Infection DOI 10.1007/s15010-013-0541-9
CASE REPORT
Gonococcal endocarditis: a case report and review of the literature Antonio Ramos • Pablo Garcı´a-Pavı´a • Beatriz Orden • Marta Cobo • Margarita Sa´nchez-Castilla • Isabel Sa´nchez-Romero • Elena Mu´n˜ez • Mercedes Marı´n • Carlos Garcı´a-Montero
Received: 21 March 2013 / Accepted: 3 October 2013 Ó Springer-Verlag Berlin Heidelberg 2013
Abstract A 59-year-old Caucasian male presented with progressive dyspnea, arthralgias and fever for three days. A diastolic regurgitation murmur was detected in the aortic area. A transesophageal echocardiograph showed several vegetations and severe aortic regurgitation. Blood cultures yielded Neisseria gonorrhoeae beta-lactamase negative. The patient had not noticed any urogenital discomfort or urethral discharge. The patient successfully underwent surgery for septal abscess debridement. The patient received ceftriaxone 2 g bid for eight weeks and the clinical follow-up was uneventful. The review of the literature revealed a total of the 38 additional cases reported between
A. Ramos (&) E. Mu´n˜ez Department of Internal Medicine (Infectious Diseases Unit), Hospital Universitario Puerta de Hierro, Universidad Auto´noma de Madrid, Maestro Rodrigo 2, Majadahonda, 28220 Madrid, Spain e-mail: [email protected] P. Garcı´a-Pavı´a M. Cobo Department of Cardiology, Hospital Universitario Puerta de Hierro, Majadahonda, 28220 Madrid, Spain B. Orden I. Sa´nchez-Romero Department of Microbiology, Hospital Universitario Puerta de Hierro, Majadahonda, 28220 Madrid, Spain M. Sa´nchez-Castilla Department of Anesthesiology, Hospital Universitario Puerta de Hierro, Majadahonda, 28220 Madrid, Spain M. Marı´n Department of Clinical Microbiology, Hospital Universitario Gregorio Maran˜o´n, 28007 Madrid, Spain C. Garcı´a-Montero Department of Cardiac Surgery, Hospital Universitario Puerta de Hierro, Majadahonda, 28220 Madrid, Spain
1980 and the present. The majority of the patients were young, male and with native valve involvement. There has been a clear tendency for left-sided valve involvement (especially in the aortic valve). All valve cultures were reported negative despite, in most cases, the marked tissue destruction. Polymerase chain reaction was performed in two patients and positive results were shown in both. Cultures of exudates from other locations were negative in most cases. One striking fact is the high proportion of patients who underwent surgery (72 %). Information regarding antibiotic sensitivity was available in 28 cases, with penicillin resistance reported in six patients (21 %) and intermediate sensitivity in four patients (14 %). Resistance to ciprofloxacin was reported in two cases (7 %). A rapid increase and distribution of isolates resistant to third generation cephalosporins have been recently detected. The mortality is high, particularly taking into account that most were young patients who had not presented previous heart disease. Keywords Endocarditis Neisseria gonorrhoeae Cardiac surgical procedures Penicillins Echocardiography
Introduction Gonococcal endocarditis (GE) was common in the preantibiotic era [1]. However, its incidence has dramatically decreased since effective antibiotics have been available [2]. Currently, disseminated infection occurs in 1–3 % of all gonococcal infections, and 1–2 % of these develop GE as a complication [1]. Since 1938, only about 70 cases of GE have been reported. This infection commonly affects native valves (mainly aortic) in young patients and causes
