Endocarditis Due to Accidental Penetrating Foreign Bodies
SHELDON M. MARKOWlTZ, SZABOLCS
M.D.
SZENTF’ETERY, M.D.
RICHARD R. LOWER, M.D. RICHARD J. DUMA, M.D. Richmond, Virginia
From the Division of Infectious Disease& Department of Mediine and the Division of Thorack and Cardiovascular Surgery, Department of Surgery, The Medical College of Virginia, Health Sciences D&ion, Virginia Commonwealth University, Richmond, Virginia 23298. Request for reprints should be addressed to Dr. Sheldon M. Markowitz. Infectious Diseases Division, Medical College of Virginia, Richmond. Virginia 23296. Manuscript accepted August 8, 1975.
A 15 year old boy had an eight month history of recurrent fever, malaise and poor appetite. Chest roentgenogram reveaied a foreign object overlying the right ventrkie. Muttipie biood cultures grew Enterobacter cioacae. The patient’s condition improved and blood cultures became negative following gentamkin and carbenicillin therapy. E. cloacae was isoiated from the foreign body (a finishing nail) at surgery. Antimicrobial therapy was continued for a total of 30 days, and the patient made an uneventful recovery. Endocarditis due to accidental penetrating foreign body is a rare entity. Seven such cases have been reported. Surgical removal of the foreign body seems necessary for cure, regardless of the response to antibiotic therapy. Of those with endogenous penetration, Escherichia coli was the most common organism isolated from the blood. E. cloacae is an unusual cause of bacteremia and an extremely rare cause of endocarditis. The isolation of E. cioacae and other environmental organisms from the Mood of otherwise healthy persons should suggest a foreign body in the endocardial or endotheliai tissues. Sepsis is mentioned frequently as a major indication for the removal of foreign objects from the cardiovascular system [l-4]. These infections are usually associated with such devices as plastic catheters [5-71, permanent transvenous pacemakers [8,9], ventriculoatrial shunts [lo] and prosthetic heart valves [ 1 l-131. Less common are the documented instances of endocarditis due to penetrating foreign bodies, accidentally introduced, that are clearly not nosocomially related. Seven such cases have been reported [2,14-191. Of these seven cases, the diagnosis was made antemortem and the patients cured of the endocarditis in two, and in only one of the two did blood cultures confirm the diagnosis. In the patient we describe endocarditis developed from a nail which had penetrated his right ventricle. Cultures of blood and foreign body grew Enterobacter cloacae, and the patient was cured by antimicrobial therapy and surgical removal of the object. Although E. cloacae is reported to produce endocarditis in heroin addicts [20,21], the exact extent of the disease in man caused by this gram-negative bacillus is still unknown.
April 1976
The American Journal of Medicine
Volume 60
571
ENDOCARDITIS DUE TO FOREIGN BODIES-MARKOWITZ
ET AL.
Figure 7. Chesf roentgenogram, both posteroanterior opaque density overlying the right ventricle.
(left)
CASE REPORT A 15 year old black boy was admitted to the Medical College of Virginia Hospitals on December 13, 1974, with an eight month history of recurrent fever and malaise. In June 1974 he had been admitted to a nearby hospital for similar complainis. Evaluation was unrevealing except for one blood culture which grew E. cloacae. The patient received parenteral gentamicin and carbenicillin for approximately four days, during which time he became afebrile and regained his appetite. The improvement was temporary, for several weeks after discharge he again experienced fever, malaise and poor appetite. Subsequent visits to several physicians and clinics were to no avail and his symptoms persisted except for periods during which he was given antimicrobials empirically. He received no antimicrobials for six weeks prior to admission. Three days before admission, pleuritic pain in the left side of his chest developed, but a chest roentgenogram taken at a local health clinic was interpreted as showing no abnormality. The patient was referred to the Medical College of Virginia Hospitals for evaluation. On the day of admission, a chest roentgenogram revealed what appeared to be a metallic object overlying the right ventricle (Figure 1) and a left pleural effusion. Further questioning of the patient revealed that his illness began aboyt one week after he experienced a brief episode of sharp anterior chest pain while cutting grass with a power mower that did not have a protective deflector. He noticed a trickle of blood from a small wound site to the right of the sternum. However, the wound healed without difficulty. Physical examination on admission revealed a young black boy in, no acute distress. The oral temperature was 37OC, pulse rate 68 beats/min, blood pressure 110/70 mm Hg and respiratory rate 16/min. No abnormalities were noted except for a 1 cm scar to the right of the sternum adjacent to the xiphoid, and decreased breath sounds
572
April 1976
The American Journal of Medicine
Volume 60
and lateral (right),
taken on the day of admission.
Note
over the base of the left lung posteriorly. Laboratory tests including white blood cell and differential counts, a urinalysis, blood urea nitrogen, blood glucose, serum electrolytes, lheumatoid factor, serologic test for syphilis (VDRL), lactic dehydrogenase and serum glutamic oxaloacetic transaminase were negative or within normal limits. A sedimentation rate was 50 mm/hour and the hemoglobin level was 11.9 g/100 ml. An electrocardiogram showed a sinus arrythmia and T wave inversion in leads VI through v3.
A left thoracentesis yielded several centimeters of a yellow, cloudy fluid. The fluid contained 12,500 red blood cells/mm3, 604 white blood cells/mm3 of which 71 per cent were lymphocytes, 24 per cent mesothelial cells and 5 per cent polymorphonuclear leukocytes. The protein was 4.2 g, the amylase
SHELDON M. MARKOWlTZ, SZABOLCS
M.D.
