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Group B streptococcal tricuspid valve endocarditis:
International Journal of Cardiology 64 (1998) 259–263
Group B streptococcal tricuspid valve endocarditis: A case report and review of literature a, a a a b a Z.S. Azzam *, Y. Ron , I. Oren , W. Sbeit , D. Motlak , N. Krivoy a
Department of Medicine ‘‘ A’’, Rambam Medical Center and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel b Unit of Noninvasive Cardiology, Rambam Medical Center and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel Received 13 August 1997; accepted 10 February 1998
Abstract Group B streptococcal endocarditis involving the tricuspid valve is an uncommon disease. We describe herein a young healthy woman who developed this disease following an elective abortion. She was treated with penicillin and gentamycin with no response. The patient was operated urgently and recovered. Few reports have described the disease in the last 25 years (our case is the thirteenth). Five of them were IV drug abusers, four patients suffered from debilitating diseases and in five women endocarditis developed following an obstetric procedure. In general the mortality from tricuspid valve endocarditis is low, indeed 2 / 13 (15%) died. The drug of choice is penicillin with gentamycin. 1998 Elsevier Science Ireland Ltd Keywords: Group B streptococcal infection; Infective endocarditis; Tricuspid valve; Abortion
1. Introduction Streptococcus agalactiae (group B streptococcus) was first identified as the major cause of bovine endocarditis [1]. Later on it was reported to be the pathogen in human beings especially causing bacteremia and meningitis in the neonates [2]. Group B streptococcal infection has been considered unusual in adults and it is recognized in debilitated patients with diabetes mellitus, alcoholism and malignancies [3]. However, recently its incidence is rising consistently in adult ˜ nonpregnant patients, Munoz and colleagues [4]
*Corresponding author.
reported that the incidence of group B streptococcal bacteremia rose from 0.08 per 1000 admissions in 1985 to 0.3 per 1000 in 1994. The majority had an underlying disease, however in their series there was only one patient with endocarditis. Group B streptococcal endocarditis is an uncommon disease involving mitral and aortic valves and rarely tricuspid valve [5]. We herein describe a patient with tricuspid valve endocarditis due to group B streptococci and review the literature.
2. Case report A 33-year-old woman was admitted with fever, chills, fatigue and malaise of 4 weeks duration. These
0167-5273 / 98 / $19.00 1998 Elsevier Science Ireland Ltd All rights reserved. PII S0167-5273( 98 )00052-7
260
Z.S. Azzam et al. / International Journal of Cardiology 64 (1998) 259 – 263
symptoms appeared 2 days after a therapeutic abortion which was performed because of fetal death during the fifth month of pregnancy. The patient denied drug abuse. The physical examination revealed a patient in mild respiratory distress. Her temperature was 408C, tachycardia 110 per min, blood pressure was 110 / 70 mmHg. There was a mild jugular distention with hepatojugular reflux. Her lungs were clear to auscultation. Cardiac examination revealed a blowing systolic murmur at the apex and lower left sternal border. Her liver was mildly enlarged, tender and pulsatile. The ECG recording revealed sinus tachycardia. The chest X-ray showed mild enlargement of the cardiac silhouette. On transthoracic and transesophageal echocardiography a large vegetation attached to the anterior tricuspid valve leaflet with a severe regurgitation was found (Figs. 1 and 2). Laboratory studies revealed leukocytosis of 16 700 per mm 3 , hemoglobin of 7.9 g / dl and erythrocyte sedimentation rate of 60 mm / h. A diagnosis of right sided endocarditis was made and blood cultures were obtained. A staphylococcal infection was suspected and a treatment with vancomycin and gentamycin was begun. Meanwhile cultures of five blood samples yielded
group B streptococci. Vancomycin was stopped and penicillin was started. On the fourth hospital day the patient complained of pleuritic chest pain and dyspnea. Arterial blood gases were normal. A pulmonary ventilation–perfusion scan revealed several matched perfusion and ventilation defects. A gallium scan was consistent with lung abscesses secondary to septic pulmonary emboli. During the first two weeks, her temperature was low-grade. Recurrent blood cultures were negative. On the fourteenth hospital day, the patient developed a fever of 39.48C with chills. A recurrent transesophageal echocardiogram showed a further growth of the vegetation on the tricuspid valve with formation of an abscess. The right chambers were enlarged compared to the previous examination. The patient underwent surgery. Several large vegetations were attached to the tricuspid valve with valve destruction. Gram stain revealed many polymorphonuclear leukocytes with organisms. The valve was excised and replaced by a bioprosthesis. The postoperative course was uneventful. Six weeks of antibiotic therapy were completed, fever gradually resolved and at the time of follow-up the patient was doing well.
