Sudden death in infective endocarditis

The case fatality rate of infective endocarditis (IE) is high and is associated with varying causes. Among them, acute myocardial infarction due to an embolism in a coronary artery is rare; the incidence of this complication in the setting of IE is reported to be up to 1.5%. We report a case of sudden death in a 22-year-old woman diagnosed with systemic lupus erythematosus who was referred to the Cardiology Center for the treatment of mitral valve incompetence due to IE. She was hemodynamically stable with antibiotic therapy and vasoactive drugs, despite severe mitral valve regurgitation. Unexpectedly, she presented cardiac arrest and died. The autopsy showed total occlusion of the left main coronary artery by septic embolus, which originated from the mitral vegetation, as the cause of death. Thus, although a rare complication, it should always be kept in mind that a coronary embolism can be a lethal complication of IE, and the possibility of surgical treatment combined with the underlying antibiotic therapy should be raise

Sudden death in infective endocarditis

The case fatality rate of infective endocarditis (IE) is high and is associated with varying causes. Among them, acute myocardial infarction due to an embolism in a coronary artery is rare; the incidence of this complication in the setting of IE is reported to be up to 1.5%. We report a case of sudden death in a 22-year-old woman diagnosed with systemic lupus erythematosus who was referred to the Cardiology Center for the treatment of mitral valve incompetence due to IE. She was hemodynamically stable with antibiotic therapy and vasoactive drugs, despite severe mitral valve regurgitation. Unexpectedly, she presented cardiac arrest and died. The autopsy showed total occlusion of the left main coronary artery by septic embolus, which originated from the mitral vegetation, as the cause of death. Thus, although a rare complication, it should always be kept in mind that a coronary embolism can be a lethal complication of IE, and the possibility of surgical treatment combined with the underlying antibiotic therapy should be raise

Bacteroides fragilis endocarditis: a case report and review of literature

Endocarditis due to Bacteroides fragilis is a rare disorder. This article describes a case of Bacteroides fragilis endocarditis associated with portal and superior mesenteric venous thrombosis in a patient without preexisting valvular heart disease and review the cases of endocarditis due to this anaerobic bacterium in medical literature since 1980

Endocarditis due to Coxiella burnetii (Q fever): a rare or underdiagnosed disease? Case report

A febre Q é uma zoonose de distribuição mundial causada por Coxiella burnetii, sendo raros os registros da doença no Brasil. Estudos soroepidemiológicos mostraram uma freqüência relativamente elevada de anticorpos contra Coxiella burnetii em populações com exposição ocupacional. Em humanos, pode se manifestar clinicamente como doença aguda ou crônica, sendo que a endocardite é a forma crônica mais freqüente da febre Q e de maior morbi-mortalidade. Relatamos um caso grave de endocardite por Coxiella burnetii adquirida no Brasil com desfecho fatal, apesar de antibioticoterapia adequada e tratamento cirúrgico valvar.Q fever is a zoonosis of worldwide distribution that is caused by Coxiella burnetii. However, reports of this disease in Brazil are rare. Seroepidemiological studies have shown relatively high frequencies of antibodies against Coxiella burnetii in populations with occupational exposure. In humans, it can be manifested clinically as acute or chronic disease. Endocarditis is the most frequent chronic form of Q fever and the form with the greatest morbidity and mortality. We report a severe case of endocarditis due to Coxiella burnetii acquired in Brazil that had a fatal outcome, despite specific antibiotic therapy and valve surgery treatment

Incremental value of B-type natriuretic peptide for early risk prediction of infective endocarditis

SummaryBackgroundEarly and accurate risk prediction is an unmet clinical need in patients with infective endocarditis (IE). The aim of this study was to determine the value of B-type natriuretic peptide (BNP) levels obtained on admission for the prediction of in-hospital death in IE patients.MethodsBetween 2009 and 2011, consecutive patients with IE diagnosed using the revised Duke criteria and admitted to the emergency department were evaluated prospectively. BNP levels were measured on admission. Death during hospitalization was the primary endpoint.ResultsAmong 104 consecutive patients with IE and with available BNP levels, 34 (32.7%) died in hospital. BNP levels were significantly higher in patients who died as compared to survivors (709.0 pg/ml vs. 177.5 pg/ml, p<0.001). The accuracy of BNP to predict death as quantified by the area under the receiver operating characteristics curve was 0.826 (95% confidence interval (CI) 0.747–0.905). The value of BNP was additive to that provided by clinical, microbiological, and echocardiography assessment. On multivariate analysis, new heart failure (hazard ratio (HR) 2.02, 95% CI 1.15–3.57, p=0.015), sepsis (HR 2.10, 95% CI 1.25–3.55, p=0.005), Staphylococcus aureus endocarditis (HR 2.67, 95% CI 1.60–4.45, p<0.001), left ventricular ejection fraction ≤55% (HR 1.63, 95% CI 1.00–2.65, p=0.047), and BNP (HR 1.04, 95% CI 1.02–1.06, p<0.001) were independent predictors of in-hospital mortality.ConclusionAmong patients with IE, BNP levels obtained on admission provide incremental value for early and accurate risk prediction

Validated Risk Score for Predicting 6-Month Mortality in Infective Endocarditis.

