Campbell, NP

Kerr, JR

McGimpsey, JG

Webb, CH

English

PubMed

St George's Online Research Archive

The Ulster Medical Journal, Volume 63, No. 1, pp. 108 - 110, April 1994.Case Report:Infective endocarditis due toGemella morbillorum complicatinghypertrophic obstructive cardiomyopathyJ R Kerr, C H Webb, J G McGimpsey, NPS CampbellAccepted 11 January 1994.This report documents successful medical treatment of endocarditis caused byan infrequently encountered and recently renamed organism, occurring fourweeks post-dental extraction in a patient with pre-existing hypertrophicobstructive cardiomyopathy.CASE REPORTA 29 year old woman with hypertrophic obstructive cardiomyopathy wasadmitted to hospital in July 1992 with a history of persistent lethargy. Threeweeks previously she had suffered a flu-like illness with night sweats and drycough. The sweats had subsided but she still felt unusually warm at night. Aweek prior to this episode she had developed a swollen and tender left kneewhich had quickly settled on a non-steroidal anti-inflammatory drug. Threemonths prior to admission extraction of two wisdom teeth had been performedunder oral antibiotic prophylaxis: this had comprised three doses each of 3gamoxycillin; (1 hr before, 3 and 18 hr post-operation). Recovery following thisprocedure had been uneventful. She had been taking propranolol 40mg fourtimes a day to increase exercise tolerance, and thyroxine 50,ug daily to induceshrinkage of a goitre. The day before admission her general practitioner hadprescribed vitamin B12 1 000,ug and ofloxacin 400mg twice a day. On examinationshe had a small goitre, temperature 37.50C, heart rate 1 00/min, blood pressure90/60mmHg; there was a loud systolic murmur at the left sternal edge radiatingto all areas. Dental examination was unremarkable. The erythrocytesedimentation rate was 45 mm in the first hour, white cell count 8,200/uL.Electrocardiography showed marked left ventricular hypertrophy, and a trans-thoracic echocardiogram showed severe hypertrophic obstructivecardiomyopathy. No vegetations were seen.Royal Victoria Hospital, Belfast BT12 6BA.J R Kerr, BSc, MB, DipRCPath, Senior Registrar in Microbiology.C H Webb, BDS, MB, FRCPath, Consultant Microbiologist.J G McGimpsey, BDS, BSc, MDS, FDSRCPS, FFDRCS, Consultant Oral Surgeon.N P S Campbell, MD, FRCP, Consultant Cardiologist.Correspondence to Dr Kerr© The Ulster Medical Society, 1994.Gemella morbillorumOn the second day blood cultures grew an a-haemolytic, nutritionally variantgram-positive coccus growing in chains, requiring serum and vitaminsupplements in order to grow; this was biochemically identified by the APIStrepidentification system (BioMerieux, France) as Gemella morbillorum. Empiricaltreatment was started with intravenous benzylpenicillin 1.2g four times a day,and gentamicin 80mg three times a day. Both the minimum inhibitoryconcentration and the minimum bactericidal concentration of penicillin for theorganism were subsequently shown to be less than 0.06,ug/ml. The pyrexiaresolved after four days. At this stage serological tests for Q fever, chlamydia,adenovirus, mycoplasmia, legionella and brucella infection were reported to benegative. During the second week the patient gradually became lethargic, theerythrocyte sedimentation rate rose to 1 1Omm in the first hour, her temperaturerose to 380C and a self-limiting left elbow arthralgia developed. She wasthought to have become sensitised to penicillin and towards the end of the thirdweek of treatment antibiotics were changed to oral erythromycin 500mg fourtimes a day and oral rifampicin 900mg per day. The minimum inhibitoryconcentrations of the isolate were <0.25 and <0.5gg/ml respectively and ineach case the minimum bactericidal concentration was equal to the minimuminhibitory concentration. Two days later her temperature had settled again. Onday 26 a generalised itchy erythematous maculopapular rash