Fig. 1. Echocardiographic transesophageal image. Elongated mobile vegetation attached to the tricuspid annulus is presented. Abbreviations: LV – left ventricle, RA – right atricum, RV – right ventricle, Veg – vegetation.
Z.S. Azzam et al. / International Journal of Cardiology 64 (1998) 259 – 263
261
Fig. 2. Repeat echocardiographic transesophageal study 5 days later. Marked increase in vegetation size is noted.
3. Discussion Group B streptococcal infections are well established as a cause of sepsis and meningitis in the neonate. Adult group B streptococcal infections are less known [6]. Recently the incidence is increasing, however endocarditis is still uncommon, it is present in 2 to 9% of infections with group B streptococci [7,4]. In one series the mitral and aortic valves were involved in 48 and 29%, respectively, the patients were old and had underlying diseases mostly rheumatic heart disease [3]. Conditions that impair polymorphonuclear function such as diabetes mellitus, pregnancy, alcohol and drug abuse are known to precipitate group B streptococcal endocarditis [3,8]. It is thought that the major virulence factor is the antiphagocytic polysaccharide capsule [9]. The involvement of the tricuspid valve is common in intravenous drug abusers, staphylococcus aureus is the most common organism causing right sided endocarditis in this population of patients [10]. Group B streptococcus is a rare cause of tricuspid endocarditis and involves both drug addicts and patients without a history of drug abuse, those usually suffer from an underlying disease such as malignancy, alcoholism and diabetes [11].
The incidence of infective endocarditis after obstetric and gynaecological procedures is low, ranging between 0.03 to 0.14 per 1000 deliveries [12]. The incidence is especially lower after abortions, it is estimated to be approximately one per million abortions [13]. Seaworth and colleagues reviewed the English literature and selected European papers from the last 40 years and found 124 cases of endocarditis in the gynaecological and obstetric practice. Seven patients had group B streptococcal endocarditis. The tricuspid valve was involved in 32 women and 25 cases occured following abortions [14]. Group B streptococcal endocarditis involving the tricuspid valve has been reported in 12 patients [11,15,16], our patient is the thirteenth to be described (Table 1). Five of them were IV drug abusers, four patients suffered from a debilitating diseases and in five women endocarditis developed following an obstetric procedure. The drug of choice in the treatment of group B streptococcal endocarditis is penicillin combined with aminoglycoside [17], valve surgery was performed in five patients, the indication for surgery is less established than in left sided group B streptococci endocarditis where early operation is recommended [5,11,14]. In our patient the valve was
Z.S. Azzam et al. / International Journal of Cardiology 64 (1998) 259 – 263
262
Table 1 Reported group B streptococcal endocarditis involving the tricuspid valve Case No. (Reference)
Age
Sex
Presentation
Underlying disease / condition
Intravenous drug abuse
Pulmonary emboli
Surgery
Outcome
1 [19]
24
F
Acute
Cesarean section
No
Yes
Yes
Recovery
2 3 4 5 6
[20] [15] [16] [5] [18]
19 18 30 35 65
F F F M F
Subacute Acute Subacute Acute Acute
Abortion Abortion Abortion None Alcoholism, breast cancer
Yes No No Yes No
Yes Yes Yes Yes Yes
Yes No Yes No Yes
Recovery Recovery Recovery Recovery Recovery
7 [18] 8 [18] 9 [18] 10 [11] 11 [11] 12 [11] 13 a
32 56 54 22 13 32 33
F M M F F F F
Subacute Acute Acute Acute Acute Acute Acute
None Diabetes Mellitus Alcoholism, None None None Abortion
Yes No No Yes No Yes No
Yes Yes Yes Yes No Yes Yes
No No No No No No Yes
Recovery Death Recovery Death Recovery Recovery Recovery
a
Index case.
excised and replaced because of ongoing infection despite antibiotic therapy, right ventricular failure and destruction of the valve with abscess formation and worsening of the tricuspid regurgitation. In general the mortality in tricuspid valve endocarditis is low, indeed 2 / 13 (15%) died. On the contrary, the mortality in left sided group B streptococcal endocarditis is higher at 45% [5,18], those patients were old with acute symptoms and underlying diseases. Our patient’s relatively complicated course is most probably due to a late presentation, after four weeks of ongoing infection, which caused valvular damage and formation of lung abscesses. In summary, group B streptococcal endocarditis is an unusual entity that affects both IV drug abusers and those who do not have a history of drug abuse. It can damage normally native valves and is more prevalent in patients with underlying diseases. The treatment of choice is penicillin with gentamycin.
