Rothia dentocariosa endocarditis and aortic root abscess

292

Case Reports

Rothia dentocariosa Endocarditis and Aortic Root Abscess V. Ferraz 1, K. McCarthy .1, D. Smith 2 and H. J. Koornhof ~ 1Department of Clinical Microbiology and Infectious Diseases, South African Institute for Medical Research and University of the Witwatersrand and 2Divison of Cardiology, Department of Medicine, University of the Witwatersrand, Johannesburg, South Africa We report a case of endocarditis and associated paravalvular abscess due to Rothia dentocariosa which did not respond to antibiotic therapy. Nine case reports describing endocarditis caused by this organism, formerly thought to be non-pathogenic, have been recorded in the literature. The isolates were extremely sensitive to penicillin, and eight patients responded to this agent which, in most cases, was used in combination with an aminoglycoside. Surgery is recommended for an associated abscess, as the outcome in the two recorded cases has been fatal.

Introduction Rothia dentocariosa is a normal inhabitant of the oral cavity and has rarely been described as a pathogen in the human host. There are nine case reports describing R. dentocariosa causing endocarditis of which one was associated with a paravalvular abscess. 1 We describe a case of R. dentocariosaendocarditis complicated by paravalvular abscess, and review the literature.

Case Report A 54-year-old male gardener originally from Zimbabwe was admitted to the Johannesburg Hospital, South Africa with a 4week history of fever, malaise, dizziness, palpitations, pedal oedema, mild intermittent left-sided chest pain and dyspnoea on moderate effort (New York Heart Association grade 2). He had been diagnosed 20 years previously as having valvular heart disease and had been advised to have surgery; however, he had refused. There was no history of recent dental manipulation nor of dental infection. The patient had returned from Zimbabwe 3 weeks prior to admission and had not taken any malaria prophylaxis. On examination he was pyrexial with a temperature of 38 °C, his blood pressure was 140/50 mmHg, his pulse was 120 per rain, collapsing in nature and regular. His respiratory rate was 28 breaths per min. He had evidence of heart failure with a jugular venous pressure of 4 cm water at 45 °, pedal oedema and fine pulmonary crepitations. He had a high pitched early diastolic murmur, with a harsh mid-systolic murmur radiating into the neck and down the sternal border. He had peripheral signs consistent with endocarditis, including splinter haemorrhages of his nail beds, clubbing, flame haemorrhages on his retina and blood and protein in his urine. The rest of the examination was normal. The admission electrocardiogram showed a rate of 120/min with a mean frontal axis of positive 30 °, the PR interval was

* Please address all correspondence to: K. McCarthy, Department of Clinical Microbiology and Infectious Diseases, South African Institute for Medical Research, P.O. Box 1038, Johannesburg 2000, Republic of South Africa. Accepted for publication 9 July 1998.