developed whichsettled within 24 hours on oral chlorpheniramine. Treatment continued for atotal of six weeks after which she was discharged. She remains clinically well to date.DISCUSSIONInfective endocarditis is a rare complication of hypertrophic obstructivecardiomyopathy. Sixty-one cases were reported between 1961 and 1990.1 Theoverall mortality rate of infective endocarditis associated with hypertrophicobstructive cardiomyopathy is reported as 39%, compared to 20-30% for otherforms of endocarditis.2 3 Antibiotic prophylaxis is given for dental or otherprocedures which may cause bacteraemia in patients with underlying heartdisease predisposing to endocarditis.The British Society for Antimicrobial Chemotherapy recommendations for oralantibiotic prophylaxis for patients who are not allergic to penicillin and whoundergo general anaesthesia for a dental procedure are 3g amoxycillin orallyfour hours before anaesthesia followed by a further 3g as soon as possibleafterwards.4 Gemella morbillorum, formerly known as Streptococcusmorbillorum,5 is an anaerobic to aerotolerant gram-positive coccus whosetaxonomic position has been uncertain. The natural habitat of the organism isthe human intestinal tract. It is a rare but important pathogen and has beenassociated with endocarditis and suppurative infections.6 As the dental antibioticprophylaxis given in this case can be considered adequate, and the causativeorganism was fully sensitive to penicillin, infective endocarditis may haveresulted from a spontaneous bacteraemia of gastro-intestinal origin occurringat a different time from the dental extraction; most cases of infective endocarditisfollow seemingly 'spontaneous' bacteraemia7. This case illustrates theunpredictable nature of bacteraemia which may result in infective endocarditisin predisposed individuals, and underlines the role of hypertrophic obstructivecardiomyopathy as a risk factor.© The Ulster Medical Society, 1994.109110 The Ulster Medical JournalREFERENCES1. Alessandri N, Pannarale G, del Monte F, Moretti F, Marino B, Reale A. Hypertrophicobstructive cardiomyopathy and infective endocarditis: a report of seven cases and a reviewof the literature. Europ Heart J 1990; 1 1: 1041 -8.2. Gray IR. Infective Endocarditis. 1937-1987. Br Heart J 1987; 57: 211-3.3. Gorodezky M. Endocarditis Maligna. Perspectiva hist6rica. Arch Inst Cardiol Mex 1986; 1 12:107-13.4. Working Party of the British Society for Antimicrobial Chemotherapy. Antibiotic prophylaxisof infective endocarditis. Lancet 1990; 335: 88-9.5. Kilpper-Balz R, Schleifer KH. Transfer of Streptococcus morbillorum to the genus Gemella asGemella morbillorum combe. nov. Int J System Bacteriol 1988; 38: 442-43.6. Mandell GL, Douglas RG Jr, Bennett JE. Eds. Principles and Practice of Infectious Diseases.3rd Edition, New York/Edinburgh: Churchill Liuingstone 1990; 1564-5.7. Oakley CM. Controversies in the prophylaxis of infective endocarditis: a cardiological view.J Antimicrob Chemother 1987; 20 Suppl A: 99-104.© The Ulster Medical Society, 1994.

Controversies in the prophylaxis of infective endocarditis: a cardiological view.

Endocarditis Maligna. Perspectiva hist6rica. Arch Inst Cardiol Mex

Hypertrophic obstructive cardiomyopathy and infective endocarditis: a report of seven cases and a review of the literature.

Infective Endocarditis.

Principles and Practice of Infectious Diseases. 3rd Edition,

Transfer of Streptococcus morbillorum to the genus Gemella as Gemella morbillorum combe.

Working Party of the British Society for Antimicrobial Chemotherapy. Antibiotic prophylaxis of infective endocarditis. Lancet

INFECTIVE ENDOCARDITIS DUE TO GEMELLA-MORBILLORUM COMPLICATING HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2449104

INFECTIVE ENDOCARDITIS DUE TO GEMELLA-MORBILLORUM COMPLICATING HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY

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