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Pneumococcal Endocarditis Causing Valve Destruction in the Absence of Vegetations on Transesophageal Echocardiography: A Series of 3 Consecutive Cases
Canadian Journal of Cardiology 29 (2013) 519.e7–519.e9 www.onlinecjc.ca
Case Report
Pneumococcal Endocarditis Causing Valve Destruction in the Absence of Vegetations on Transesophageal Echocardiography: A Series of 3 Consecutive Cases Michael Tsang, MD, Suresh Perera, MBBS, Eva Lonn, MD, and Hisham Dokainish, MD Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
ABSTRACT
RÉSUMÉ
Streptococcus pneumoniae endocarditis is uncommon. It has a predilection for the aortic valve and is associated with high mortality. We present 3 consecutive cases of pneumococcal endocarditis, each preceded by a different extracardiac infection but all causing destructive aortic valve lesions associated with severe regurgitation, in the absence of vegetations on transesophageal echocardiography. This case series illustrates the aggressive nature of pneumococcal endocarditis and the need for early diagnosis. Echocardiography should be considered in all individuals with persistent extracardiac pneumococcal infections.
L’endocardite à Streptococcus pneumoniae n’est pas fréquente. Elle a tendance à siéger dans la valve aortique et est associée à une mortalité élevée. Nous présentons 3 cas consécutifs d’endocardite à pneumocoque, chacune précédée d’une infection extracardiaque différente, mais toutes ayant causé des lésions destructrices à la valve aortique associées à une régurgitation grave en l’absence de végétations à l’échocardiographie transœsophagienne. Cette série de cas illustre la nature agressive de l’endocardite à pneumocoque et la nécessité d’un diagnostic précoce. L’échocardiographie devrait être envisagée chez tous les individus ayant des infections à pneumocoques extracardiaques persistantes.
Streptococcus pneumoniae endocarditis is uncommon. It has a predilection for the aortic valve (AV) and is associated with high mortality. We present 3 consecutive cases of pneumococcal endocarditis, each preceded by a different extracardiac infection but all causing destructive AV lesions associated with severe regurgitation, in the absence of vegetations on transesophageal echocardiography.
murmur, but transesophageal echocardiogram (TEE) performed 7 days post admission revealed rupture and flail of the right aortic cusp with severe AR, but no vegetations (see Fig. 1 ; view videos online). A diagnosis of pneuand Videos 1-4 mococcal endocarditis was made. Progressive neurologic deterioration ensued; the patient died 14 days post admission.
Received for publication March 22, 2012. Accepted June 27, 2012.
Case 2 A man aged 51 years was treated with penicillin at a community hospital for pneumococcal pneumonia and meningitis. He was discharged after improvement; however, he returned with chills, headache, and ear pain. On readmission, he suffered respiratory collapse requiring intubation. TTE suggested a small mass on the AV associated with moderate AR. TEE performed at our centre 6 days after TTE revealed perforation of the aortic right coronary cusp with severe AR; no vegetations were seen (see Videos 5-9 ; view videos online). Ceftriaxone and vancomycin were started. Acute respiratory distress syndrome followed, and the patient died.
Corresponding author: Dr Hisham Dokainish, Associate Professor of Medicine, McMaster University, Director of Echocardiography, Hamilton Health Sciences, 237 Barton St E, CVSRI #C3 111, Hamilton, Ontario L8L 2X2, Canada. E-mail: [email protected] See page 519.e9 for disclosure information.
Case 3 A man aged 69 years was admitted to a community hospital with left shoulder pain and fever. Because of pneumococcal septic arthritis with abscess in the left biceps muscle, he under-
Case 1 A man aged 76 years, presented with fever and confusion. Radiography showed pulmonary infiltrate, and both blood and sputum cultures grew S. pneumoniae. Transthoracic echocardiogram (TTE) 3 days post admission revealed moderate left ventricular dysfunction, thought due to sepsis, and mild aortic regurgitation (AR) and mitral regurgitation without vegetations. Cerebral magnetic resonance 6 days post admission showed several ischemic lesions (Fig. 1). There was no new
0828-282X/$ – see front matter © 2013 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.cjca.2012.06.022
519.e8
Canadian Journal of Cardiology Volume 29 2013
Figure 1. (A) Cerebral magnetic resonance imaging with axial diffusion sequence demonstrating bilateral infarcts (black arrows) consistent with embolic events. (B) Transesophageal echocardiography with colour flow in the same patient demonstrating 2 jets of aortic regurgitation (arrows 1 and 2). The second jet (arrow 2) flows through the rupture site of the right aortic cusp. Ao, aorta; LA, left atrium; LVOT, left ventricular outflow tract.