123
A. R. Martı´nez et al.
high mortality [2]. Most patients do not report prior genitourinary or osteoarticular symptoms [2]. During the last 30 years, there have been significant changes in susceptibility to gonococci antibiotics. First, susceptibility to penicillin of N. gonorrhoeae has significantly declined since the 1980s [3] and, more recently, there has been a spread of strains with a high level resistance to fluoroquinolones [minimum inhibitory concentration (MIC) of ciprofloxacin [1.0 mg/L]. Moreover, it has been noticed that there has been a dissemination of cefixime resistant strains in North America and Europe [4]. In Spain, there has been observed an increase in the incidence of sexually transmitted diseases that would be related to a reduced fear of HIV infection. [5] The percentages of intermediately susceptible (15 %) and isolates resistant to penicillin (27 %), tetracycline (50 %) and ciprofloxacin (50 %) detected during the last years represent a relevant therapeutic challenge [5]. Additionally, imaging techniques have improved thereby allowing better identification of vegetations as well as some cardiac complications, such as abscesses and fistulae [6]. Finally, valve replacement, and even valve repair, have become commonplace in the management of many complicated GE cases whereas, until 1979, only two cases of GE had undergone surgery [1]. We present a case of N. gonorrhoeae endocarditis and a review of GE cases published during the last three decades.
Case report A 59-year-old Caucasian male presented with progressive dyspnea, arthralgias and fever, which had persisted for three days. He denied having any previous disease, and he was not taking any medication. On hospital admission, the patient had a temperature of 38 °C, blood pressure of 90/60 mm Hg and a pulse of 30 beats/min. A grade 3 diastolic regurgitation murmur was detected in the aortic area. Neurological, respiratory, and osteoarticular examinations were normal. Laboratory investigations showed a hemoglobin level of 14.6 g/dL, a platelet count of 242,000/ lL and a white-cell count of 25,400/lL. An electrocardiogram demonstrated atrioventricular and left bundlebranch block that required the implantation of a pacemaker. Because of an inadequate patient acoustic window, a transthoracic echocardiogram was not implemented. Instead, a transesophageal echocardiogram (TEE) was carried out on the day of hospital admission, showing several vegetations and severe aortic regurgitation. Initial treatment included procaine penicillin four million U/4 h, cloxacillin 2 g/4 h and gentamycin 80 mg bid. On day 3, the aerobic bottles of the two sets of blood cultures taken on the day of hospital admission became positive and were
123
identified as N. gonorrhoeae in the API NH test (bioMe´rieux, Marcy l’Etoile, France). The isolate was serovar 1A and ST 8123. Antibiotic susceptibility was determined by Etests (AB Biodisk, Solna, Sweden). The strain was beta-lactamase negative but showed a MIC of 0.38 mg/L to penicillin (intermediate resistance 0.12–1 mg/L). The MIC to other antibiotics was as follows: ceftriaxone B0.016 mg/ L, ciprofloxacin 1 mg/L, tetracycline 12 mg/L and erythromycin 0.125 mg/L. The treatment was changed to ceftriaxone 2 g bid. The patient admitted having had several unprotected sexual encounters with unknown persons up to six weeks prior to admission. He had not noticed any urogenital discomfort or urethral discharge. Swab samples collected from oropharyngeal, urethral and rectal sites did not yield gonococcus. HIV and syphilis (FTA and VDRL) serology was negative. The patient successfully underwent surgery for septal abscess debridement. The native aortic valve was replaced with a 25-mm mechanical prosthetic St. Jude valve. Valvular tissue cultures were negative. 16S rRNA gene sequencing was performed on tissue taken from the heart valve to detect bacterial species. DNA was extracted from the heart valve tissue using the QIAmp DNA Minikit method (Qiagen Ltd, West Sussex, UK) according to the manufacturer’s recommendations. Amplification of the bacterial 16S rRNA gene was performed by real-time PCR in a Light-Cycler instrument (Roche Diagnostics, Mannheim, Germany). Amplicons produced from heart valves were subsequently sequenced by the Big Dye Terminator method using the same primers and detected in an AbiPrism 3130xl automatic DNA sequencer (Applied Biosystems Inc.) [7]. This search identified the bacterium present in the heart valve as N. gonorrhoeae. On the 22nd day, the patients presented fever and TEE showed communication between the right sinus of Valsalva and the right atrium. The patient underwent surgery again for valve replacement and implantation of a surgical patch. The patient received ceftriaxone 2 g bid for eight weeks and the clinical followup was uneventful.