shortened to 0.08 s, the QRS duration was 0.1 s and q waves were seen in the inferior leads. Tall T waves were present throughout, with deep T wave inversion seen in the lateral leads. A delta wave was present. These electrocardiogram changes were in keeping with an accessory conduction pathway. An intermittent ECG showed normal sinus rhythm with normal atrioventricular conduction, PR interval, QRS duration and no delta waves. The accessory pathway was presumably dormant at this time. The chest roentgenogram showed signs compatible with heart failure, with a cardiothoracic ratio of 50%. His full blood count showed a leucocytosis with a white ceil count of 19 x 109/1, a haemoglobin concentration of 11.8 g/dl and a platelet count of 149 x 109/1. The leucocytes consisted of 80% neutrophils, 6% lymphocytes and 9% monocytes. His blood urea and electrolytes were normal except for a low sodium of 130 mmol/1. His C-reactive protein concentration was 194 g/ dl (normal <11 g/dl). Malaria was excluded and his HIV antibody test was negative. An initial diagnosis of infective endocarditis was made, blood cultures were taken and the patient was started empirically on penicillin 16 mu intravenously daily and gentamicin 240 mg intravenously daily. Of the six blood cultures taken in the first 2 days, four yielded growth of pleomorphic Gram-positive coccobacilli. Blood cultures became negative 4 days after the onset of therapy. An initial transthoracic echocardiogram was done which confirmed the mixed aortic valve disease with moderate aortic regurgitation and stenosis. No vegetations were seen. The patient remained pyrexial and his heart failure persisted despite diuretics and angiotensin-converting enzyme inhibitors. The patient was continued on penicillin and aminoglycoside therapy. Cloxacillin 24 g daily was added pending the identification of the Gram-positive bacteria isolated from the blood. A transoesophageal echocardiogram was performed which showed an extensive aortic root abscess located above the sinotubular junction encircling the root of the aorta and extending into the left atrial cavity posteriorly down over the anterior mitral leaflet and anteriorly towards the pulmonary artery between the pulmonary artery and aorta. There was also evidence of destruction of the aortic leaflets and vegetations were seen. The patient was advised to have surgery but refused. He remained pyrexial, and vancomycin 1 g daily was added in addition to penicillin and gentamicin. Cloxaeillin was stopped.

Case Reports The organism was provisionally identified as R. dentocariosa. The patient's condition continued to deteriorate, with a persistent pyrexia and progressive cardiac failure despite appropriate therapy. Forty-eight days after admission the patient died. A postmortem examination was not done as permission was refused.

Bacteriology The organism was recovered from four aerobic BacT/Alert bottles (Organon Teknika, Turnhout, Belgium). Growth was detected after approximately 3 0 h incubation at 35 °C and showed on Gram's stain the presence of coccobacillary Grampositive forms. It failed to grow in anaerobic BacT/Alert bottles. Gram's stain of colonies demonstrated Gram-positive bacilli that showed a tendency towards filamentous forms which appeared to fragment into coccoid forms. The bacillus was non-motile and non-acid fast. On horse-blood agar the colonies were offwhite, rough with wrinkled surfaces and smooth margins. The colonies were pitted into the agar. No aerial mycelium was formed. The organism was able to grow anaerobically and micro-aerophilically, but best growth was observed under aerobic conditions. This organism was catalase-positive, oxidase-negative and had a fermentative metabolism of glucose. Biochemical reactions displayed in Table I were typical of those described for R. dentocariosa. 2 API Coryne test strips (Bio Merieux, Marcy l'Etoflle, France) used to identify the organism yielded codes of 1042121 or 3040125 which were not listed in the database. Chemotaxonomic investigations relating to sugar and amino acid content of cell walls, guanine and cytosine (G + C) tool %, metabolic end products following glucose fermentation and cellular fatty acid analysis which would assist with the identificalion of the organism were not performed. 2 Differential characteristics, which pointed clearly to a R, dentocariosa identity, were, however, determined in the laboratory (Table I). Using the Kirby-Bauer method] the isolate was found to be sensitive to penicillin, cefazolin, erythromycin, clindamycin, cotrimoxazole, and vancomycin. Minimum bactericidal concentrations (MBCs) determined according to the United States National Committee for Laboratory Standards ~ were 1 mg/1 for vancomycin, 0.25 rag/1 for gentamicin, and 0.05 mg/1 for penicillin.