went surgery. Thoracic computed tomography showed right-sided pleural effusion suggestive of empyema (Fig. 2). Three days later, the patient developed respiratory failure and arrest with resuscitation. TTE showed severe AR and suspected vegetation on the AV. TEE 2 days later at our institution showed right aortic coronary cusp rupture and severe AR (see Fig. 2 and Videos 10-12 ; view videos online); no vegetations or abscess was seen. The patient underwent AV replacement 10 days later; AV destruction and drained aortic root abscess were seen; pathology revealed AV microvegetations and microabscesses. The patient improved and was eventually discharged.
Discussion Pneumococcal endocarditis is uncommon, accounts for 4% of endocarditis, occurs in 0.5% to 1.2% of patients with pneumococcal bacteremia, and is associated with a high mortality rate (24%-63%).1,2,3 Alcoholism and pre-existing valvular heart disease often coexist.4 Pneumonia is often the first presentation, and upper respiratory tract infections can precede endocarditis in 13.7% of cases.4 Concomitant pneumococcal meningitis is present in ⬎ 50% of cases; when pneumococcal meningitis is present with pneumonia and endocarditis, the combination is called the Austrian triad.4 Antecedent extracardiac infections make the diagnosis of pneumococcal endocar-
Figure 2. (A) Chest computed tomography showing right-sided loculated effusion (arrow), which, in the setting of concomitant pneumonia, was thought to be empyema. (B) Transesophageal echocardiography in the same patient with simultaneous 2-dimensional and colour Doppler imaging. Perforation of the right aortic cusp is seen (arrow 1). A jet of aortic regurgitation (arrow 2) is seen flowing through the site of aortic valve leaflet rupture. Ao, aorta; LA, left atrium; LVOT, left ventricular outflow tract; PE, pleural effusion.
Tsang et al. Destructive Pneumococcal Endocarditis
ditis challenging, with delay until diagnosis of 16 days being reported.5 The AV is affected in S. pneumoniae endocarditis in 74% of cases.4 Vegetations may not be seen, even in the presence of valve destruction. Vegetations are seen on TTE in 50% of cases;4 our series shows that vegetations may not be seen on TEE, possibly because of partial antibiotic treatment by the time of endocarditis diagnosis, and/or embolization of vegetations. The novel aspects herein are 3 consecutive cases of pneumococcal endocarditis occurring at our institution; absence of vegetations on TEE despite valve destruction; and 3 different extracardiac infections that preceded endocarditis. Overall, echocardiography is recommended early in the course of ongoing or severe pneumococcal infection in order to exclude endocarditis. Disclosures The authors have no conflicts of interest to disclose. References 1. Wolff M, Regnier G, Witchitz S, Gibert C, Amoudry C, Vachon F. Pneumococcal endocarditis. Eur Heart J 1984;5(suppl C):77-80.
519.e9 2. Kan B, Ries J. Normark BH, et al. Endocarditis and pericarditis complicating pneumococcal bacteraemia, with special reference to the adhesive abilities of pneumococci: results from a prospective study. Clin Microbiol Infect 2006;12:338-44. 3. Lindberg J, Schønheyder HC, Møller JK, Prag J. Incidence of pneumococcal endocarditis: a regional health register-based study in Denmark 19811996. Scand J Infect Dis 2005;37:417-21. 4. Aronin SI, Mukherjee SK, West JC, Cooney EL. Review of pneumococcal endocarditis in adults in the penicillin era. Clin Infect Dis 1998; 26:165-71. 5. Hill EE, Herijgers P, Claus P, Vanderschueren S, Herregods MC, Peetermans WE. Infective endocarditis: changing epidemiology and predictors of 6-month mortality: a prospective cohort study. Eur Heart J 2007;28:196203.
