UnUsUal presentation of endoCarditis with nUtritional variant streptoCoCCi Case presentation

Case presentation We describe a 61 year-old caucasian male who presented to our hospital complaining of sudden onset diplopia which lasted over 24-hour period. He had become aware of double images while working at his computer the previous night. There were no other associated symptoms like orbital pain, headache, neck stiffness, fever, chills, night sweets, skin rash, lightheadedness, dizziness, weakness or paresthesias. Review of systems was only positive for 30 pounds weight loss over the previous six-month period. He denied head trauma, recent dental procedures or intravenous drug use. The patient's past medical history was significant for a lumbar epidural abscess 6 months before this presentation. He underwent lumbar decompression, bone and facet removal due to complete erosion and drainage of the epidural abscess. The pathology only showed reactive periostitis and cultures of bacteria and fungi were both negative. Trans-thoracic echocardiogram did not reveal any vegetation. He was discharged home on intravenous Ceftriaxone to complete an 8 weeks course. Follow up MRI of the lumbar region showed no evidence of recurrent or persistent infection. On physical examination the patient was a middleaged man in no apparent distress. His vital signs were within normal limit. There were no conjunctival hemorrhages, splinter hemorrhages, Janeway lesions or Osler nodes noted. Heart examination revealed an old grade 3/6 systolic murmur best heart over the apex, with no radiation. His neurological exam was normal except for the following ocular findings: binocular diplopia, the adduction of the right eye was impaired while the abduction was intact. The majority blood work was essentially normal ruling out the common infectious agents, except for erythrocyte sedimentation rate (ESR) which was 60 (normal values <15). Soon after the admission, imaging of the head was performed with computer tomography (CT) scan, followed by an magnetic resonance imaging (MRI) of the brain and both tests failed to reveal any focal abnormalities of the brain that could explain the symptoms and the physical findings. The ultrasound of the carotids showed no significant stenosis on either side. Meningitis was ruled out with a lumbar puncture which failed to reveal any infectious process in the central nervous system (CNS) The culture, the Lyme antibody and Herpes polymerase chain reaction (PCR) obtained from the cerebrospinal fluid were all negative. The trans-thoracic echocardiogram was performed to rule out endocarditis and it revealed a mobile echogenic structure attached to the anterior mitral valve leaflet. The echocardiodiogram was followed by a trans-esophageal echocardiogram (TEE) and blood cultures to confirm the diagnosis. TEE showed a mobile mass very suggestive for endocarditi

Cardiovascular Biomarkers and Subclinical Brain Disease in the Atherosclerosis Risk in Communities Study

BACKGROUND AND PURPOSE: Cerebrovascular and cardiovascular disease share common risk factors. Our goal was to determine if levels of N-terminal brain natriuretic peptide (NT-proBNP) and cardiac troponin T measured with a highly sensitive assay (hs-cTnT) are associated with silent brain infarcts (BI) and white matter lesions (WML) on magnetic resonance imaging (MRI) in the Atherosclerosis Risk In Communities (ARIC) study. METHODS: 1920 participants had brain MRI at ARIC visit 3 (1993–1995). NT-proBNP and hs-cTnT were measured in all individuals at ARIC visit 4 (1996-1998). Of 1920 individuals, 1112 had a follow-up MRI in 2004-2006. We analyzed the association of NT-proBNP and hs-cTnT with MRI-defined BI and WML on the initial MRI and incident BI and WML progression on the follow-up MRI in participants without heart failure, coronary heart disease, or stroke. RESULTS: In the adjusted model, individuals in the highest NT-proBNP quartile had significantly more BI (odds ratio [OR] 3.50, 95% confidence interval [CI]2.03-6.20) and WML (β-coefficient 0.09[standard error](SE) 0.03]) on the baseline MRI and more incident BI (OR 2.18, 95% CI [1.38-3.47]) and WML progression (β-coefficient 0.22 (SE 0.10)] on the follow-up MRI. Individuals in the highest hs-cTnT category had more BI (OR 3.03, 95% CI [1.57-5.82) and WML (β-coefficient 0.11 [SE 0.04]) on the initial MRI and more WML progression (β-coefficient 0.43 [0.17]) on the follow-up MRI. CONCLUSION: NT-proBNP and hs-cTnT are independently associated with silent MRI-defined BI and WML suggesting that cardiovascular biomarkers may be useful to identify individuals with subclinical cerebral injury

Cardiovascular biomarkers and subclinical brain disease in the atherosclerosis risk in communities study