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Proprionibactelqum avidum, Corynebacterium matruchotii and R. dentocariosa all have similar laboratory characteristics. (~ Dermobacter does not reduce nitrate, but produces alkaline phosphatase, ]3-galactosidase and ferments sucrose and ribose. Actinomyces viscosus does not hydrolyse gelatine and ferments mellibiose. 7 Proprionibacterium avidum is ]3-haemolytic and CoJvnebacterium matruchotii demonstrates 'whip handle'-like forms on Gram stain. (' Additional chemotaxonomJc analyses may differentiate R. dentocariosa from other Gram-positive rods. z Originally thought not to be pathogenic in humans, R. dentocariosa was first described to cause infection in a 19-yearold girl with a peri-appendiceal abscess in 1975. The next recorded case was in 1978 in a 17-year-old girl who presented with a pilonidal abscess. ~ Nine cases of R. dentocariosa endocarditis have been described subsequently between 1979 and 1998, and are summarized in Table II. Of the nine patients with R. dentocariosa endocarditis recorded in the literature ~'9-~ together with the case described here, two died. Both these patients were complicated by para-aortic root abscess formation. The other eight patients were all cured, five being on penicillin plus gentamicin or streptomycin treatment9-~21s three patients were given triple antibiotic therapy combining vancomycin in addition to penicillin and gentamicin~'x3'~ and one received amoxicfllin and metronidazolexf' in two of the eight patients there was progression of the disease requiring valve replacement surgery2 '~' Penicillin MICs of six of the 10 patients have been reported and varied from 0.03 mg/l to 0.12 mg/1 with a mean of O.07mg/1, showing that the strains were susceptible to penicillin,9<2'x~With regard to the source of the organism, three patients gave a history of recent dental manipulation,~°-:2 one was an intravenous drug abuser ~ and one had carious teeth. ~(' The aortic valve was involved in five cases, one of which was a prosthetic valve, while in another of these patients, a congenital bicuspid valve was affected. Four patients had mitral valve endocarditis and one patient had triple valve endocarditis involving the aortic, tricuspid and mitral valves. Severe complications, including progression of the disease, occurred in seven of the 10 patients. As mentioned, two patients required surgery due to progression of the disease9" while another two who had died developed aortic root abscesses? A further two patients had cerebraI emboli resulting in cerebral abscess and a mycotic aneurysm with haemorrhage, respectively. ~2~3 Another patient developed an abdominal aneurysm, n~

Discussion

Conclusion

Clinically this case was interesting lbr a number of reasons. i?irstly, the patient presented with a severe form of disease with a long-standing history of not being well and a late presentation 1:o hospital. Secondly, the valvular abscess was extensive and involved an unusual causative organism R. dentocariosa. Thirdly, his electrocardiogram showed conductive abnormalities out of keeping with what one would expect from an aortic root abscess. His electrocardiogram was suggestive of an underlying accessory pathway which was probably not related to his presenting problem. Urgent surgery would have been the treatment of choice for this patient, with radical resection and reconstruction of the infected area. s Microbiologically, the identification of Gram-positive rods with similar growth properties proved to be challenging. Various laboratory characteristics are useful in differentiating similar appearing organisms. Dermabacter species, Actinomyces viscosus,

While only 10 cases of endocarditis, including ours, have been described, various trends are emerging: (i) Rothia dentocariosa is a normal commensal of the oral cavity and is not commonly isolated from laboratory specimens. Kong et al. in a review of specimens over 8 years from two reference laboratories in France, revealed a total of 1.03 specimens, of which 69 were isolated from the respiratory tract and were most likely contaminants. The large number of nonsignificant specimens from which R. dentocariosa was isolated by these laboratories does not negate the pathogenic potential of this organism. 1~' A growing body of case report literature suggests that this organism has definite pathogenic potential. The failure to grow the organism from the two patients' heart valves after surgery is probably a result of the significant antibiotic therapy they both received prior to surgery. Microscopy of both of these patients' valves showed Gram-positive

Fermentative + + --

Glucose Maltose Sucrose Mannitol Xylose Lactose Raffinose Mellibiose Fructose

Glycogen

Nil

Dental manipulation Dental manipulation Dental manipulation Nil

Nil

IV drug abuser

Nil

Carious teeth, Hepatoma, alcohol Nil

Pape 9

Schafer et al. 1° Broeren and Peel 1~ [saacson et al. ~2 Shands 1~

Anderson et al. 14

Sudduth et al. ~

Weersink et al. ~s

Kong et al. 16

Our case

Predisposing factors

Reference

Probable rheumatic heart disease

Undefined cardiac murmur Rheumatic fever with no d o c u m e n t e d valve disease Nil