Supplementary Material To access the supplementary material accompanying this article, visit the online version of the Canadian Journal of Cardiology at www.onlinecjc.ca and at http://dx.doi.org/ 10.1016/j.cjca.2012.06.022.
Case Report
Pneumococcal Endocarditis Causing Valve Destruction in the Absence of Vegetations on Transesophageal Echocardiography: A Series of 3 Consecutive Cases Michael Tsang, MD, Suresh Perera, MBBS, Eva Lonn, MD, and Hisham Dokainish, MD Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
ABSTRACT
RÉSUMÉ
Streptococcus pneumoniae endocarditis is uncommon. It has a predilection for the aortic valve and is associated with high mortality. We present 3 consecutive cases of pneumococcal endocarditis, each preceded by a different extracardiac infection but all causing destructive aortic valve lesions associated with severe regurgitation, in the absence of vegetations on transesophageal echocardiography. This case series illustrates the aggressive nature of pneumococcal endocarditis and the need for early diagnosis. Echocardiography should be considered in all individuals with persistent extracardiac pneumococcal infections.
L’endocardite à Streptococcus pneumoniae n’est pas fréquente. Elle a tendance à siéger dans la valve aortique et est associée à une mortalité élevée. Nous présentons 3 cas consécutifs d’endocardite à pneumocoque, chacune précédée d’une infection extracardiaque différente, mais toutes ayant causé des lésions destructrices à la valve aortique associées à une régurgitation grave en l’absence de végétations à l’échocardiographie transœsophagienne. Cette série de cas illustre la nature agressive de l’endocardite à pneumocoque et la nécessité d’un diagnostic précoce. L’échocardiographie devrait être envisagée chez tous les individus ayant des infections à pneumocoques extracardiaques persistantes.
Streptococcus pneumoniae endocarditis is uncommon. It has a predilection for the aortic valve (AV) and is associated with high mortality. We present 3 consecutive cases of pneumococcal endocarditis, each preceded by a different extracardiac infection but all causing destructive AV lesions associated with severe regurgitation, in the absence of vegetations on transesophageal echocardiography.
murmur, but transesophageal echocardiogram (TEE) performed 7 days post admission revealed rupture and flail of the right aortic cusp with severe AR, but no vegetations (see Fig. 1 ; view videos online). A diagnosis of pneuand Videos 1-4 mococcal endocarditis was made. Progressive neurologic deterioration ensued; the patient died 14 days post admission.
Received for publication March 22, 2012. Accepted June 27, 2012.
Case 2 A man aged 51 years was treated with penicillin at a community hospital for pneumococcal pneumonia and meningitis. He was discharged after improvement; however, he returned with chills, headache, and ear pain. On readmission, he suffered respiratory collapse requiring intubation. TTE suggested a small mass on the AV associated with moderate AR. TEE performed at our centre 6 days after TTE revealed perforation of the aortic right coronary cusp with severe AR; no vegetations were seen (see Videos 5-9 ; view videos online). Ceftriaxone and vancomycin were started. Acute respiratory distress syndrome followed, and the patient died.
Corresponding author: Dr Hisham Dokainish, Associate Professor of Medicine, McMaster University, Director of Echocardiography, Hamilton Health Sciences, 237 Barton St E, CVSRI #C3 111, Hamilton, Ontario L8L 2X2, Canada. E-mail: [email protected] See page 519.e9 for disclosure information.
Case 3 A man aged 69 years was admitted to a community hospital with left shoulder pain and fever. Because of pneumococcal septic arthritis with abscess in the left biceps muscle, he under-
Case 1 A man aged 76 years, presented with fever and confusion. Radiography showed pulmonary infiltrate, and both blood and sputum cultures grew S. pneumoniae. Transthoracic echocardiogram (TTE) 3 days post admission revealed moderate left ventricular dysfunction, thought due to sepsis, and mild aortic regurgitation (AR) and mitral regurgitation without vegetations. Cerebral magnetic resonance 6 days post admission showed several ischemic lesions (Fig. 1). There was no new
0828-282X/$ – see front matter © 2013 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.cjca.2012.06.022
519.e8
Canadian Journal of Cardiology Volume 29 2013
Figure 1. (A) Cerebral magnetic resonance imaging with axial diffusion sequence demonstrating bilateral infarcts (black arrows) consistent with embolic events. (B) Transesophageal echocardiography with colour flow in the same patient demonstrating 2 jets of aortic regurgitation (arrows 1 and 2). The second jet (arrow 2) flows through the rupture site of the right aortic cusp. Ao, aorta; LA, left atrium; LVOT, left ventricular outflow tract.
