Vascular complications of infective endocarditis

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www.sciencedirect.com Médecine et maladies infectieuses 42 (2012) 213–217

Original article

Vascular complications of infective endocarditis Les complications vasculaires de l’endocardite infectieuse S. Pessinaba a , Ad. Kane a,∗ , M.B. Ndiaye a , A. Mbaye b , M. Bodian a , M.M. Dia a , S.A. Sarr a , M. Diao a , M. Sarr a , A. Kane b , S.A. Ba a a

Clinique cardiologique du CHU Aristide-Le-Dantec, BP 3001, Dakar, Sénégal b Service de l’Hôpital Général de Grand Yoff, Grand Yoff, Dakar, Sénégal

Received 12 May 2011; received in revised form 25 October 2011; accepted 7 March 2012 Available online 17 April 2012

Abstract The complications of infective endocarditis (IE) are frequent and severe. Our objectives were to analyze the clinical, paraclinical, and prognostic features of IE vascular complications observed in two cardiology units, in Dakar. Patients and methods. – We retrospectively studied 90 patients presenting with of IE, hospitalized between January 2005 and February 2011. The diagnostic criteria for IE were modified Duke University criteria. We selected in our study population, patients with vascular complications. Results. – Seventeen patients (18.8%) presented with one or more vascular complications of IE: eight male and nine female patients, with a mean age of 28 years. Infective endocarditis occurred on an abnormal valve in 15 cases. We identified 22 vascular lesions: ten neurological complications, seven arterial complications in the limbs, two myocardial infarctions, two cases of pulmonary embolism, and one splenic infarction. The vascular complication revealed an IE in seven cases. The vascular complication occurred during antibiotic treatment, in 15 cases including seven cases before the 14th day, nine of the 17 patients died. Death was related to vascular complications in six cases, in one case it was related to septic shock. Conclusion. – Vascular complications of IE are frequent, the most common are neurological. Their prevention requires early and adequate management of IE. © 2012 Elsevier Masson SAS. All rights reserved. Keywords: Vascular complications; Infective endocarditis

Résumé Les complications de l’endocardite infectieuse sont fréquentes et graves. Nos objectifs étaient d’analyser les aspects cliniques, paracliniques et pronostiques des complications vasculaires de l’endocardite infectieuse recensées dans deux services de cardiologie de Dakar. Patients et méthodes. – Il s’agit d’une étude rétrospective portant sur 90 cas d’endocardites infectieuses hospitalisés entre janvier 2005 et février 2011. Les critères diagnostiques des EI sont ceux de la Duke Université modifiés. Parmi ces patients, nous avons retenu ceux ayant présenté une ou plusieurs complications vasculaires. Résultats. – Dix-sept cas (18,8 %) d’endocardite infectieuse ont présenté des complications vasculaires. Il s’agissait de huit hommes et neuf femmes, âgés en moyenne de 28 ans. L’endocardite infectieuse est survenue sur une valvulopathie sous-jacente dans 15 cas. Nous avons recensé 22 atteintes vasculaires : dix complications neurologiques, sept complications artérielles des membres, deux infarctus du myocarde, deux embolies pulmonaires et un infarctus splénique. La complication vasculaire a révélé l’EI dans sept cas. Elle est survenue dans 15 cas en cours de traitement antibiotique. Neuf malades sont décédés dans le groupe des malades ayant présenté une ou plusieurs complications vasculaires. Dans six cas le décès était en rapport avec la complication vasculaire, un patient est décédé de choc septique. Conclusion. – Les complications vasculaires de l’endocardite infectieuse sont fréquentes et dominées par les accidents neurologiques. Leur prévention passe par une prise en charge précoce et correcte des endocardites infectieuses. © 2012 Elsevier Masson SAS. Tous droits réservés. Mots clés : Complications vasculaires ; Endocardite infectieuse

∗

Corresponding author. E-mail address: [email protected] (Ad. Kane).

0399-077X/$ – see front matter © 2012 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.medmal.2012.03.001

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Table 1 Distribution of various vascular complications. Répartition des différentes complications vasculaires. Vascular complications

Number (22)

Neurological Ischemic accidents Hemorrhagic accidents Arterial, lower limbs Embolic Mycotic aneurysm Myocardial infarction Splenic infarction Pulmonary embolism

