Alam, Mahboob

Ismai, Faisal Wasim

Smego, Raymond A

Tariq, M.

English

eCommons@AKU

eCommons@AKUSection of Internal Medicine Department of MedicineJanuary 2006Spectrum of neurological involvement in adultpatients with bacterial endocarditisFaisal Wasim IsmaiM. TariqAga Khan University, muhammed.tariq@aku.eduMahboob AlamRaymond A SmegoFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_med_intern_medPart of the Internal Medicine CommonsRecommended CitationIsmai, F., Tariq, M., Alam, M., Smego, R. (2006). Spectrum of neurological involvement in adult patients with bacterial endocarditis.Journal of College of Physicians and Surgeons Pakistan, 16(5), 343-346.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_med_intern_med/25ORIGINAL ARTICLE SPECTRUM OF NEUROLOGICAL INVOLVEMENT IN ADULT . PATIENTS WITH BACTERIAL ENDOCARDITIS Faisal Wasim Ismail, Mohammad Tariq, Mehboob Alam. Mohammad Ata Khan and Raymond Smego Jr ABSTRACT Objective: To describe the spectrum of neurological involvement, and document in-hospital mortality in adult patients with bacterial endocarditis. Design: Descriptive, non~interventional. Place and Duration of Study: Department of Gastroenterology, The Aga Khan University Hospital, Karachi from November 1999 to October 2002. Patients and Methods: Patients were enrolled from the emergency and outpatient departments, using purposive, non-probability sampling, provided they fulfilled pre-defined inclusion and exclusion criteria. Case records of patients admitted to hospital with a diagnosis of bacterial endocarditis were prospectively analyzed. Data was entered and analyzed on SPSS 11. Frequency, Mean, Mode and Percentage were calculated. Results: Neurological complications were observed in 14 out of 40 patients (35%). The most frequent complication was embolic infarction (33%), followed by intra-cranial hemorrhage (22 %). Seizures, encephalopathy, abscess and meningitis were all observed in decreasing order of frequency. Out of a total of 14 patients who suffered neurological complications, 06 died (42 %). Conclusion: The nervous system is frequently involved in patients with bacterial endocarditis. The nature of neurological involvement can vary from a fatal embolic infarction to infective complications, such as cerebral abscess or meningitis, to mild encephalopathy. The most frequently noted complication was embolic infarction. In-hospital mortality is significantly high in patients who suffer neurological complications. KEYWORDS: Bacterial endocarditis. Infection. Neurological complication. Mortality. Embolic infarction. INTRODUCTION Bacterial endocarditis (BE) is the proliferation of microorganisms on the endothelium of the heart. A similar process, involving arteriovenous shunts, arterioarterial shunts, or coarctation of the aorta is called bacterial endarteritis, but the patho-physiological process is the same. 1 Bacterial endocarditis can be divided into acute or sub-acute, or native or prosthetic valve endocarditis. In developed countries, the incidence of native valve endocarditis ranges from 1.5 to 6.2 cases per 100,000 populations per year.2 The incidence in the United States is 2-4 cases per 100,000.2 In Pakistan, the incidence is reported to be 0.43% in a single hospital based study.3 Endocarditis affects not only the heart, but also produces a wide variety of systemic signs and symptoms through several mechanisms, including both sterile and infected emboli, and a variety of immunological phenomena.4 Most patients with infective endocarditis have a heart murmur (most commonly pre-existing), and patients may have petechiae on the skin, conjunctivae, or oral mucosa, as well as splenomegaly and other peripheral manifestations. Sterile and infected emboli, and a variety of immunological phenomena underlie the peripheral manifestations. Among these are glomerulo-nephritis, Osler nodes, Roth spots, subungual (splinter) Department of __ ~~~!-~!.~-~: __ "!"_':1_~--~9~--~-~~n University Hospital, Karachi, Pakistan Correspondence: Dr. Faisal wasim Ismail, Department of Medicine, The Aga Khan University_t!