went surgery. Thoracic computed tomography showed right-sided pleural effusion suggestive of empyema (Fig. 2). Three days later, the patient developed respiratory failure and arrest with resuscitation. TTE showed severe AR and suspected vegetation on the AV. TEE 2 days later at our institution showed right aortic coronary cusp rupture and severe AR (see Fig. 2 and Videos 10-12 ; view videos online); no vegetations or abscess was seen. The patient underwent AV replacement 10 days later; AV destruction and drained aortic root abscess were seen; pathology revealed AV microvegetations and microabscesses. The patient improved and was eventually discharged.
Discussion Pneumococcal endocarditis is uncommon, accounts for 4% of endocarditis, occurs in 0.5% to 1.2% of patients with pneumococcal bacteremia, and is associated with a high mortality rate (24%-63%).1,2,3 Alcoholism and pre-existing valvular heart disease often coexist.4 Pneumonia is often the first presentation, and upper respiratory tract infections can precede endocarditis in 13.7% of cases.4 Concomitant pneumococcal meningitis is present in ⬎ 50% of cases; when pneumococcal meningitis is present with pneumonia and endocarditis, the combination is called the Austrian triad.4 Antecedent extracardiac infections make the diagnosis of pneumococcal endocar-
Figure 2. (A) Chest computed tomography showing right-sided loculated effusion (arrow), which, in the setting of concomitant pneumonia, was thought to be empyema. (B) Transesophageal echocardiography in the same patient with simultaneous 2-dimensional and colour Doppler imaging. Perforation of the right aortic cusp is seen (arrow 1). A jet of aortic regurgitation (arrow 2) is seen flowing through the site of aortic valve leaflet rupture. Ao, aorta; LA, left atrium; LVOT, left ventricular outflow tract; PE, pleural effusion.
Tsang et al. Destructive Pneumococcal Endocarditis
ditis challenging, with delay until diagnosis of 16 days being reported.5 The AV is affected in S. pneumoniae endocarditis in 74% of cases.4 Vegetations may not be seen, even in the presence of valve destruction. Vegetations are seen on TTE in 50% of cases;4 our series shows that vegetations may not be seen on TEE, possibly because of partial antibiotic treatment by the time of endocarditis diagnosis, and/or embolization of vegetations. The novel aspects herein are 3 consecutive cases of pneumococcal endocarditis occurring at our institution; absence of vegetations on TEE despite valve destruction; and 3 different extracardiac infections that preceded endocarditis. Overall, echocardiography is recommended early in the course of ongoing or severe pneumococcal infection in order to exclude endocarditis. Disclosures The authors have no conflicts of interest to disclose. References 1. Wolff M, Regnier G, Witchitz S, Gibert C, Amoudry C, Vachon F. Pneumococcal endocarditis. Eur Heart J 1984;5(suppl C):77-80.
519.e9 2. Kan B, Ries J. Normark BH, et al. Endocarditis and pericarditis complicating pneumococcal bacteraemia, with special reference to the adhesive abilities of pneumococci: results from a prospective study. Clin Microbiol Infect 2006;12:338-44. 3. Lindberg J, Schønheyder HC, Møller JK, Prag J. Incidence of pneumococcal endocarditis: a regional health register-based study in Denmark 19811996. Scand J Infect Dis 2005;37:417-21. 4. Aronin SI, Mukherjee SK, West JC, Cooney EL. Review of pneumococcal endocarditis in adults in the penicillin era. Clin Infect Dis 1998; 26:165-71. 5. Hill EE, Herijgers P, Claus P, Vanderschueren S, Herregods MC, Peetermans WE. Infective endocarditis: changing epidemiology and predictors of 6-month mortality: a prospective cohort study. Eur Heart J 2007;28:196203.
Supplementary Material To access the supplementary material accompanying this article, visit the online version of the Canadian Journal of Cardiology at www.onlinecjc.ca and at http://dx.doi.org/ 10.1016/j.cjca.2012.06.022.