10 05 05 07 06 01 02 01 02

1. Introduction Complications of infective endocarditis (IE) are frequent and severe, despite progress made in antibiotherapy and cardiac surgery [1]. The global intrahospital mortality of IE is 16% [2] and reaches 37% after one year of follow-up [3]. This mortality mostly related to complications. The complications of IE are first cardiac complications, and vascular complications [1]. Our objectives were to analyze the clinical, paraclinical, and prognostic features of IE vascular complications observed in two cardiology units, in Dakar. 2. Patients and methods We retrospectively studied 90 patients presenting with of IE, hospitalized between January 2005 and February 2011 (6 year and 2 months) in the cardiology units of the Aristide-Le-Dantec teaching hospital and the Grand Yoff general hospital. The diagnostic criteria of IE were modified Duke University criteria [4]. We selected in our study population, patients with one or several vascular complications, diagnosed on clinical and/or paraclinical data. All vascular complications related to rhythm disorders and/or inadequate anticoagulant treatment were excluded from the study. The studied parameters were demographic, clinical, bacteriological (hemocultures), echocardiographic and Doppler (screening for vegetations, valvular and paravalvular lesions) data, and data of other paraclinical examinations according to the type of vascular complication (Brain CT scan, vascular echo Doppler, angioscan). The results of necropsy were sometimes studied. No arteriography was performed. The following vascular complications were investigated: neurological vascular complications, arterial complications in the limbs, myocardial infarction, splenic and renal infarction, and pulmonary embolism. 3. Results Among the 90 patients hospitalized during 6 years and 2 months for an IE, 17 (18.8%) presented with one or more vascular complications. Eight male and nine female patients, with a mean age of 28 years (range: 11 to 60 years). The 17 patients presented with 22 vascular complications presented in Table 1. Thirteen patients presented with an isolated complication, three

patients with two complications, and one patient with three complications. The vascular complication revealed the IE in seven cases. It occurred in 15 cases during antibiotic treatment including seven cases before the 14th day. On clinical examination, all patients presented with fever and a regurgitation murmur at cardiac auscultation. Five cases of cardiac insufficiency were reported. The portal of entry was suspected in 11 cases: dental infections (eight cases), ENT (two cases), cutaneous (one case), and gynecological (one case). It was urinary and confirmed in one case with the same bacterium isolated in hemoculture and uroculture. IE occurred with an underlying rheumatismal valve disease in 15 cases, four of which were undiagnosed before the Oslerian graft. In the two other cases IE occurred on apparently healthy tricuspid valves. In one case, IE on tricuspid occurred after peripheral venous catheter insertion and in the other cases, no risk factor was identified. No IE on prosthesis was reported. Hemocultures were performed in 15 patients and positive in six patients (40%). The identified bacteria were: Staphylococcus aureus (two cases), Staphylococcus sp (one case), Citobacter spp. (one case), and Streptococcus a-viridans (two cases). Transthoracic echocardiography (TTE) revealed vegetations in every case. These vegetations were located on mitral valves in ten cases, on aortic valves in three cases, on mitral and aortic valves in two cases, and on tricuspid valves in two cases. The vegetations were pediculated and mobile in every case. Besides vegetations, TTE also revealed prolapse of the great mitral valve due to chordal rupture (one case) and a mitral ring abscess (one case). The distribution of vascular complications according to location of vegetations is reported in Table 2. All patients were administrated a double empirical antibiotherapy adapted later to the antibiogram when hemocultures were positive. Vascular complications were treated in some patients. Nine out of 17 patients having presented with one or more vascular complications of IE died (53%). In six cases death was related to vascular complication, in one case death was related to septic shock. Two deaths occurred after IE was cured, one due to intractable cardiac insufficiency and one due to digestive hemorrhage caused by an antivitamin K adverse event.

4. Vascular complications were distributed as follows 4.1. Neurological vascular complications We observed ten neurological vascular complications. Clinical presentations included: eight cases of hemiplegia, four cases of aphasia and facial palsy, and one case of seizure. The neurological vascular complication revealed the IE in seven cases. It was an ischemic stroke (IS) in five patients (sylvian territory) and hemorrhagic stroke (HS) in five cases (three cases of intracerebral hemorrhage, one case of cerebromeningeal hemorrhage, and one case of subdural frontoparietal hematoma). Four patients died in this group (one patient presenting with IS and HS, one patient with isolated HS, and one patient with intracerebral hemorrhage and subdural hematoma). One patient died in septic shock.