~.~£~!§._~·--~?.~!i!f_~!t .. E~~istan. E-mail: faisal.ismail @aku.edu Received November 26, 2004; accepted April 10, 2006 JCPSP 2006, Vol. 16 (5): 343-346 hemorrhages, abnormalities. microemboli.S and possibly, various musculoskeletal Janeway lesions usually arise from infected The nervous system is a common site of involvement in BE, which can have profound and devastating neurological consequences. In 10-15% of patients with BE, the nervous system yields the first clinical signs.2 The incidence of central nervous system (CNS) complications in BE is approximately 30%, but ranges, according to various studies, from 15-55%. The nervous system can be involved in a wide variety of ways in BE, ranging from mild encephalopathy to a fatal cerebral hemorrhage or embolic infarction.6 In-hospital mortality is globally very high in these patients, but data regarding the spectrum of neurological involvement, and associated mortality is lacking from developing countries. Therefore, the objective of this study was to describe the spectrum of neurological involvement, and document in-hospital mortality in adult patients with bacterial endocarditis. p ATTENTS AND METHODS The study was a non-interventional, descriptive study conducted for a period of three years, starting November 1999 to November 2002. Patients were enrolled from the emergency and outpatient departments, using purposive, non-probability sampling. Data was collected with the help of a proforma, which was concise and relevant to the objectives of the study. Main 3 Neurological involvement in bacterial endocarditis from seizure_<; to be between 10-30 %. Le Cam reports 24 %HI, and Kanter9 reports 19% in their studies on the frequency of ' seizures in adults ~uffering· from bacterial endocarditis. Results from other studies also support this finding.12,!3 Cerebral abscesses (Figure 3), occurring as a complication of ·endocarditis, has been reported in literature. Similar observations were made by Lernt..>rl2, K-mter9 and Jone.<:;14 who reported frequencies of 10.5%, 15°1<), and 16.4% respectively. Le Cam10 reported a frequency of 4 out of 48 patients, with a percentage of 8.3%. However, a study by Patel reported a high frequency of 31% of abscesses.JS This may be because this was a study based on autopsy material, where small micro abscess are picked up in higher numbers compared to other studies where imaging is the modality for identifying abscesses in the living. EncephalopJthy was observed in 11.2 %. Encephalopathy is said to be present in 5-15% of patients with endocarditis, which can be attributable purely to non-metabolic cauf;es.2 In this study, only those patient!-> suffered from encephalopathv in whom other causes for an encephalopathic state, such ;s renal, hepatic or septic abnormalities were nnt present. In this way, the results of this study reflect similar ob.'>ervation_c; as in various published data. K;:mter reported encephalopt~thy in 22% of patients with endocarditis, but after excluding other contributing factors, reported a percentage of 14'1,,9, which was attributable to endocarditis. Francioli reported encephalo-pathy in 10% of patients in his study.l6 Meningitis occurred in 5.5 % of patients. Kanter observed a frequency of 5 %9, although Le Cam reported a frequency of 6 cases of meningitis in 48 patients (12.5 %)!0, and Patel reported meningitis to occur in 14% of patients.15 Other data have reported the frequency of meningitis between 5-15%_14,16,17 The present results of an in-hospital mortality rate of 42.86 % arc consistent with global literature that document similar figures. Multiple studies have shown that neurological complications are associated with increased mortality in patients with endocarditis. However, Millaire reported no increase in mortality rates in patients with neurological com plica tlon;;;.17 Most studies have, however, reported an increased mortality in patients with neurological complication_.:; in endocarditis.18,!9 Chen repnrted a 