Mitral valve prolapse Rheumatic heart disease Bicuspid aortic valve Mitral valve regurgitation Prosthetic aortic valve

Mitral regurgitation

Prior cardiac condition

+ + +

Result

Penicillin, vancomycin, gentamicin

Amoxicillin, metronidazole

Penicillin, streptomycin Penicillin, gentamicin Penicillin, gentamicin Penicillin, vancomycin, gentamicin Penicillin, vancomycin, gentamicin Penicillin, vancomycin, gentamicin Penicillin, gentamicin

0.05 ( M B C )

Not stated

<0.03

Not stated

Not stated

0.01 0.12 0.06 Not stated

0.1

MIC (rag/l) of penicillin

Catalase Oxidase Urease DNAse ct-glucosidase Cystine arylamidase Leucine aminopeptidase ~3-galactosidase Alkaline phosphatase

Test

Enzyme production

Penicillin, gentamicin

Treatment

Test

Result

Test Gelatin Aesculine Casein

Substrate hydrolysis

Carbohydrate utilization

Biochemical characteristics

Table II. Summary of cases of R. dentocariosa endocarditis.

Colonies offwhite, wrinkled, petted i n t o agar

Aerobic optimal Anaerobic Microaerophilic

F i l a m e n t o u s forms

Coccobacilli

Morphology and growth

Table 1. Characteristics of the Gram-positive bacterium.

+ + + + + -

Nitrate reduction Resistance to lysozome

Test

Progressive disease requiring surgery Para-aortic root abscess

Abdominal aneurysm

Para-aortic root abscess

Progressive disease requiring surgery None None Brain abscess Mycotic aneurysm, cerebral haemorrhage None

Complications

Result

Other

Died

Cure

Cure

Died

Cure

Cure Cure Cure Cure

Cure

Outcome

+ +

Result

¢D "O O

¢,D

Case Reports cocci or rods suggestive of R. dentocariosa w h i c h was isolated from blood culture prior to surgery, s'9 (ii) Urgent surgery should be considered for perivascular abscess due to R. dentocariosa. (iii) Based on the MIC results, t r e a t m e n t of R. dentocariosa infections should be with penicillin. W h e t h e r the addition of a n aminoglycoside would improve the prognosis of endocarditis caused by this o r g a n i s m h a s n o t been established, b u t because of the occurrence of severe complications two agents would be advisable. Two of the isolates reported in the literature h a d low MICs for aminoglycosides (0.1 mg/1 a n d 0.12 mg/1), but the latest case reported resistance to aminoglycosides o n disk diffusion susceptibility testing. ~ More work needs to be done to determine the best antibiotic c o m b i n a t i o n to treat R. dentocariosa endocarditis.

4

5 6 7 8 9

Acknowledgemen~s The authors would like to t h a n k Dr Guido Funke, D e p a r t m e n t of Microbiology, University of Zurich, Switzerland for confirming the identity of the o r g a n i s m a n d Mrs M a r s h e i n e Smith for h e r technical assistance. V. Ferraz a n d K. McCarthy t h a n k Professor H.J. K o o r n h o f for his e n c o u r a g e m e n t a n d support.

References 1 St~dduth EJ, Rozich JD, Farrar WE. Rothia dentocariosa endocarditis complicated by perivalvular abscess. Clin Infect Dis 1993; 17:

772-775. 2 Gerencser MA, Bauden GH. Genus Rothia. In: Holt JG, Sneath PH, Mair NF, Sharp ME, eds Berge~fs manual of sgstemic bacteriology, Volume 2. Baltimore: Williams and Wilkins 1986: pp. 1342-1346. 3 National Committee for Clinical Laboratory Standards. Performance