References [1] Pringle SD, McCartney AC, Marshel DA, Cobbe SM. Infective endocarditis caused by streptococcus agalactiae. Intl J Cardiol 1989;24:179–83. [2] Grossman J, Tomkins RL. Group B beta haemolytic streptococcal meningitis in mother and infant. N Engl J Med 1974;29:387.
[3] Gallagher PG, Watankunakorn C. Group B streptococcal bacteremia in a community teaching hospital. Am J Med 1985;78:795–800. ˜ P, Llancaqueo A, Eodriguez-Creixems ´ ´ T, Martin [4] Munoz M, Pelaez L, Bouza E. Group B streptococcus bacteremia in nonpregnant adults. Arch Intern Med 1997;157:213–6. [5] Gallagher PG, Watankunakorn C. Group B streptococcal endocarditis: Report of seven cases and review of the literature 1962– 1985. Rev Infect Dis 1986;8:175–88. [6] Bayer A, Chow A, Anthony B, Guze L. Serious infections in adults due to group B streptococci. Am J Med 1976;61:498–503. [7] Schwartz B, Schuchat A, Oxtoby MJ, Cochi S, Hightower A, Broome CV. Invasive group B streptococcal disease in adults. A population-based study in Metropolian Atlanta. JAMA 1991;266:1112–4. [8] Farley MM, Harvey RC, Stull T et al. A population-based assessment of invasive disease due to group B streptococcus in nonpregnant adults. N Engl J Med 1993;328:1807–11. [9] Hakansson SL, Bergholm AM, Holm SE, Wagner B, Wagner M. Properties of high and low density subpopulations of group B streptococci: enhanced virulence of low density variant. Microb Pathog 1988;5:345–55. [10] Derssler FA, Roberts WC. Infective endocarditis in opiate addicts: analysis of 80 cases studied at necropsy. Am J Cardiol 1989;63:1240–57. [11] Watankunakorn C, Habte-Gaber Y. Group B streptococcal endocarditis of tricuspid valve. Chest 1991;100:569–71. [12] Ward H, Hickman RC. Bacterial endocarditis in pregnancy. Aust NZ Obstet Gynaecol 1971;11:189–91. [13] Henshaw S, Forrest JD, Sullivan E, Tietze C. Abortion in the United States, 1978–1979. Fam Plan Perspect 1981;13:6–7. [14] Seaworth BJ, Durack DT. Infective endocarditis in obstetric and gynecologic practice. Am J Obsetet Gynecol 1986;154:180–8. [15] Atri ML, Cohen DH. Group B streptococcus endocarditis following second-trimester abortion. Arch Intern Med 1990;150:2579–80. [16] Vartian CV, Septimus EJ. Tricuspid valve Group B streptococcal endocarditis following elective abortion. Rev Infect Dis 1991;13:997–8.
Z.S. Azzam et al. / International Journal of Cardiology 64 (1998) 259 – 263 [17] Wilson WR, Karchmer AW, Dajani AS et al. Antibiotic treatment of adults with infective endocarditis due to streptococci, enterococci, staphylococci and HACEK microorganisms. JAMA 1995;274:1706– 13. [18] Scully BE, Spriggs D, Neu HC. Streptococcus agalactiae (group B) endocarditis: a discription of 12 cases and review of the literature. Infection 1987;15:175–88.
263
[19] Acar J, Antebi L, Cabrol C, Vilde J-L, Morin B, Damelon F et al. Endocardite aigue tricuspidinne post partum a streptocogue du groupe B; post dune valve de starr. Ann Med Intern 1972;123:217– 24. [20] Jemsek JG, Gentry LO, Greenberg SB. Malignant group B streptococcal endocarditis associated with saline-induced abortion. Chest 1979;76:695–7.