50% mortality rate7, while Santoshkumar reported a mortality of 41.4 %.11 Le Cam observed a very high mortality rate of 83% in pa tient,s with neurological complications.10 The majority of studies, though, have observed mortality rates between 40-55 %_20-24 In contrast, in the 36 patients without neurolot,-rical involvement, only 4 patients died (11%), which clearly demonstrates that neurological involvement is related to increased mortality. CN('LUSION The nervous system is frequently involved in patients with bacterial endocarditis. The natt1re of neurological involvement can vary from a fatal embolic infarction to infective complications, such as cerebral abscess or meningitis, to mild encephalopathy. The most frequently noted complication is embolic infarction. In-hospital mortality is significantly high in patients who .suffer neurological complications. The focus must be on better preventive, diagnostic and therapeutic JCPSP 2006, Vol. 16 (5): 343-346 measures to prevent. the development of neurological complications. Rtl LRENCES 1. Karchmer AW. Infective endocarditis. In: Braunwald E, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL, (edi). Harrison's principles of internal medicine. 15th ed. New York: McGraw-Hill, 2001 : 809-16. 2. Hargrave K, Kothari M. Neurological sequelae of infectious endocarditis. e~edicine J [serial online] April2002 [cited 2002 Jun 1]; 3(4). Available from URL: http://www.emedicine.com/ neurology/infections/neurological sequelae of infectious endocarditis. 3. Tareen AM, Aziz KD, Najeeb MA. Clinical profile of infective endocarditis at NICVD Karachi. Pak] Cardto/1998; 9: 53-6. 4. Pelletier L, Brusch J. Infectious endocarditis. eMedicine J [serial online] January 2002 [cited 2002 July 10]; 1(2). Available from URL: http://www.emedicine.com/internal medicine/infection/ infectious endocarditis 5. Mylonakis E, Calderwood SB. Infective endocarditis in adults. t·iEngl]Med 2001; 345:1318-28. 6. Sadiq M, Rathore AH, Nazir M, Sheikh SA. Infective endocarditis in children: diagnosis and management in a developing country. ltlkl'tu:dCardio/j 2000; 2(1-2): 9-14. 7. Chen CH, Lo MC, Hwang KL, Liu CE, Young TG. Infective endocarditis with neurological complications: 1 0-year experience. ] Microbial Jmmuno/ Infect 2001; 34: 119·24. 8. Mansur AJ, Grinberg M, da Luz PL, Belloti G. The complications of infective endocarditis. A re-appraisal in the 1980s. Arch Intern Med 1992; 152: 2428-32. 9. Kanter MC, Hart RG. Neurologic complications of infective endocarditis. Neurology 1991; 41: 1015-20. 10. Le Cam B. Guivarch G, Boles JM, Garre M, Cartier F. Neurological complications in a group of 86 bacterial endocarditis. Eur lleart] 1984; 5: 97-100. 11. Santoshkumar B, Radhakrishnan K, Balakrishnan KG, Sarma PS. Neurological complications of infective endocarditis observed in a south Indian referral hospital.] Neurol Sd 1996; 137: 139·44. 12. Lerner P. Neurologic complications of infective endocarditis. !vied Clin North Am 1985; 69: 385-98. 13. Tornos MP, O!ona M, Permanyer·Miralda G, Almirante B, Evangelista A, Soler-Soler J. Is the clinical spectrum and prognosis of native valve infective endocarditis in non-addicts changing? Eur lleartj 1995; 16: 1686-91. 14. Jones HR, Siekert RG. Neurological manifestations of infective endocarditis. Review of clinical and therapeutic challenges. Brain 1989; 112( P15): 1295-315. 15. Patel FM, Das A, Banerjee AK. Neuropathological complications of infective endocarditis: study of autopsy material. Neurol India 2001; 49:41-6. 16. Francioli P. Central nervous system complications of infective endocarditis. In: Scheid WM, Whiteley RJ, Durack OT, (edi). Infections of the central nervous system. New York: Raven Press, 1991: 515-59. 17. Millaire A, Leroy 0, Gaday V, de Groote P, Beuscart C, Goullard L. Incidence and prognosis of embolic events and metastatic infections in infective endocarditis. Eur Heart] 1997; 18: 677-84. 18. Watanakunakorn C, Burkert T. Infective endocarditis at a large community teaching hospital, 1980·1990. A review of 210 episodes. Medidne 1993; 72: 90-102. 