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Table 2 Distribution of vascular complications according to location of vegetations. Répartition des complications vasculaires en fonction du siège des végétations. Location of vegetations

Number of patients (17)

Number of complications (22)

Embolic (16)

Hemorrhagic (5)

Aneurysm (1)

Mitral Aortic Mitro-aortic Tricuspid

10 03 02 02

14 04 02 02

09 (56.3%) 03 (18.8%) 02 (12.5%) 02 (12.5%)

05 (100%) – – –

– 01 (100%) – –

4.2. Arterial complications in the limbs There were seven arterial complications in the limbs. Six embolisms were observed: three in the common femoral artery, one in the deep femoral artery, one in the popliteal artery, and one in the humeral artery (the last two mentioned were observed in the same one patient). One patient presented with embolism of the right common femoral artery and aortic IE; there was a recurrence in the contralateral side one month later. These complications were revealed by acute limb ischemia, which in one case was complicated by toe gangrene (popliteal embolism). One case of mycotic sacciform aneurysm 9.6 mm in axial diameter the diagnosis of which had been suspected was confirmed by an angioscan of the lower limbs. Arterial disobstruction with a Fogarty probe was performed in three cases of arterial embolism (femoral). The one case of aneurysm was treated surgically. Two patients, one presenting with deep femoral embolism and the other with popliteal and humeral embolism were discharged against medical advice. Two patients died in this group after cure of IE, one because of intractable cardiac insufficiency and one because of digestive hemorrhage. 4.3. Myocardial infarction (MI) (two cases) In one case it was an antero-septal MI occurring after 4 days of hospitalization for a mitro-aortic IE and in the other case an extended anterior MI after 27 days of hospitalization for a mitral IE. Both cases were complicated by cardiogenic shock followed by death. 4.4. Pulmonary embolism It was observed in two cases. Both patients presented with basithoracic pain and hemoptysis on tricuspid IE. The control TTE showed a significant decrease of vegetation size. The thoracic angioscan has revealed a bilateral pulmonary embolism in one case and a right pulmonary embolism in the other case. The outcome was favorable with medical treatment. 4.5. Splenic infarction Its diagnosis was made post-mortem in one case of mitroaortic IE in a 35 year-old patient. The patient died, presenting with diffuse abdominal pain. The necropsy revealed mitro-aortic vegetations, diffuse purulent peritonitis due to a ruptured splenic abscess within a splenic infarcts.

The relationship between the causal IE bacterium and vascular complications is reported in Table 3. The three cases of staphylococcus and the cases of streptococcal infection resulted in embolisms whereas the two other bacteria caused hemorrhagic accidents. 5. Discussion Vascular complications (VC) of IE are frequent and diverse. But their global frequency is difficult to assess, because on one hand most publications are made on isolated cases or only deal with the study of some VCs, and on the other hand because these complications are often asymptomatic. Around 20% of embolisms during IE could be totally asymptomatic [5]. The frequency and localization of VC in our study are comparable to those of other African [6] and European studies [3,4] even though underlying cardiac diseases are different (rheumatismal valve diseases in Africa, degenerative valve diseases and valve prosthesis in Europe). All the authors report the early occurrence of VCs in the course of IE and its revealing character [7,8]. Zarzur [7] reported that VC had revealed the IE in ten cases and more than half of complications (54%) occurred before the end of the second week of antibiotic treatment. In our study, seven VC (31.8%) revealed the IE and seven complications (31.8%) occurred before the end of the second week of antibiotic treatment. The incidence of VC decreases sharply after initiation of antibiotic treatment [9]. The number of negative hemocultures was high in our study as in most African series [7] contrary to European series. This may be explained in part by antibiotic intake prior to hospitalization, the lack of financial means for patient who must pay for hemoculture (no social security coverage), and probably due to an inadequate hemoculture technique. But it should be stressed that hemocultures remained negative even when they were performed in febrile patients and on appropriate medium. Echocardiography is essential for the prediction of embolisms [10]. Several factors are associated to an increased risk of embolisms. The volume and mobility of vegetations are the most predictive independent factors for new embolisms [10]. In our study, all the patients presented with valve vegetations as visualized by echocardiography. This could increase the risk for embolisms or simply be related to diagnostic criteria for IE which we used since most hemocultures were negative. Staphylococcus aureus IE is another factor positively associated with embolisms [11,12]. In our study, the three patients with staphylococcal IE presented with embolisms.

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Table 3 Relationship between bacteria implicated in infective endocarditis (IE) and vascular complications. Relation entre bactérie en cause de l’endocardite infectieuse (EI) et les complications vasculaires. Complications

Total number (22)

Staphylococcus (3)

Streptococcus (2)

Citobacter spp. (1)

Hemoculture (–) (10)

Embolism Hemorrhage Aneurysm

16 5 1

3 (100%) – –

1 (50%) 1 (50%) –

– 1 (100%) –

12 (120%) 3 (30%) 1 (10%)