Group B streptococcal tricuspid valve endocarditis: A case report and review of literature a, a a a b a Z.S. Azzam *, Y. Ron , I. Oren , W. Sbeit , D. Motlak , N. Krivoy a
Department of Medicine ‘‘ A’’, Rambam Medical Center and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel b Unit of Noninvasive Cardiology, Rambam Medical Center and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel Received 13 August 1997; accepted 10 February 1998
Abstract Group B streptococcal endocarditis involving the tricuspid valve is an uncommon disease. We describe herein a young healthy woman who developed this disease following an elective abortion. She was treated with penicillin and gentamycin with no response. The patient was operated urgently and recovered. Few reports have described the disease in the last 25 years (our case is the thirteenth). Five of them were IV drug abusers, four patients suffered from debilitating diseases and in five women endocarditis developed following an obstetric procedure. In general the mortality from tricuspid valve endocarditis is low, indeed 2 / 13 (15%) died. The drug of choice is penicillin with gentamycin. 1998 Elsevier Science Ireland Ltd Keywords: Group B streptococcal infection; Infective endocarditis; Tricuspid valve; Abortion
1. Introduction Streptococcus agalactiae (group B streptococcus) was first identified as the major cause of bovine endocarditis [1]. Later on it was reported to be the pathogen in human beings especially causing bacteremia and meningitis in the neonates [2]. Group B streptococcal infection has been considered unusual in adults and it is recognized in debilitated patients with diabetes mellitus, alcoholism and malignancies [3]. However, recently its incidence is rising consistently in adult ˜ nonpregnant patients, Munoz and colleagues [4]
*Corresponding author.
reported that the incidence of group B streptococcal bacteremia rose from 0.08 per 1000 admissions in 1985 to 0.3 per 1000 in 1994. The majority had an underlying disease, however in their series there was only one patient with endocarditis. Group B streptococcal endocarditis is an uncommon disease involving mitral and aortic valves and rarely tricuspid valve [5]. We herein describe a patient with tricuspid valve endocarditis due to group B streptococci and review the literature.
2. Case report A 33-year-old woman was admitted with fever, chills, fatigue and malaise of 4 weeks duration. These
0167-5273 / 98 / $19.00 1998 Elsevier Science Ireland Ltd All rights reserved. PII S0167-5273( 98 )00052-7
260
Z.S. Azzam et al. / International Journal of Cardiology 64 (1998) 259 – 263
symptoms appeared 2 days after a therapeutic abortion which was performed because of fetal death during the fifth month of pregnancy. The patient denied drug abuse. The physical examination revealed a patient in mild respiratory distress. Her temperature was 408C, tachycardia 110 per min, blood pressure was 110 / 70 mmHg. There was a mild jugular distention with hepatojugular reflux. Her lungs were clear to auscultation. Cardiac examination revealed a blowing systolic murmur at the apex and lower left sternal border. Her liver was mildly enlarged, tender and pulsatile. The ECG recording revealed sinus tachycardia. The chest X-ray showed mild enlargement of the cardiac silhouette. On transthoracic and transesophageal echocardiography a large vegetation attached to the anterior tricuspid valve leaflet with a severe regurgitation was found (Figs. 1 and 2). Laboratory studies revealed leukocytosis of 16 700 per mm 3 , hemoglobin of 7.9 g / dl and erythrocyte sedimentation rate of 60 mm / h. A diagnosis of right sided endocarditis was made and blood cultures were obtained. A staphylococcal infection was suspected and a treatment with vancomycin and gentamycin was begun. Meanwhile cultures of five blood samples yielded
group B streptococci. Vancomycin was stopped and penicillin was started. On the fourth hospital day the patient complained of pleuritic chest pain and dyspnea. Arterial blood gases were normal. A pulmonary ventilation–perfusion scan revealed several matched perfusion and ventilation defects. A gallium scan was consistent with lung abscesses secondary to septic pulmonary emboli. During the first two weeks, her temperature was low-grade. Recurrent blood cultures were negative. On the fourteenth hospital day, the patient developed a fever of 39.48C with chills. A recurrent transesophageal echocardiogram showed a further growth of the vegetation on the tricuspid valve with formation of an abscess. The right chambers were enlarged compared to the previous examination. The patient underwent surgery. Several large vegetations were attached to the tricuspid valve with valve destruction. Gram stain revealed many polymorphonuclear leukocytes with organisms. The valve was excised and replaced by a bioprosthesis. The postoperative course was uneventful. Six weeks of antibiotic therapy were completed, fever gradually resolved and at the time of follow-up the patient was doing well.