34" Neurological involvement in bacterial endocarditis from seizures to be between 10-30 %. Le Cam reports 24 %10, and Kanter9 reports 19% in their studies on the freguency of seizures in adults suffering from bacterial endocarditis. Results from other studies also support this finding.l2J3 Cerebral abscesses (Figure 3), occurring as a complication of t'!ndocarditis, has been reported in literature. Similar observations were made by Lernerl2, Kanter9 and Jones14 who reported frequencies of 10.5%, 15%, and 16.4% respectively. Le Cam10 reported a frequency of 4 out of 48 patients, with a percentage of 8.3%. However, a study by Patel reported a high frequency of 31% of abscesses.l-~ This may be because this was a study based on autopsy material, where small micro abscess are picked up in higher numbers compared to other studies where imaging is the modality for identifying abscesses in the living. Encephalopathy was observed in 11.2 %. Encephalopathy is said to be present in 5-JS% of patients with endocarditis, which can be attributable purely to non-metabolic causes.2 In this study;. only those patients suffered from encephalopathy in whom other causes for an encephalopathic state, such as renal, hepatic or septic abnormalities were not present. In this way, the results of this study renect similar observations as in various published data. Kanter reported encephalopathy in 22% of patients with endocarditis, but after excluding other contributing factors, reported a percentage of 14'Yo9, which was attributable to endoccHditis. Francioli reported encephalo-! pathy in 10 ';.{,of patients in his study.J6 Meningitis occurred in 5.5 % of patients. Kanter observed a frequency of 5 %9, although Le Cam reported a frequency of 6 case-; of meningitis in 48 patients (12.5 %)10, and Patel reported meningitis to occur in 14% of patients.IS Other data have reported the frequency of meningitis between 5-15%.14,16,17 The present results of an in-hospital mortality rate of 42.86 o;.:, are consistent with global literature that document similar figures. Multiple studies have shown that neurological complications are associated with increased mortality in patients with endocarditis. However, Millaire reported no increase in mortality rates in patients with neurological complications. I? Most studies have, however, reported an increased mortality in patients with neurological complications in endocarditis.lfl,19 Chen reported a 50% mortality rate7, while Santoshkumar reported a mortality of 41.4 %.11 Le Cam observed a very high mortality rate of 83% in patients with neurological complications.lO The majority of studies, though, have observed mortality rates between 40-55 %.20·24 In contrast, in the 36 patients without neurological involvement, only 4 patients died (11 %), which dearly demonstrates that neurological involvement is related to increased mortality. Co:\cLLJSION The nervous system is frequently involved in patients with bacterial endocarditis. The nature of neurological involvement can vary from a fatal embolic infarction to infective complications, such as cerebral abscess or meningitis, to mild encephalopathy. The most frequently noted complication is embolic infarction. In-hospital mortality is significantly high in patients who suffer neurological complications. The focus must be on better preventive, diagnostic and therapeutic JCPSP 2006, Vol. 16 (5): 343-346 measures to prevent ·the development of neurological complications. RcTLRENCLS 1. Karchmer AW. Infective endocarditis. In: Braunwald E, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL, (edi). Harrison's principles of internal medicine. 15th ed. New York: McGraw·Hill, 2001:809-16. 2. Hargrave K, Kothari M. Neurological sequelae of infectious endocarditis. eMedicine J [serial online] Apri12002 [cited 2002 Jun 1]; 3(4). Available from URL: http://www.emedicine.com/ neurology/infections/neurological sequelae of infectious endocarditis. 