Discussion Gonococcal endocarditis is an uncommon complication of N. gonorrhoeae infection. [1]. Our review of the literature revealed a total of 38 additional cases reported between 1980 and the present [1, 2, 6, 8–18]. Most reported cases were described in Europe and the US. Their clinical characteristics, together with that presented in this report, are summarized in Table 1. The majority of the patients were young, male and with native valve involvement [1, 14]. Only two patients (5 %)
Gonococcal endocarditis Table 1 Clinical features of 39 cases of gonococcal endocarditis reported during the last 32 years N = 39 (%) Age (years) mean ± SD
30 ± 9
Male gender
26 (67)
Genitourinary symptomsa
8 (21)
Arthritisa
5 (13)
Arthralgiasa
7 (18)
Valveb Aortic Mitral
28 (72) 9 (23)
Tricuspid
4 (10)
Pulmonary Perivalvular abscess
4 (10) 10 (26)
Antibiotic treatment Penicillin Third G cephalosporin
25 (64) 13 (33)
Surgery
28 (72)
Death
9 (23)
SD standard deviation a
During the previous three months
b
Three patients had simultaneous infection in two or more valves
suffered prosthetic valve infection. One reason for this low rate may be the low proportion of patients with prosthetic valves in the population most affected (i.e., young people) [14]. According to published information, very few patients experienced genitourinary symptoms in the days prior to hospital admission, and this fact could result in patients not receiving antibiotics, thereby allowing disseminated infection to develop [2]. It should be noted that, in those cases with a positive genitourinary history, symptoms mainly occurred several months prior to admission [8]. Few cases made reference to musculoskeletal symptoms, so these may not be considered as useful clinical indications that lead to a suspicion of GE (Table 1). Although right-sided heart involvement was common in the pre-antibiotic era, during the last few decades there has been an apparent tendency for left-sided valve involvement (especially in the aortic valve, 59 % of reported cases, Table 1) [1]. However, it is unknown whether there are any factors that make the aortic valve more susceptible to N. gonorrhoeae infection. As expected in patients with bacterial endocarditis, blood cultures were positive in all cases. However, all valve cultures were reported negative despite, in most cases, the marked tissue destruction. Therefore, the sensitivity of the valve culture was clearly lower in cases of GE than in cases due to other bacteria, and negative cultures seem to be a characteristic of this entity, which, in some cases, may limit diagnosis [1, 2, 13]. Factors that may
hypothetically have a role in this problem could be the fastidious nature of N. gonorrhoeae or previous antibiotic treatments. PCR was performed in two patients and positive results were shown in both [15]. The role that PCR may have in diagnosing cases with negative cultures must be emphasised [15]. Cultures of exudates from other locations were, in most cases, negative and not very helpful in the diagnosis. Twenty-two cultures from the pharynx, urethra, cervix, rectum and urine were performed in ten patients, most of whom were undergoing antibiotic treatment. Only one pharyngeal and one cervical culture proved positive [1, 8]. One striking fact is the high proportion of patients who underwent surgery (72 %). This percentage was clearly higher than the 25–50 % reported in other endocarditis series [19]. Four patients (10 %) did not undergo surgery due to rapid clinical deterioration that ruled it out [14]. The notable necessity for surgery observed in these patients may be related to marked tissue destruction and the high percentage of aortic valve involvement. Information regarding antibiotic sensitivity was available in 28 cases, with penicillin resistance reported in six patients (21 %) and intermediate sensitivity in four patients (14 %). A progressive increase in penicillin resistance would be worrying taking into consideration the antibiotic regimens, which are empirically administered together with the severity of many GE cases [14]. Resistance to ciprofloxacin was reported in two cases (7 %), which is lower than the 53 % reported in a large European survey [5]. Cefixime and ceftriaxone remain the recommended therapy for gonorrhoea across Europe and Spain. However, a rapid increase and distribution of isolates resistant to third generation cephalosporins have been recently detected [20]. One of the limitations of this study is that several of the reported cases did not include some relevant information, such as the antibiotic sensitivity or type of echocardiography performed. Acknowledgments The authors wish to thank to Dr. Julio Vazquez of the Bacteriology Department of the Instituto de Salud Carlos III for gonococcal serotyping and ST typing and to Martin Hadley-Adams for assisting with the English language and preparation of the manuscript. Conflict of interest
The authors declare no conflict of interest.