Background Host factors and complications have been associated with higher mortality in infective endocarditis (IE). We sought to develop and validate a model of clinical characteristics to predict 6-month mortality in IE. Methods and Results Using a large multinational prospective registry of definite IE (International Collaboration on Endocarditis [ICE]-Prospective Cohort Study [PCS], 2000-2006, n=4049), a model to predict 6-month survival was developed by Cox proportional hazards modeling with inverse probability weighting for surgery treatment and was internally validated by the bootstrapping method. This model was externally validated in an independent prospective registry (ICE-PLUS, 2008-2012, n=1197). The 6-month mortality was 971 of 4049 (24.0%) in the ICE-PCS cohort and 342 of 1197 (28.6%) in the ICE-PLUS cohort. Surgery during the index hospitalization was performed in 48.1% and 54.0% of the cohorts, respectively. In the derivation model, variables related to host factors (age, dialysis), IE characteristics (prosthetic or nosocomial IE, causative organism, left-sided valve vegetation), and IE complications (severe heart failure, stroke, paravalvular complication, and persistent bacteremia) were independently associated with 6-month mortality, and surgery was associated with a lower risk of mortality (Harrell's C statistic 0.715). In the validation model, these variables had similar hazard ratios (Harrell's C statistic 0.682), with a similar, independent benefit of surgery (hazard ratio 0.74, 95% CI 0.62-0.89). A simplified risk model was developed by weight adjustment of these variables. Conclusions Six-month mortality after IE is 25% and is predicted by host factors, IE characteristics, and IE complications. Surgery during the index hospitalization is associated with lower mortality but is performed less frequently in the highest risk patients. A simplified risk model may be used to identify specific risk subgroups in I

Community-acquired endocarditis due to Bartonella spp. and Coxiella burnetii: etiologic, epidemiologic and clinical investigations in patients with culture-negative endocarditis

Endocardite infecciosa é uma doença associada à elevada morbidade e letalidade. O diagnóstico precoce e o reconhecimento de sua etiologia podem contribuir para o sucesso do tratamento antibiótico; entretanto, cerca de um quarto das endocardites permanece sem diagnóstico etiológico. Este estudo teve como objetivo principal identificar a frequência de endocardite por Bartonella spp. e Coxiella burnetii dentre as endocardites com culturas negativas comunitárias e avaliar os fatores preditores dessas infecções. Como objetivo secundário compararam-se as características clínicolaboratoriais e prognósticas entre as endocardites comunitárias com culturas negativas e positivas. Foram avaliados também os fatores associados à letalidade intra-hospitalar das endocardites com culturas negativas. Entre janeiro de 2004 e janeiro de 2009, foram investigados 369 episódios consecutivos de endocardite em pacientes atendidos no Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - InCor HC-FMUSP. Foram estudados os casos que ocorreram em adultos, classificados pelos critérios de Duke modificados como \"endocardite definida\" e de origem comunitária. Assim, foram incluídos 221 episódios de endocardite, 170 com culturas positivas e 51 com culturas negativas. Neste último grupo, foram feitas as pesquisas sorológicas (reação de imunofluorescência indireta) e histopatológica de Bartonella spp. e Coxiella burnetii. Consideraram-se positivos títulos de imunoglobulina G (IgG) >= 800 para Bartonella henselae e ou Bartonella quintana, e IgG antifase I para C. burnetii > 800. O estudo histopatológico das valvas cardíacas foi capaz de identificar morfologicamente a etiologia de 87% das endocardites com culturas negativas, enquanto que o método de Gram do tecido a fresco o fez em somente 10% dos casos. As endocardites com culturas negativas apresentaram maior frequência de dispneia à admissão (p=0,001), menor valor de proteína C reativa (p=0,009), menor Fração de Ejeção do Ventrículo Esquerdo (Feve) (p=0,022) e necessitaram de mais tempo para o início do tratamento antibiótico para endocardite (p = 800 and for Coxiella burnetii with antiphase I IgG titers > 800. Histopathological studies of the cardiac valves were capable of morphologically identifying the etiology in 87% of the culture-negative endocarditis cases, whereas the Gram stain was only positive in 10% of cases using fresh tissue. Culture-negative endocarditis patients presented a greater frequency of dyspnea on admission (p=0.001), lower C-reactive protein levels (p=0.009), and a lower left ventricular ejection fraction (LVEF) (p=0.022), and they required more time to start antibiotic therapy (p < 0.001) when compared with culture-positive patients. There was no statistically significant difference between the two groups regarding in-hospital lethality or survival after hospital discharge. Diabetes mellitus (p=0.01) or severe sepsis on admission (p=0.01) were independently associated with in-hospital death for culture-negative endocarditis. Ten cases of endocarditis caused by Bartonella spp. (frequency 19.6% [IC95%: 9.8 - 33.1]) and 4 caused by Coxiella burnetii (frequency 7.8% [IC95%: 2.2 - 18.9]) were diagnosed among the 51 cases of culture-negative endocarditis. Endocarditis caused by Bartonella spp. was associated with lower LVEF values (p=0.025), the identification of Gram-negative coccobacilli in cardiac valve histology (p=0.001) and the presence of a cat in the patient\'s residence (p=0.001). Conclusions: Bartonella spp. and Coxiella burnetii were the causative etiology of almost one-third (27.5%) of the community-acquired cases of culture-negative endocarditis. The presence of a cat in the patient\'s residence, a LVEF <= 45% and the identification of Gram-negative coccobacilli in the histological examination of the cardiac valve in patients with culturenegative endocarditis appear to be associated with Bartonella spp. as the causative etiology. Histological examination of the cardiac valves allowed for morphological identification of the causative microorganism in the majority of cases, even when blood cultures were negative. There was no difference in in-hospital lethality or long-term survival between the two groups. The presence of diabetes mellitus or severe sepsis at admission was associated with in-hospital death in cases of culture-negative endocarditi