Fig. 1. Echocardiographic transesophageal image. Elongated mobile vegetation attached to the tricuspid annulus is presented. Abbreviations: LV – left ventricle, RA – right atricum, RV – right ventricle, Veg – vegetation.
Z.S. Azzam et al. / International Journal of Cardiology 64 (1998) 259 – 263
261
Fig. 2. Repeat echocardiographic transesophageal study 5 days later. Marked increase in vegetation size is noted.
3. Discussion Group B streptococcal infections are well established as a cause of sepsis and meningitis in the neonate. Adult group B streptococcal infections are less known [6]. Recently the incidence is increasing, however endocarditis is still uncommon, it is present in 2 to 9% of infections with group B streptococci [7,4]. In one series the mitral and aortic valves were involved in 48 and 29%, respectively, the patients were old and had underlying diseases mostly rheumatic heart disease [3]. Conditions that impair polymorphonuclear function such as diabetes mellitus, pregnancy, alcohol and drug abuse are known to precipitate group B streptococcal endocarditis [3,8]. It is thought that the major virulence factor is the antiphagocytic polysaccharide capsule [9]. The involvement of the tricuspid valve is common in intravenous drug abusers, staphylococcus aureus is the most common organism causing right sided endocarditis in this population of patients [10]. Group B streptococcus is a rare cause of tricuspid endocarditis and involves both drug addicts and patients without a history of drug abuse, those usually suffer from an underlying disease such as malignancy, alcoholism and diabetes [11].
The incidence of infective endocarditis after obstetric and gynaecological procedures is low, ranging between 0.03 to 0.14 per 1000 deliveries [12]. The incidence is especially lower after abortions, it is estimated to be approximately one per million abortions [13]. Seaworth and colleagues reviewed the English literature and selected European papers from the last 40 years and found 124 cases of endocarditis in the gynaecological and obstetric practice. Seven patients had group B streptococcal endocarditis. The tricuspid valve was involved in 32 women and 25 cases occured following abortions [14]. Group B streptococcal endocarditis involving the tricuspid valve has been reported in 12 patients [11,15,16], our patient is the thirteenth to be described (Table 1). Five of them were IV drug abusers, four patients suffered from a debilitating diseases and in five women endocarditis developed following an obstetric procedure. The drug of choice in the treatment of group B streptococcal endocarditis is penicillin combined with aminoglycoside [17], valve surgery was performed in five patients, the indication for surgery is less established than in left sided group B streptococci endocarditis where early operation is recommended [5,11,14]. In our patient the valve was
Z.S. Azzam et al. / International Journal of Cardiology 64 (1998) 259 – 263
262
Table 1 Reported group B streptococcal endocarditis involving the tricuspid valve Case No. (Reference)
Age
Sex
Presentation
Underlying disease / condition
Intravenous drug abuse
Pulmonary emboli
Surgery
Outcome
1 [19]
24
F
Acute
Cesarean section
No
Yes
Yes
Recovery
2 3 4 5 6
[20] [15] [16] [5] [18]
19 18 30 35 65
F F F M F
Subacute Acute Subacute Acute Acute
Abortion Abortion Abortion None Alcoholism, breast cancer
Yes No No Yes No
Yes Yes Yes Yes Yes
Yes No Yes No Yes
Recovery Recovery Recovery Recovery Recovery
7 [18] 8 [18] 9 [18] 10 [11] 11 [11] 12 [11] 13 a
32 56 54 22 13 32 33
F M M F F F F
Subacute Acute Acute Acute Acute Acute Acute
None Diabetes Mellitus Alcoholism, None None None Abortion
Yes No No Yes No Yes No
Yes Yes Yes Yes No Yes Yes
No No No No No No Yes
Recovery Death Recovery Death Recovery Recovery Recovery
a
Index case.
excised and replaced because of ongoing infection despite antibiotic therapy, right ventricular failure and destruction of the valve with abscess formation and worsening of the tricuspid regurgitation. In general the mortality in tricuspid valve endocarditis is low, indeed 2 / 13 (15%) died. On the contrary, the mortality in left sided group B streptococcal endocarditis is higher at 45% [5,18], those patients were old with acute symptoms and underlying diseases. Our patient’s relatively complicated course is most probably due to a late presentation, after four weeks of ongoing infection, which caused valvular damage and formation of lung abscesses. In summary, group B streptococcal endocarditis is an unusual entity that affects both IV drug abusers and those who do not have a history of drug abuse. It can damage normally native valves and is more prevalent in patients with underlying diseases. The treatment of choice is penicillin with gentamycin.
