Native Valve Endocarditis with Group B Streptococcus ...
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Discussion Case Description References Introduction • The patient had one major and two minor Duke criteria for endocarditis evident by echocardiogram showing endocardial involvement, vascular phenomena as shown by new RBBB, and positive blood cultures. • Literature review shows that infective endocarditis with GBS is rare. This case highlights the severity of illness of native valve endocarditis caused by GBS as this patient went from being in her normal state of health the day prior to her presentation and quickly suffered from multi-organ failure, and eventually death. • The patient had recent bilateral knee steroid injections, which could have been the source of her infection as she has no other risk factors for endocarditis. 1. Abdelghany, M., & Schenfeld, L. (2014). Group b streptococcal infective endocarditis. Journal of Infection and Public Health, 7(3), 237-239. doi:10.1016/j.jiph.2014.01.006 2. Teran, C. G., Antezana, A. O., Salvani, J., & Abaitey, D. (2011). Group b streptococcus endocarditis associated with multiple pulmonary septic emboli. Clinics and Practice, 1(1), 11-13. doi:10.4081/cp.2011.e7 3. Backes, R. J. (1985). Group B Streptococcal infective endocarditis. Archives of Internal Medicine, 145(4), 693. doi:10.1001/archinte.1985.00360040117026 4. Sambola, A., Miro, J. M., Tornos, M. P., Almirante, B., Moreno-Torrico, A., Gurgui, M., . . . Gatell, J. M. (2002). Streptococcus AgalactiaeInfective Endocarditis: Analysis of 30 cases and review of the LITERATURE, 1962– 1998. Clinical Infectious Diseases, 34(12), 1576-1584. doi:10.1086/340538 Initial Presentation: 68-year-old female with past medical history of hypertension, hyperlipidemia, osteoarthritis, chronic back and bilateral knee pain, lumbar spine canal stenosis, and seizure disorder presented to the emergency department with lethargy and confusion Vital Signs: T 36.8, HR 88, BP 91/58 (69) RR 22, 98% O2 Data: EKG showed new right bundle branch block Labs: VBG 7.37/29/60 Troponin 4.04, BNP 2327 Lactate 3.4, Anion Gap 15 Urinalysis positive for bacteria Clinical Course: - Received IV fluid bolus and broad-spectrum antibiotics - Shortly after her presentation she briefly went into cardiac arrest with return of spontaneous circulation after receiving chest compressions - An arterial line showed a widened pulse pressure indicating aortic insufficiency - An echocardiogram showed tricuspid vegetations with severe tricuspid regurgitation, aortic valve vegetations with severe aortic insufficiency, mitral vegetations with mitral regurgitation, and possible aorto-mitral curtain abscess/perforation - She was admitted to the ICU with multi-organ failure requiring multiple vasopressors and died the next day - Two sets of blood cultures were positive for beta- hemolytic streptococcus group B • Streptococcus agalactiae (GBS) is a bacteria usually associated with infections in newborns and pregnant women. • It rarely causes invasive infection in healthy adults and is an uncommon cause of infective endocarditis. • A literature review study found GBS to cause 1.7% of all cases of bacterial endocarditis. • Although endocarditis secondary to GBS is uncommon, it can cause serious complications and is associated with a high mortality rate despite surgical intervention. Native Valve Endocarditis with Group B Streptococcus, Septic Shock, and Multi-Organ Failure Benjamin Barmaan MD, Andrew Alberter MD VCU Health System Department of Emergency Medicine Conclusion • Patients with infective endocarditis caused by GBS can deteriorate quickly. Studies have shown mortality rates from 10-40% with native valve involvement, and even higher in prosthetic valves. • Patents can also suffer from heart failure and complications of septic emboli such as septic pulmonary embolism, endophthalmitis, and intracranial lesions/infections. • Patients require aggressive antibiotic treatment along with appropriate imaging and work up to evaluate for further complications. B-lactam antibiotics in combination with aminoglycosides have been shown to have a synergistic effect in treating GBS. • Patents require cardiac surgery evaluation, however they still suffer from high mortality rates despite surgical intervention. Figure 1. A: Vegetation present on non-coronary cusp of aortic valve. B: Significant turbulent flow seen on color flow imaging due to valve damage. Figure 2. Color flow imaging showing A: Severe aortic regurgitation secondary to aortic valve vegetation. B: Mitral regurgitation arising near the aorto-mitral curtain concerning for perforation.