References 1. Wall TC, Peyton RB, Corey GR. Gonococcal endocarditis: a new look at an old disease. Medicine (Baltimore). 1989;68:375–80. 2. Thompson EC, Brantley D. Gonoccocal endocarditis. J Natl Med Assoc. 1996;88:353–6. 3. Martin I, Jayaraman G, Wong T, Liu G, Gilmour M. Trends in antimicrobial resistance in Neisseria gonorrhoeae isolated in Canada: 2000–2009. Sex Transm Dis. 2011;38:892–8.
123
A. R. Martı´nez et al. 4. European Centre for Disease Prevention and Control (ECDC). Gonococcal antimicrobial surveillance in Europe, 2010. Stockholm ECDC, May 2012. Available from: http://ecdc.europa.eu/ en/publications/Publications/1206-Gonococcal-AMR.pdf. 5. Dı´az-Franco A, Noguer-Zambrano I, Cano-Portero R. Vigilancia epidemiolo´gica de las infecciones de transmisio´n sexual. Espan˜a, 1995–2003. Med Clin (Barc). 2005;125:529–30. 6. Sobel JL, Maisel AS, Tarazi R, Blanchard DG. Gonococcal endocarditis: assessment by transesophageal echocardiography. J Am Soc Echocardiogr. 1997;10:367–70. 7. Goldenberger D, Kunzli A, Vogt P, Zbinden R, Altwegg M. Molecular diagnosis of bacterial endocarditis by broad-range PCR amplification and direct sequencing. J Clin Microbiol. 1997;35:2733–9. 8. Romero E, Gonza´lez M, Calzo´n S, Riesgo MA. Gonococcal endocardtis. Rev Esp Cardiol. 1987;40:293–6. 9. de’Clari F, Nikolic J, Genoni M, Riva A, Moccetti T. Gonococcal endocarditis: an infection as rare as it dangerous. Apropos of a case: the importance of suspicion in diagnosis and of immediate treatment. Schweiz Med Wochenschr. 1990;120:1880–3. 10. Porcel JM, Herrejo´n P, Tornos MP, Arderiu A. Neisseria gonorrhoeae endocarditis. Med Clin (Barc). 1991;97:437–8. 11. Pate MA, Adegbola RA, Ison C, Corrah T. Neisseria gonorrhoeae endocarditis. Trop Doct. 1996;26:131. 12. Pantanowitz L, Hodkinson J, Zeelie R, Jones N. Gonococcal endocarditis after a threatened abortion. A case report. J Reprod Med. 1998;43:1043–5.
