatomegaly. Blood tests revealed a normochromic normocytic anemia, with normal white blood cells and platelets, and schistocytosis in the peripheral blood (suggestive of hemolytic anemia). Her transaminases, alkaline phosphatase, and LDH levels were slightly increased, with a normal serum iron concentration, transferrin saturation, and iron stores. Serological tests and first blood and urine cultures were negative. An abdominal ultrasound study, CT scan (thorax and abdomen), colonoscopy, and initial transesophageal echocardiography failed to shed light on the cause of the fever, which recurred while the patient was in the hospital. High temperatures alternated with afebrile periods despite empirical antibiotic treatment. The last blood culture was positive for Stenotrophomona maltophilia and L. monocytogenes. The decision was made to perform transesophageal echocardiography a second time and the results suggested prosthetic valve endocarditis with important valve dysfunction. Accordingly, after therapy with trimethoprim–sulfamethoxazole and aminoglycoside antibiotics, surgical treatment for valve replacement was recommended.
fallen to 12% since then, probably because of an increase in indications for surgery and the improved results of it. Fortyone patients only received antibiotics and 18 received antibiotics plus valve replacement; of these, 16 (39%) and 4 (22%), respectively, died. Of the 23 patients with L. monocytogenes prosthetic valve endocarditis described in the literature, 16 (69%) had a valve dysfunction and 15 (65%) had heart failure. Four of the 23 patients (17%) died in the hospital [1–6]. The antibiotic treatment of choice was ampicillin plus gentamicin, or vancomycin plus gentamicin as an alternative. Fifty percent of the patients required valve replacement owing to valve insufficiency with heart failure, large vegetations, or local complications. Mortality is not as high as first thought; in recent decades, it has decreased appreciably and is lower than in other cases of endocarditis involving prostheses, whose mean mortality is 25% [1–6]. 4. Learning points • Endocarditis due to L. monocytogenes is a rare and severe disease that often causes valve dysfunction and heart failure. • Treatment with penicillin or ampicillin plus gentamicin seems to be the most effective, but vancomycin plus gentamicin may offer a good alternative treatment. • Antibiotic treatment alone may be efficient, even in cases of endocarditis on prosthetic valves. Valve replacement should be reserved for complications with valve dehiscence, heart failure, or myocardial abscess. • Mortality has fallen considerably in recent decades.
3. Discussion References Since it was first described in 1955, 68 cases of endocarditis due to L. monocytogenes have been published [1–6]. Sixty percent of the patients had some type of valve alteration and 23 (33%) had a prosthetic valve; this percentage was 18% in 1955–1984 and 53% in 1985–2000. Rheumatic valve disease, hypertrophic myocardiopathy, mitral valve prolapse, and ischemia were other alterations predisposing patients to L. monocytogenes endocarditis [1–6]. Meningitis, a frequent manifestation in listeriosis, is very rare in patients with L. monocytogenes endocarditis. L. monocytogenes is sensitive to penicillin, vancomycin, trimethoprim–sulfamethoxazole, and some quinolones. Penicillin and ampicillin are the drugs most frequently used, although their action against L. monocytogenes is not completely bactericidal. The combination of penicillin and gentamicin has a synergic activity in vitro and in vivo and has thus been considered the treatment of choice. Twenty-four (35%) of the patients with L. monocytogenes endocarditis died, most of them before 1985; mortality has
[1] Goulet V, Marchetti P. Listeriosis in 225 non-pregnant patients in 1992: Clinical aspects and outcome in relation to predisposing conditions. Scand J Infec Dis 1996;28:367–74. [2] Julián A, Jiménez A, Górgolas M, Fernández Roblas R, Fernández Guerrero ML. Infecciones por Listeria monocytogenes en el adulto. Aspectos clínicos y microbiológicos de una enfermedad cambiante. Enferm Infecc Microbiol Clin 2001;19:297–303. [3] Spyrou N, Anderson M, Foale R. Listeria endocarditis: current management and patient outcome world literature review. Heart 1997;77:380–3. [4] Fernandez-Guerrero ML, Rivas P, Rábago R, Núñez A, Gárgolas M, Martinell J. Prosthetic valve endocarditis due to Listeria monocytogenes. Report of two cases and reviews. Int J Infect Dis 2004;8:97–102. [5] De Miguel-Yanes JM, González-Ramallo VJ, Pastor L. Outcome of Listeria monocytogenes prosthetic valve endocarditis: As bad as it looks? Scand J Infect Dis 2004;36:709–11. [6] Akowuah EF, Davies W, Oliver S, Stephens J, Riaz I, Zadik P, et al. Prosthetic valve endocarditis: early and late outcome following medical or surgical treatment. Heart 2003;89:269–72.