Transcript of Native Valve Endocarditis with Group B Streptococcus ...
DiscussionCase Description
References
Introduction• The patient had one major and two minor Duke criteria for
endocarditis evident by echocardiogram showing endocardial involvement, vascular phenomena as shown by new RBBB, and positive blood cultures.
• Literature review shows that infective endocarditis with GBS is rare. This case highlights the severity of illness ofnative valve endocarditis caused by GBS as this patient went from being in her normal state of health the day prior to her presentation and quickly suffered from multi-organ failure, and eventually death.
• The patient had recent bilateral knee steroid injections, which could have been the source of her infection as she has no other risk factors for endocarditis.
1. Abdelghany, M., & Schenfeld, L. (2014). Group b streptococcal infective endocarditis. Journal of Infection and Public Health, 7(3), 237-239. doi:10.1016/j.jiph.2014.01.0062. Teran, C. G., Antezana, A. O., Salvani, J., & Abaitey, D. (2011). Group b streptococcus endocarditis associated with multiple pulmonary septic emboli. Clinics and Practice, 1(1), 11-13. doi:10.4081/cp.2011.e73. Backes, R. J. (1985). Group B Streptococcal infective endocarditis. Archives of Internal Medicine, 145(4), 693. doi:10.1001/archinte.1985.003600401170264. Sambola, A., Miro, J. M., Tornos, M. P., Almirante, B., Moreno-Torrico, A., Gurgui, M., . . . Gatell, J. M. (2002). Streptococcus AgalactiaeInfective Endocarditis: Analysis of 30 cases and review of the LITERATURE, 1962–1998. Clinical Infectious Diseases, 34(12), 1576-1584. doi:10.1086/340538
Initial Presentation: 68-year-old female with past medical history of hypertension, hyperlipidemia, osteoarthritis, chronic back and bilateral knee pain, lumbar spine canal stenosis, and seizure disorder presented to the emergency department with lethargy and confusion
Vital Signs: T 36.8, HR 88, BP 91/58 (69) RR 22, 98% O2
Data:EKG showed new right bundle branch blockLabs:
VBG 7.37/29/60Troponin 4.04, BNP 2327Lactate 3.4, Anion Gap 15Urinalysis positive for bacteria
Clinical Course:- Received IV fluid bolus and broad-spectrum antibiotics- Shortly after her presentation she briefly went into
cardiac arrest with return of spontaneous circulationafter receiving chest compressions
- An arterial line showed a widened pulse pressure indicating aortic insufficiency
- An echocardiogram showed tricuspid vegetations with severe tricuspid regurgitation, aortic valve vegetations with severe aortic insufficiency, mitral vegetations with mitral regurgitation, and possible aorto-mitral curtain abscess/perforation
- She was admitted to the ICU with multi-organ failure requiring multiple vasopressors and died the next day
- Two sets of blood cultures were positive for beta-hemolytic streptococcus group B
• Streptococcus agalactiae (GBS) is a bacteria usually associated with infections in newborns and pregnant women.
• It rarely causes invasive infection in healthy adults and is an uncommon cause of infective endocarditis.
• A literature review study found GBS to cause 1.7% of all cases of bacterial endocarditis.
• Although endocarditis secondary to GBS is uncommon, it can cause serious complications and is associated with a high mortality rate despite surgical intervention.
Native Valve Endocarditis with Group B Streptococcus, Septic Shock, and Multi-Organ Failure Benjamin Barmaan MD, Andrew Alberter MDVCU Health System Department of Emergency Medicine
Conclusion• Patients with infective endocarditis caused by GBS can
deteriorate quickly. Studies have shown mortality rates from 10-40% with native valve involvement, and even higher in prosthetic valves.
• Patents can also suffer from heart failure and complications of septic emboli such as septic pulmonary embolism, endophthalmitis, and intracranial lesions/infections.
• Patients require aggressive antibiotic treatment along with appropriate imaging and work up to evaluate for further complications. B-lactam antibiotics in combination with aminoglycosides have been shown to have a synergistic effect in treating GBS.
• Patents require cardiac surgery evaluation, however they still suffer from high mortality rates despite surgical intervention.
Figure 1. A: Vegetation present on non-coronary cusp of aortic valve.B: Significant turbulent flow seen on color flow imaging due to valve damage.
Figure 2. Color flow imaging showing A: Severe aortic regurgitation secondary to aortic valve vegetation. B: Mitral regurgitation arising near the aorto-mitral curtain concerning for perforation.