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13. Kholwadwala S, Benink E. Unusual cause of acute respiratory distress: gonococcal endocarditis. Am J Emerg Med. 2000;18: 502–3. 14. Cove-Smith A, Klein JL. Gonococcal endocarditis: forgotten but not quite gone. Scand J Infect Dis. 2006;38:696–7. 15. Nielsen US, Knudsen JB, Pedersen LN, Møller JK. Neisseria gonorrhoeae endocarditis confirmed by nucleic acid amplification assays performed on aortic valve tissue. J Clin Microbiol. 2009;47:865–7. 16. Akkinepally S, Douglass E, Moreno A. Tricuspid valve gonococcal endocarditis: fourth case report. Int J Infect Dis. 2010;14(Suppl 3):e196–7. 17. Faibis F, Tlili M, Dervanian P, et al. Endocardite infectieuse compliquant une infection a` Neisseria gonorrhoeae. Med Mal Infect. 2010;40:368–9. 18. Campos JD, Saniel MC, Maran˜on DR. Acute gonococcal endocarditis in a filipino seafarer. Philipp J Microbiol Infect Dis. 2004;33:79–82. 19. Prendergast BD, Tornos P. Surgery for infective endocarditis: who and when? Circulation. 2010;121:1141–52. 20. de Vries HJ, van der Helm JJ, van der Loeff MFS, van Dam AP. Multidrug-resistant Neisseria gonorrhoeae with reduced cefotaxime susceptibility is increasingly common in men who have sex with men, Amsterdam, the Netherlands. Euro Surveill. 2009;14:19330.
CASE REPORT
Gonococcal endocarditis: a case report and review of the literature Antonio Ramos • Pablo Garcı´a-Pavı´a • Beatriz Orden • Marta Cobo • Margarita Sa´nchez-Castilla • Isabel Sa´nchez-Romero • Elena Mu´n˜ez • Mercedes Marı´n • Carlos Garcı´a-Montero
Received: 21 March 2013 / Accepted: 3 October 2013 Ó Springer-Verlag Berlin Heidelberg 2013
Abstract A 59-year-old Caucasian male presented with progressive dyspnea, arthralgias and fever for three days. A diastolic regurgitation murmur was detected in the aortic area. A transesophageal echocardiograph showed several vegetations and severe aortic regurgitation. Blood cultures yielded Neisseria gonorrhoeae beta-lactamase negative. The patient had not noticed any urogenital discomfort or urethral discharge. The patient successfully underwent surgery for septal abscess debridement. The patient received ceftriaxone 2 g bid for eight weeks and the clinical follow-up was uneventful. The review of the literature revealed a total of the 38 additional cases reported between
A. Ramos (&) E. Mu´n˜ez Department of Internal Medicine (Infectious Diseases Unit), Hospital Universitario Puerta de Hierro, Universidad Auto´noma de Madrid, Maestro Rodrigo 2, Majadahonda, 28220 Madrid, Spain e-mail: [email protected] P. Garcı´a-Pavı´a M. Cobo Department of Cardiology, Hospital Universitario Puerta de Hierro, Majadahonda, 28220 Madrid, Spain B. Orden I. Sa´nchez-Romero Department of Microbiology, Hospital Universitario Puerta de Hierro, Majadahonda, 28220 Madrid, Spain M. Sa´nchez-Castilla Department of Anesthesiology, Hospital Universitario Puerta de Hierro, Majadahonda, 28220 Madrid, Spain M. Marı´n Department of Clinical Microbiology, Hospital Universitario Gregorio Maran˜o´n, 28007 Madrid, Spain C. Garcı´a-Montero Department of Cardiac Surgery, Hospital Universitario Puerta de Hierro, Majadahonda, 28220 Madrid, Spain
1980 and the present. The majority of the patients were young, male and with native valve involvement. There has been a clear tendency for left-sided valve involvement (especially in the aortic valve). All valve cultures were reported negative despite, in most cases, the marked tissue destruction. Polymerase chain reaction was performed in two patients and positive results were shown in both. Cultures of exudates from other locations were negative in most cases. One striking fact is the high proportion of patients who underwent surgery (72 %). Information regarding antibiotic sensitivity was available in 28 cases, with penicillin resistance reported in six patients (21 %) and intermediate sensitivity in four patients (14 %). Resistance to ciprofloxacin was reported in two cases (7 %). A rapid increase and distribution of isolates resistant to third generation cephalosporins have been recently detected. The mortality is high, particularly taking into account that most were young patients who had not presented previous heart disease. Keywords Endocarditis Neisseria gonorrhoeae Cardiac surgical procedures Penicillins Echocardiography
Introduction Gonococcal endocarditis (GE) was common in the preantibiotic era [1]. However, its incidence has dramatically decreased since effective antibiotics have been available [2]. Currently, disseminated infection occurs in 1–3 % of all gonococcal infections, and 1–2 % of these develop GE as a complication [1]. Since 1938, only about 70 cases of GE have been reported. This infection commonly affects native valves (mainly aortic) in young patients and causes