References [1] Pringle SD, McCartney AC, Marshel DA, Cobbe SM. Infective endocarditis caused by streptococcus agalactiae. Intl J Cardiol 1989;24:179–83. [2] Grossman J, Tomkins RL. Group B beta haemolytic streptococcal meningitis in mother and infant. N Engl J Med 1974;29:387.
[3] Gallagher PG, Watankunakorn C. Group B streptococcal bacteremia in a community teaching hospital. Am J Med 1985;78:795–800. ˜ P, Llancaqueo A, Eodriguez-Creixems ´ ´ T, Martin [4] Munoz M, Pelaez L, Bouza E. Group B streptococcus bacteremia in nonpregnant adults. Arch Intern Med 1997;157:213–6. [5] Gallagher PG, Watankunakorn C. Group B streptococcal endocarditis: Report of seven cases and review of the literature 1962– 1985. Rev Infect Dis 1986;8:175–88. [6] Bayer A, Chow A, Anthony B, Guze L. Serious infections in adults due to group B streptococci. Am J Med 1976;61:498–503. [7] Schwartz B, Schuchat A, Oxtoby MJ, Cochi S, Hightower A, Broome CV. Invasive group B streptococcal disease in adults. A population-based study in Metropolian Atlanta. JAMA 1991;266:1112–4. [8] Farley MM, Harvey RC, Stull T et al. A population-based assessment of invasive disease due to group B streptococcus in nonpregnant adults. N Engl J Med 1993;328:1807–11. [9] Hakansson SL, Bergholm AM, Holm SE, Wagner B, Wagner M. Properties of high and low density subpopulations of group B streptococci: enhanced virulence of low density variant. Microb Pathog 1988;5:345–55. [10] Derssler FA, Roberts WC. Infective endocarditis in opiate addicts: analysis of 80 cases studied at necropsy. Am J Cardiol 1989;63:1240–57. [11] Watankunakorn C, Habte-Gaber Y. Group B streptococcal endocarditis of tricuspid valve. Chest 1991;100:569–71. [12] Ward H, Hickman RC. Bacterial endocarditis in pregnancy. Aust NZ Obstet Gynaecol 1971;11:189–91. [13] Henshaw S, Forrest JD, Sullivan E, Tietze C. Abortion in the United States, 1978–1979. Fam Plan Perspect 1981;13:6–7. [14] Seaworth BJ, Durack DT. Infective endocarditis in obstetric and gynecologic practice. Am J Obsetet Gynecol 1986;154:180–8. [15] Atri ML, Cohen DH. Group B streptococcus endocarditis following second-trimester abortion. Arch Intern Med 1990;150:2579–80. [16] Vartian CV, Septimus EJ. Tricuspid valve Group B streptococcal endocarditis following elective abortion. Rev Infect Dis 1991;13:997–8.
Z.S. Azzam et al. / International Journal of Cardiology 64 (1998) 259 – 263 [17] Wilson WR, Karchmer AW, Dajani AS et al. Antibiotic treatment of adults with infective endocarditis due to streptococci, enterococci, staphylococci and HACEK microorganisms. JAMA 1995;274:1706– 13. [18] Scully BE, Spriggs D, Neu HC. Streptococcus agalactiae (group B) endocarditis: a discription of 12 cases and review of the literature. Infection 1987;15:175–88.
263
[19] Acar J, Antebi L, Cabrol C, Vilde J-L, Morin B, Damelon F et al. Endocardite aigue tricuspidinne post partum a streptocogue du groupe B; post dune valve de starr. Ann Med Intern 1972;123:217– 24. [20] Jemsek JG, Gentry LO, Greenberg SB. Malignant group B streptococcal endocarditis associated with saline-induced abortion. Chest 1979;76:695–7.