Background and purpose: Cerebrovascular and cardiovascular disease share common risk factors. Our goal was to determine whether levels of N-terminal brain natriuretic peptide (NT-proBNP) and cardiac troponin T measured with a highly sensitive assay (hs-cTnT) are associated with silent brain infarcts (BIs) and white matter lesions (WMLs) on MRI in the Atherosclerosis Risk in Communities (ARIC) study.Methods: At ARIC visit 3 (1993-1995), 1920 participants had brain MRI. NT-proBNP and hs-cTnT were measured in all individuals at ARIC visit 4 (1996-1998). Of 1920 individuals, 1112 had a follow-up MRI [2004-2006]). We analyzed the association of NT-proBNP and hs-cTnT with MRI-defined BI and WML on the initial MRI and incident BI and WML progression on the follow-up MRI in participants without heart failure, coronary heart disease, or stroke.Results: In the adjusted model, individuals in the highest NT-proBNP quartile had significantly more BI (odds ratio, 3.50; 95% confidence interval, 2.03-6.20), and WML (β-coefficient, 0.09; SE, 0.03) on the baseline MRI and more incident BI (odds ratio, 2.18; 95% confidence interval, 1.38-3.47) and WML progression (β-coefficient, 0.22; SE, 0.10) on the follow-up MRI. Individuals in the highest hs-cTnT category had more BI (odds ratio, 3.03; 95% confidence interval, 1.57-5.82) and WML (β-coefficient, 0.11; SE, 0.04) on the initial MRI and more WML progression (β-coefficient, 0.43; SE, 0.17) on the follow-up MRI.Conclusions: NT-proBNP and hs-cTnT are independently associated with silent MRI-defined BI and WML, suggesting that cardiovascular biomarkers may be useful to identify individuals with subclinical cerebral injury

Ceruloplasmin and Heart Failure in the Atherosclerosis Risk in Communities Study

BACKGROUND: Ceruloplasmin (Cp) decreases nitric oxide bioavailability in blood and has been associated with cardiovascular disease (CVD) in clinical studies. We assessed the association between Cp and incident heart failure (HF), death and CVD in the Atherosclerosis Risk in Communities (ARIC) Study. METHODS AND RESULTS: Cp was measured at ARIC visit 4 (1996–1998). We studied 9,240 individuals without HF or CVD at ARIC visit 4, and followed them for a mean of 10.5 years. Genome-wide association study was performed to identify genetic determinants of Cp levels and evaluate their association with incident HF. Cp levels (mean±standard deviation) were higher in women vs men (335±79 vs 258±44 mg/L, p<0.0001), women on vs not on hormone-replacement therapy (398±89 vs 291±60 mg/L, p<0.0001) and African Americans vs Caucasians (299±63 vs 293±74 mg/L, p=0.0005). After adjusting for traditional risk factors, high-sensitivity C-reactive protein, N-terminal pro–B-type natriuretic peptide, and high-sensitivity cardiac troponin T, higher levels of Cp were associated with HF (hazard ratio [HR] 1.44, 95% confidence interval [CI] 1.13–1.83) and mortality (HR 1.38, 95% CI 1.11–1.63). A locus on the ceruloplasmin gene on chromosome 3 was significantly associated with Cp levels (normal 295.56±77.60mg/L, heterozygote 316.72±88.02mg/L; homozygote 331.04±85.40mg/L, p=8.3×10(−)) but not with incident HF. After adjustment for traditional risk factors Cp levels were also weekly associated with CVD. CONCLUSIONS: Cp was associated with incident, HF mortality and CVD in the ARIC population. A single locus on chromosome 3 was associated with Cp levels but not with HF

Ceruloplasmin and heart failure in the atherosclerosis risk in communities study

Background: Ceruloplasmin (Cp) decreases nitric oxide bioavailability in blood and has been associated with cardiovascular disease (CVD) in clinical studies. We assessed the associations between Cp and incident heart failure (HF), death, and CVD in the Atherosclerosis Risk in Communities (ARIC) study.Methods and results: Cp was measured at ARIC visit 4 (1996-1998). We studied 9240 individuals without HF or CVD at ARIC visit 4 and followed them for a mean of 10.5 years. Genome-wide association study was performed to identify genetic determinants of Cp levels and evaluate their association with incident HF in ARIC participants. Cp levels (mean±SD) were higher in women versus men (335±79 versus 258±44 mg/L; P\u3c0.0001), women on versus not on hormone-replacement therapy (398±89 versus 291±60 mg/L; P\u3c0.0001), and African Americans versus whites (299±63 versus 293±74 mg/L; P=0.0005). After adjusting for traditional risk factors, high-sensitivity C-reactive protein, N-terminal pro-B-type natriuretic peptide, and high-sensitivity cardiac troponin T, higher levels of Cp were associated with HF (hazard ratio, 1.44; 95% confidence interval, 1.13-1.83) and mortality (hazard ratio, 1.38; 95% confidence interval, 1.11-1.63). A locus on the ceruloplasmin gene on chromosome 3 was significantly associated with Cp levels (normal 295.56±77.60 mg/L; heterozygote 316.72±88.02 mg/L; homozygote 331.04±85.40 mg/L; P=8.3×10(-13)) but not with incident HF. After adjustment for traditional risk factors, Cp levels were also weekly associated with CVD.Conclusions: Cp was associated with incident HF, mortality, and CVD in the ARIC population. A single locus on chromosome 3 was associated with Cp levels but not with HF