123
A. R. Martı´nez et al.
high mortality [2]. Most patients do not report prior genitourinary or osteoarticular symptoms [2]. During the last 30 years, there have been significant changes in susceptibility to gonococci antibiotics. First, susceptibility to penicillin of N. gonorrhoeae has significantly declined since the 1980s [3] and, more recently, there has been a spread of strains with a high level resistance to fluoroquinolones [minimum inhibitory concentration (MIC) of ciprofloxacin [1.0 mg/L]. Moreover, it has been noticed that there has been a dissemination of cefixime resistant strains in North America and Europe [4]. In Spain, there has been observed an increase in the incidence of sexually transmitted diseases that would be related to a reduced fear of HIV infection. [5] The percentages of intermediately susceptible (15 %) and isolates resistant to penicillin (27 %), tetracycline (50 %) and ciprofloxacin (50 %) detected during the last years represent a relevant therapeutic challenge [5]. Additionally, imaging techniques have improved thereby allowing better identification of vegetations as well as some cardiac complications, such as abscesses and fistulae [6]. Finally, valve replacement, and even valve repair, have become commonplace in the management of many complicated GE cases whereas, until 1979, only two cases of GE had undergone surgery [1]. We present a case of N. gonorrhoeae endocarditis and a review of GE cases published during the last three decades.
Case report A 59-year-old Caucasian male presented with progressive dyspnea, arthralgias and fever, which had persisted for three days. He denied having any previous disease, and he was not taking any medication. On hospital admission, the patient had a temperature of 38 °C, blood pressure of 90/60 mm Hg and a pulse of 30 beats/min. A grade 3 diastolic regurgitation murmur was detected in the aortic area. Neurological, respiratory, and osteoarticular examinations were normal. Laboratory investigations showed a hemoglobin level of 14.6 g/dL, a platelet count of 242,000/ lL and a white-cell count of 25,400/lL. An electrocardiogram demonstrated atrioventricular and left bundlebranch block that required the implantation of a pacemaker. Because of an inadequate patient acoustic window, a transthoracic echocardiogram was not implemented. Instead, a transesophageal echocardiogram (TEE) was carried out on the day of hospital admission, showing several vegetations and severe aortic regurgitation. Initial treatment included procaine penicillin four million U/4 h, cloxacillin 2 g/4 h and gentamycin 80 mg bid. On day 3, the aerobic bottles of the two sets of blood cultures taken on the day of hospital admission became positive and were
123
identified as N. gonorrhoeae in the API NH test (bioMe´rieux, Marcy l’Etoile, France). The isolate was serovar 1A and ST 8123. Antibiotic susceptibility was determined by Etests (AB Biodisk, Solna, Sweden). The strain was beta-lactamase negative but showed a MIC of 0.38 mg/L to penicillin (intermediate resistance 0.12–1 mg/L). The MIC to other antibiotics was as follows: ceftriaxone B0.016 mg/ L, ciprofloxacin 1 mg/L, tetracycline 12 mg/L and erythromycin 0.125 mg/L. The treatment was changed to ceftriaxone 2 g bid. The patient admitted having had several unprotected sexual encounters with unknown persons up to six weeks prior to admission. He had not noticed any urogenital discomfort or urethral discharge. Swab samples collected from oropharyngeal, urethral and rectal sites did not yield gonococcus. HIV and syphilis (FTA and VDRL) serology was negative. The patient successfully underwent surgery for septal abscess debridement. The native aortic valve was replaced with a 25-mm mechanical prosthetic St. Jude valve. Valvular tissue cultures were negative. 16S rRNA gene sequencing was performed on tissue taken from the heart valve to detect bacterial species. DNA was extracted from the heart valve tissue using the QIAmp DNA Minikit method (Qiagen Ltd, West Sussex, UK) according to the manufacturer’s recommendations. Amplification of the bacterial 16S rRNA gene was performed by real-time PCR in a Light-Cycler instrument (Roche Diagnostics, Mannheim, Germany). Amplicons produced from heart valves were subsequently sequenced by the Big Dye Terminator method using the same primers and detected in an AbiPrism 3130xl automatic DNA sequencer (Applied Biosystems Inc.) [7]. This search identified the bacterium present in the heart valve as N. gonorrhoeae. On the 22nd day, the patients presented fever and TEE showed communication between the right sinus of Valsalva and the right atrium. The patient underwent surgery again for valve replacement and implantation of a surgical patch. The patient received ceftriaxone 2 g bid for eight weeks and the clinical followup was uneventful.