3. Tareen AM, Aziz KD, Najeeb MA. Clinical profile of infective endocarditis at NICVD Karachi. Pak] Cardio/1 998; 9: 53-6. 4. Pelletier L, Brusch J. Infectious endocarditis. eMedicine J [serial online] January 2002 [cited 2002 July 10]; 1 (2). Available from URL: http://www.emedicine.com/internal medicine/infection/ infectious endocarditis 5. Mylonakis E, Calderwood SB. Infective endocarditis in adults. NEngi]Med 2001; 345: 1318-28. 6. Sadiq M, Rathore AH. Nazir M, Sheikh SA. Infective endocarditis in children: diagnosis and management in a developing country. Pak!'aedCardiolj 2000; 2(1-2): 9-14. 7. Chen CH, Lo MC, Hwang KL, Liu CE, Young TG. Infective endocarditis with neurological complications: 1 0-year experience. J Microbiol/mmunollll[ect 2001 ; 34: 11 9-24. 8. Mansur AJ, Grinberg M, da Luz PL. Belloti G. The complications of infective endocarditis. A re-appraisal in the 1980s. Arch Intern Med 1992; 152: 2428-32. 9. Kanter MC, Hart RG. Neurologic complications of infective endocarditis. Neurology 1991; 41: 1015-20. 10. Le Cam B, Guivarch G, Boles JM, Garre M, Cartier F. Neurological complications in a group of 86 bacterial endocarditis. Eur Heart] 1984; 5: 97-100. 11. Santoshkumar B, Radhakrishnan K, Balakrishnan KG, Sarma PS. Neurological complications of infective endocarditis observed in a south Indian referral hospital.] Neurol Sci 1 996; 137: 139-44. 12. Lerner P. Neurologic complications of infective endocarditis. Med C!in North Am 1985; 69: 385-98. 13. Tornos MP, Olona M, Permanyer-Miralda G, Almirante B. Evangelista A, Soler-Soler J. Is the clinical spectrum and prognosis of native valve infective endocarditis in non-addicts changing? Eur Heart j 1 995; 16: 1686-91. 14. Jones HR, Siekert RG. Neurological manifestations of infective endocarditis. Review of clinical and therapeutic challenges. Brain 1989; 112( Pt 5): 1295-315. 15. Patel FM, Das A, Banerjee AK. Neuropathological complications of infective endocarditis: study of autopsy material. Neural !tulia 2001; 49:41-6. 16. Francioli P. Central nervous system complications of infective endocarditis. In: Scheid WM, Whiteley RJ. Durack DT, (edi). Infections of the central nervous system. New York: RatJen Press, 1991: 515-59. 17. Millaire A. Leroy 0. Gaday V, de Groote P, Beuscart C. Goullard L. Incidence and prognosis of embolic events and metastatic infections in infective endocarditis. Eur Heart] 1 997; 18: 677-84. 18. Watanakunakorn C. Burkert T. Infective endocarditis at a large community teaching hospital, 1980·1990. A review of 210 episodes. Medicine 1993; 72: 90-102. 34" Faisal Wasim lsmail, Mohammad Tariq, Mehboob Alam, Mohammad Ala Khan and Raymond Smego Jr 19. Heiro M, Nikoskelainen J, Engblom E, Kotilainen E, Martti!a R, Kotilainen P. Neurologic manifestations of infective endocarditis: a 17-year experience in a teaching hospital in Finland. Arch Intern Med 2000; 160: 2781-7. 20. Jault F, Gandjbakhch I, Rama A. Active native valve endocarditis: determinants of operative death and late mortality. Ann 7borac Surg 1997; 63:1737-41. 21. John MD, Hibberd PL, Karchmer AW, Sleeper LA, Calderwood SB. Staphylococcus aureus prosthetic valve endocarditis: optimal management and risk factors for death. Clin Infect Dis 1998; 26:1302-9. 22. Choussat R, Thomas 0, lsnard R. Perivalvular abscesses associated with endocarditis: clinical features and prognostic factors of overall survival in a series of 233 cases. Eur Jleart.f 1999; 20: 232-41. 23. Netzer RO, Altwegg SC, Zollinger E, Tauber M, Carrel T, Seiler C. Infective endocarditis: determinants of long term outcome. Heart 2002; 88: 61-6. 24. Wallace SM, Walton 81, Kharbanda RK, Hardy R, Wilson AP, Swanton RH. Mortality from infective endocarditis: clinical predictors of outcome. lleart2002; 88: 53-60 . ..... r\c. .. 346 JCPSP 2006, Vol. 16 (5): 343-346 

Spectrum of neurological involvement in adult patients with bacterial endocarditis

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Spectrum of neurological involvement in adult patients with bacterial endocarditis

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