SZENTF’ETERY, M.D.
RICHARD R. LOWER, M.D. RICHARD J. DUMA, M.D. Richmond, Virginia
From the Division of Infectious Disease& Department of Mediine and the Division of Thorack and Cardiovascular Surgery, Department of Surgery, The Medical College of Virginia, Health Sciences D&ion, Virginia Commonwealth University, Richmond, Virginia 23298. Request for reprints should be addressed to Dr. Sheldon M. Markowitz. Infectious Diseases Division, Medical College of Virginia, Richmond. Virginia 23296. Manuscript accepted August 8, 1975.
A 15 year old boy had an eight month history of recurrent fever, malaise and poor appetite. Chest roentgenogram reveaied a foreign object overlying the right ventrkie. Muttipie biood cultures grew Enterobacter cioacae. The patient’s condition improved and blood cultures became negative following gentamkin and carbenicillin therapy. E. cloacae was isoiated from the foreign body (a finishing nail) at surgery. Antimicrobial therapy was continued for a total of 30 days, and the patient made an uneventful recovery. Endocarditis due to accidental penetrating foreign body is a rare entity. Seven such cases have been reported. Surgical removal of the foreign body seems necessary for cure, regardless of the response to antibiotic therapy. Of those with endogenous penetration, Escherichia coli was the most common organism isolated from the blood. E. cloacae is an unusual cause of bacteremia and an extremely rare cause of endocarditis. The isolation of E. cioacae and other environmental organisms from the Mood of otherwise healthy persons should suggest a foreign body in the endocardial or endotheliai tissues. Sepsis is mentioned frequently as a major indication for the removal of foreign objects from the cardiovascular system [l-4]. These infections are usually associated with such devices as plastic catheters [5-71, permanent transvenous pacemakers [8,9], ventriculoatrial shunts [lo] and prosthetic heart valves [ 1 l-131. Less common are the documented instances of endocarditis due to penetrating foreign bodies, accidentally introduced, that are clearly not nosocomially related. Seven such cases have been reported [2,14-191. Of these seven cases, the diagnosis was made antemortem and the patients cured of the endocarditis in two, and in only one of the two did blood cultures confirm the diagnosis. In the patient we describe endocarditis developed from a nail which had penetrated his right ventricle. Cultures of blood and foreign body grew Enterobacter cloacae, and the patient was cured by antimicrobial therapy and surgical removal of the object. Although E. cloacae is reported to produce endocarditis in heroin addicts [20,21], the exact extent of the disease in man caused by this gram-negative bacillus is still unknown.
April 1976
The American Journal of Medicine
Volume 60
571
ENDOCARDITIS DUE TO FOREIGN BODIES-MARKOWITZ
ET AL.
Figure 7. Chesf roentgenogram, both posteroanterior opaque density overlying the right ventricle.
(left)
CASE REPORT A 15 year old black boy was admitted to the Medical College of Virginia Hospitals on December 13, 1974, with an eight month history of recurrent fever and malaise. In June 1974 he had been admitted to a nearby hospital for similar complainis. Evaluation was unrevealing except for one blood culture which grew E. cloacae. The patient received parenteral gentamicin and carbenicillin for approximately four days, during which time he became afebrile and regained his appetite. The improvement was temporary, for several weeks after discharge he again experienced fever, malaise and poor appetite. Subsequent visits to several physicians and clinics were to no avail and his symptoms persisted except for periods during which he was given antimicrobials empirically. He received no antimicrobials for six weeks prior to admission. Three days before admission, pleuritic pain in the left side of his chest developed, but a chest roentgenogram taken at a local health clinic was interpreted as showing no abnormality. The patient was referred to the Medical College of Virginia Hospitals for evaluation. On the day of admission, a chest roentgenogram revealed what appeared to be a metallic object overlying the right ventricle (Figure 1) and a left pleural effusion. Further questioning of the patient revealed that his illness began aboyt one week after he experienced a brief episode of sharp anterior chest pain while cutting grass with a power mower that did not have a protective deflector. He noticed a trickle of blood from a small wound site to the right of the sternum. However, the wound healed without difficulty. Physical examination on admission revealed a young black boy in, no acute distress. The oral temperature was 37OC, pulse rate 68 beats/min, blood pressure 110/70 mm Hg and respiratory rate 16/min. No abnormalities were noted except for a 1 cm scar to the right of the sternum adjacent to the xiphoid, and decreased breath sounds
572
April 1976
The American Journal of Medicine
Volume 60
and lateral (right),
taken on the day of admission.
Note
over the base of the left lung posteriorly. Laboratory tests including white blood cell and differential counts, a urinalysis, blood urea nitrogen, blood glucose, serum electrolytes, lheumatoid factor, serologic test for syphilis (VDRL), lactic dehydrogenase and serum glutamic oxaloacetic transaminase were negative or within normal limits. A sedimentation rate was 50 mm/hour and the hemoglobin level was 11.9 g/100 ml. An electrocardiogram showed a sinus arrythmia and T wave inversion in leads VI through v3.
A left thoracentesis yielded several centimeters of a yellow, cloudy fluid. The fluid contained 12,500 red blood cells/mm3, 604 white blood cells/mm3 of which 71 per cent were lymphocytes, 24 per cent mesothelial cells and 5 per cent polymorphonuclear leukocytes. The protein was 4.2 g, the amylase