Discussion Gonococcal endocarditis is an uncommon complication of N. gonorrhoeae infection. [1]. Our review of the literature revealed a total of 38 additional cases reported between 1980 and the present [1, 2, 6, 8–18]. Most reported cases were described in Europe and the US. Their clinical characteristics, together with that presented in this report, are summarized in Table 1. The majority of the patients were young, male and with native valve involvement [1, 14]. Only two patients (5 %)
Gonococcal endocarditis Table 1 Clinical features of 39 cases of gonococcal endocarditis reported during the last 32 years N = 39 (%) Age (years) mean ± SD
30 ± 9
Male gender
26 (67)
Genitourinary symptomsa
8 (21)
Arthritisa
5 (13)
Arthralgiasa
7 (18)
Valveb Aortic Mitral
28 (72) 9 (23)
Tricuspid
4 (10)
Pulmonary Perivalvular abscess
4 (10) 10 (26)
Antibiotic treatment Penicillin Third G cephalosporin
25 (64) 13 (33)
Surgery
28 (72)
Death
9 (23)
SD standard deviation a
During the previous three months
b
Three patients had simultaneous infection in two or more valves
suffered prosthetic valve infection. One reason for this low rate may be the low proportion of patients with prosthetic valves in the population most affected (i.e., young people) [14]. According to published information, very few patients experienced genitourinary symptoms in the days prior to hospital admission, and this fact could result in patients not receiving antibiotics, thereby allowing disseminated infection to develop [2]. It should be noted that, in those cases with a positive genitourinary history, symptoms mainly occurred several months prior to admission [8]. Few cases made reference to musculoskeletal symptoms, so these may not be considered as useful clinical indications that lead to a suspicion of GE (Table 1). Although right-sided heart involvement was common in the pre-antibiotic era, during the last few decades there has been an apparent tendency for left-sided valve involvement (especially in the aortic valve, 59 % of reported cases, Table 1) [1]. However, it is unknown whether there are any factors that make the aortic valve more susceptible to N. gonorrhoeae infection. As expected in patients with bacterial endocarditis, blood cultures were positive in all cases. However, all valve cultures were reported negative despite, in most cases, the marked tissue destruction. Therefore, the sensitivity of the valve culture was clearly lower in cases of GE than in cases due to other bacteria, and negative cultures seem to be a characteristic of this entity, which, in some cases, may limit diagnosis [1, 2, 13]. Factors that may
hypothetically have a role in this problem could be the fastidious nature of N. gonorrhoeae or previous antibiotic treatments. PCR was performed in two patients and positive results were shown in both [15]. The role that PCR may have in diagnosing cases with negative cultures must be emphasised [15]. Cultures of exudates from other locations were, in most cases, negative and not very helpful in the diagnosis. Twenty-two cultures from the pharynx, urethra, cervix, rectum and urine were performed in ten patients, most of whom were undergoing antibiotic treatment. Only one pharyngeal and one cervical culture proved positive [1, 8]. One striking fact is the high proportion of patients who underwent surgery (72 %). This percentage was clearly higher than the 25–50 % reported in other endocarditis series [19]. Four patients (10 %) did not