VCs were most often neurological vascular complications (45.5%). These neurological complications are also the most frequently reported VCs of the IE. Their frequency ranges from 10 to 40% of all IE [13]. The most frequent neurological complication is ischemia. Symptomatic IS was reported in 10 to 35% of IE and accounts for around 50% of neurological complications of IE [12]. They are mainly the consequence of emboli from valve vegetations. The clinical consequences are related to the size of the emboli [12]. More than 40% of brain embolisms occur in the area of the mid-cerebral artery [14]. In our study, every case of IS concerned the area of the mid-cerebral artery (Sylvian segment). Hemorrhagic complications are less frequent than ischemia. They account for 12 to 30% of neurological complications depending on series [15,16]. Hemorrhage may be explained by three main mechanisms: the hemorrhagic transformation on an IS, the rupture of an intracranial mycotic aneurysm, and the rupture of an intracranial vessel due to necrotizing arteritis [17]. In our study, ischemic and hemorrhagic CVAs were equally frequent. Intracranial mycotic aneurysm was due to the septic embolism of a vegetation, in cerebral arteries [12]. They are rare and account for less than 10% of neurological complications of IE [18]. They present the potential risk of intracerebral or meningeal rupture. We did not observe any case of intracranial mycotic aneurysm, probably because none of our patients underwent cerebral angiography. These neurological complications contribute to the morbidity and mortality of the disease [19]. Arterial complications of the lower limbs are most often acute ischemia in the limbs due to an arterial embolism of vegetations. Their frequency ranges from 20 to 30% [20]. In our study, the frequency was 27.3%. Acute ischemia in the limbs concerns the lower limbs more than the upper limbs are usually multiple and recurrent [7]. Limb arteries are the second most frequent site of mycotic aneurysms after cerebral arteries. The diagnosis is made in the clinic with an arterial echo Doppler. But sometimes the diagnosis requires using an angioscan, as was the case for the only femoral aneurysm observed in our study. Coronary complications of septic origin are much more rare. But post-mortem studies have revealed micro-embolisms in the coronary arteries in 60% of cases in IE [21]. The clinical presentation is acute MI. Management is often difficult because of the bad hemodynamic status and the septic state of the embolus [22]. Splenic infarction is a common complication in case of left heart IE (around 40%). It is most often asymptomatic [9]. Nevertheless it is rarely associated to a splenic abscess (around 5% of the cases) [23]. It usually presents as multiple lesions due to the obliteration of a splenic artery branch or of a ramification. Complications affecting the splenic artery are more rare [24].

Splenic infarction, in our series, was complicated by a splenic abscess and diffuse peritonitis responsible for the patient’s death. Septic pulmonary embolism is a frequent complication of right heart IE. But they are less frequent than left heart IE and affect mots often the tricuspid valve. Isolated pulmonary complications are rare and usually associated to tricuspid IE. The clinical presentation of septic pulmonary embolism is repeated pneumonia. The diagnosis is made with an angioscan. The outcome depends on the virulence and antibiotic susceptibility of the bacterium [25]. 6. Conclusion Vascular complications of IE are frequent, the most common are neurological. They are life threatening and/or debilitating for patients. These complications are multiple and polymorphous, and often asymptomatic. Their incidence decreases sharply after initiation of antibiotic treatment. Hence, they may be prevented with an early and appropriate management of IE. Disclosure of interest The authors declare that they have no conflict of interest concerning this article. References [1] Baddour LM, Wilson WR, Bayer AS, Fowler Jr VG, Bolger AF, Levison ME, et al. Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the American Heart Association; endorsed by the Infectious Diseases Society of America. Circulation 2005;111:394–434. [2] Hoen B, Alla F, Selton-Suty C, Béguinot I, Bouvet A, Brianc¸on S, et al. Association pour l’étude et la prévention de l’endocardite infectieuse (AEPEI) Study Group. Changing profile of infective endocarditis: results of a 1-year survery in France. JAMA 2002;288:75–81. [3] Cabell CH, Jollis JG, Peterson GE, Corey GR, Anderson DJ, Sexton DJ, et al. Changing patient characteristics and the effect on mortality in endocarditis. Arch Intern Med 2002;162:90–4. [4] Li JS, Sexton DJ, Mick N, Nettles R, Fowler Jr VG, Ryan T, et al. Proposed modifications to the Duke criteria for diagnosis of infective endocarditis. Clin Infect Dis 2000;30:633–8. [5] Di Salvo G, Habib G, Pergola V, Avierinos JF, Philip E, Casalta JP, et al. Echocardiography predicts embolic events in infective endocarditis. J Am Coll Cardiol 2001;31:1069–76. [6] Beard Th, Hannachi N, Meddeb I. Complications vascualires dans l’endocardite infectieuse. A propos de 86 cas. Ann Cardiol Angeiol 1992;41:127–35. [7] Zarzur J, Amri R, Cherradi R, Housni A, Balafrej K, Arharbi M. Les complications vasculaires de l’endocardite infectieuse. Etude rétrospective de 18 cas. J Mal Vasc 2002;27(2):82–7.

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