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standards for antimicrobial disc susceptibility tests: fifth international supplement NCCLS document. M100 155. Villanova, Pennsylvania, 1994. National Committee for Clinical Laboratory Standards. Methods for dilution antimicrobial susceptibility tests for bacteria that grow aerobically; approved standard MT-A3. Villanova, Pennsylvania, 1993. D'Udekem Y, David TE, Feindel CM. Armstrong S. Long-term results of operation for paravalvular abscess. Ann Thorac Sm'g 1996: 62: 48-53. Funke G, yon Oraevenitz A, Clavridge I, Bernard K. Clinical microbiology of coryneform bacteria. Clin Microbiol Rev 1997; 10: 125-159. Schofield G, SchaaI K. A numerical taxonomic study of members of the Actinomycetes and related taxa. J Gen Microbiol 1981; 127: 237-259. Lutwick L, Rockhill R. Abscess associated with Rothia dentocariosa. J C/in Microbiol 1978; 8: 612-613. Pape J, Singer C, Kiehn TE, Lee B], Armstrong D. Infective endocarditis caused by Rothia dentocariosa. Ann Intern Med 1979; 91:

746-747. 10 Schafer F, Wing E, Norden C. Infections eudocarditis caused by Rothia dentocariosa. Ann lntern Med 1979; 91: 747-748. 11 Broeren S, Peel M. Endocarditis caused by Rothia dentocariosa. I Clin Pathol 1984; 37: 1298-1300. 12 Isaacson ], Grenko IL Rothia dentocariosa endocarditis complicated by brain abscess. Am l Med 1988; 84: 352-354. 13 Shands J. Rothia dentoeariosa endocarditis. Am ] Med 1988; 85: 280-281. 14 Anderson MD, Kennedy CA, Walsh TP, Bowler WA. Prosthetic valve endocarditis due to Rothia dentocariosa. Clin Infect Dis 1993; 17: 945-946. 15 Weersink AJL, Rozenberg-Arskam M. Westerhof PW, Verhoef J. Rothia clentocariosa endocarditis complicated by an abdominal aneurysm. Clin Infect Dis 1994; 18: 489-490. 16 Kong R, Mebazaa A, Heitz B e t aI. Case of a triple endocarditis caused by Rothia dentocariosa and results of a survey in France. J Clin MicrobioI 1998; 36: 309-310.

A Case of Aspergillus Myocarditis Associated with Septic Shock Y. Rouby .1, E. Combourieu 2, J. D. Perrier-Gros-Claude 1, C. Saccharin 3 and M. Huerre ~ tMicrobiology Laboratory, 2Intensive Care Unit, ~Department of Pathology, Desgenettes Military Hospital, Lyon, 4Histopathology Unit, Pasteur Institute, Paris, France We report a case of isolated myocardial i n v o l v e m e n t due to Aspelyillus sp., in a patient with multiple o r g a n failure b u t no d e m o n s t r a b l e i m m u n e deficiency a p a r t from corticosteroid therapy given for the three weeks prior to hospitalization. This patient died of septic s h o c k 7 days after hospitalization. Aspergillus was isolated only once from a s p u t u m specimen obtained 2 4 h before death. At post-mortem e x a m i n a t i o n there are emboli a n d myocardial lesions c o n t a i n i n g clusters of h y p h a e as AspergilIus confirmed by indirect immunofluorescence. The other o r g a n s were free of fungi. This observation is r e m a r k a b l e because the cardiac i n v o l v e m e n t was isolated a n d n o immunodeficiency was present.

Introduction * Please address all correspondence to: Y. Rouby, Laboratoire de Biologie, HOpital Desgenettes, 108 Bid Pinel, 69275 Lyon Cedex 03, France. Accepted for publication 9 July 1998.

Disseminated a n d / o r systemic fungal infection is one of the m a j o r complications seen in i m m u n o c o m p r o m i s e d individuals. The species of the g e n e r a Candida a n d Aspergillus are the most frequently occurring p a t h o g e n s in this type of infection.