undergo surgery due to rapid clinical deterioration that ruled it out [14]. The notable necessity for surgery observed in these patients may be related to marked tissue destruction and the high percentage of aortic valve involvement. Information regarding antibiotic sensitivity was available in 28 cases, with penicillin resistance reported in six patients (21 %) and intermediate sensitivity in four patients (14 %). A progressive increase in penicillin resistance would be worrying taking into consideration the antibiotic regimens, which are empirically administered together with the severity of many GE cases [14]. Resistance to ciprofloxacin was reported in two cases (7 %), which is lower than the 53 % reported in a large European survey [5]. Cefixime and ceftriaxone remain the recommended therapy for gonorrhoea across Europe and Spain. However, a rapid increase and distribution of isolates resistant to third generation cephalosporins have been recently detected [20]. One of the limitations of this study is that several of the reported cases did not include some relevant information, such as the antibiotic sensitivity or type of echocardiography performed. Acknowledgments The authors wish to thank to Dr. Julio Vazquez of the Bacteriology Department of the Instituto de Salud Carlos III for gonococcal serotyping and ST typing and to Martin Hadley-Adams for assisting with the English language and preparation of the manuscript. Conflict of interest
The authors declare no conflict of interest.
References 1. Wall TC, Peyton RB, Corey GR. Gonococcal endocarditis: a new look at an old disease. Medicine (Baltimore). 1989;68:375–80. 2. Thompson EC, Brantley D. Gonoccocal endocarditis. J Natl Med Assoc. 1996;88:353–6. 3. Martin I, Jayaraman G, Wong T, Liu G, Gilmour M. Trends in antimicrobial resistance in Neisseria gonorrhoeae isolated in Canada: 2000–2009. Sex Transm Dis. 2011;38:892–8.
123
A. R. Martı´nez et al. 4. European Centre for Disease Prevention and Control (ECDC). Gonococcal antimicrobial surveillance in Europe, 2010. Stockholm ECDC, May 2012. Available from: http://ecdc.europa.eu/ en/publications/Publications/1206-Gonococcal-AMR.pdf. 5. Dı´az-Franco A, Noguer-Zambrano I, Cano-Portero R. Vigilancia epidemiolo´gica de las infecciones de transmisio´n sexual. Espan˜a, 1995–2003. Med Clin (Barc). 2005;125:529–30. 6. Sobel JL, Maisel AS, Tarazi R, Blanchard DG. Gonococcal endocarditis: assessment by transesophageal echocardiography. J Am Soc Echocardiogr. 1997;10:367–70. 7. Goldenberger D, Kunzli A, Vogt P, Zbinden R, Altwegg M. Molecular diagnosis of bacterial endocarditis by broad-range PCR amplification and direct sequencing. J Clin Microbiol. 1997;35:2733–9. 8. Romero E, Gonza´lez M, Calzo´n S, Riesgo MA. Gonococcal endocardtis. Rev Esp Cardiol. 1987;40:293–6. 9. de’Clari F, Nikolic J, Genoni M, Riva A, Moccetti T. Gonococcal endocarditis: an infection as rare as it dangerous. Apropos of a case: the importance of suspicion in diagnosis and of immediate treatment. Schweiz Med Wochenschr. 1990;120:1880–3. 10. Porcel JM, Herrejo´n P, Tornos MP, Arderiu A. Neisseria gonorrhoeae endocarditis. Med Clin (Barc). 1991;97:437–8. 11. Pate MA, Adegbola RA, Ison C, Corrah T. Neisseria gonorrhoeae endocarditis. Trop Doct. 1996;26:131. 12. Pantanowitz L, Hodkinson J, Zeelie R, Jones N. Gonococcal endocarditis after a threatened abortion. A case report. J Reprod Med. 1998;43:1043–5.
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