J Echocardiogr DOI 10.1007/s12574-015-0242-8
CASE REPORT
Infective endocarditis with negative blood culture and negative echocardiographic findings Izumi Sumatani1 • Nobuyuki Kagiyama2 • Chie Saito1 • Masaki Makanae1 Hideo Kanetsuna1 • Kenta Ahn3 • Akira Mizukami4 • Yuji Hashimoto4
•
Received: 3 September 2014 / Revised: 26 January 2015 / Accepted: 6 March 2015 Ó Japanese Society of Echocardiography 2015
Abstract A 61-year-old male presented with fever. He had a history of aortic valve replacement, and infective endocarditis was suspected. The transthoracic and transesophageal echocardiography on admission could not detect vegetation, and all blood cultures obtained were negative. We concluded that infective endocarditis was not likely. However, repeated echocardiography revealed paravalvular regurgitation and paravalvular abscess. Serum antibody testing for Bartonella henselae was positive, leading to the diagnosis of blood culture-negative endocarditis. Even when blood cultures and echocardiography were negative on initial examination, careful history-taking, blood tests accounting for these pathogens, and repeated echocardiography are crucial for diagnosis. Keywords Infective endocarditis Transesophageal echocardiography Prosthetic valve Culture-negative endocarditis Paravalvular regurgitation
& Nobuyuki Kagiyama [email protected] 1
Department of Laboratory Medicine, Kameda Medical Center, 929 Higashicho, Kamogawa, Japan
2
Department of Cardiology, The Sakakibara Heart Institute of Okayama, 2-5-1 Nakaicho, Kitaku, Okayama 700-0804, Japan
3
Department of Cardiovascular Surgery, Kameda Medical Center, 929 Higashicho, Kamogawa, Japan
4
Department of Cardiology, Kameda Medical Center, 929 Higashicho, Kamogawa, Japan
Introduction Modified Duke’s criteria for the diagnosis of infective endocarditis (IE) have high sensitivity and specificity, and include positive blood culture and echocardiographic [including transesophageal echocardiography (TEE)] findings as the major criteria. Sensitivity is reported to be 95 and 86–94 %, respectively [1]. The case here is a 61-year-old male. The patient had a history of aortic valve replacement (AVR) using a 27-mm Bjo¨rk–Shiley mechanical prosthesis for aortic regurgitation at the age of 31 years. He was working in the dairy industry, with a dog and a cat as pets. He presented with fever persisting for more than 1 month, edema, and dyspnea, and was admitted to our hospital. On admission, blood culture was negative and transthoracic echocardiography (TTE) and TEE (Fig. 1a, b) did not detect any vegetation, paravalvular abscess, or valve failure. We concluded that IE was unlikely and follow-up echocardiography was not performed frequently. However, followup TTE on the 25th day revealed moderate aortic regurgitation, which was mild at admission. During this period, a total of 14 blood cultures were obtained, but all of them were negative. However, serum IgG and IgM antibody for Bartonella henselae was positive. Therefore, IE caused by Bartonella henselae was strongly suspected and antibiotics (doxycycline 400 mg/day and rifampicin 600 mg/day) were started. TEE was reperformed on the 30th day and revealed severe paravalvular aortic regurgitation with paravalvular abscess (Fig. 2), and, finally, vegetation was detected on the 38th day of admission by TEE (Fig. 1c). Since it was refractory to antibiotic therapy in spite of appropriate drug and dose, re-AVR was scheduled. Because the patient suffered cerebral infarction on the 40th day, re-AVR was deferred until the 55th day of admission.
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J Echocardiogr Fig. 1 Formation of paravalvular abscess over time. a, b There was no obvious abscess or vegetation on the prosthesis according to the short- and long-axis views on the 8th day of admission. c Transesophageal echocardiography (short-axis view of the aortic valve) on the 38th day of admission. Paravalvular echo-free space was observed with valvular instability. d Operative picture with a large paravalvular abscess around LCC and NCC (cranial side up, caudal side bottom)
Intraoperative examination revealed vegetation at the prosthetic valve, with infection extending to the paravalvular structure (Fig. 1d). Polymerase chain reaction (PCR) performed with the tissue obtained was positive for Bartonella henselae, and the diagnosis was confirmed.
Discussion In this case, none of the major criteria of Duke’s criteria were fulfilled at initial examination. But repeated echocardiography and serum antibody lead to the appropriate diagnosis. Prosthetic valve endocarditis is reported to have low detection sensitivity with TTE, and concomitant TEE is recommended. However, even with TEE, it is sometimes challenging to detect vegetation at
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mechanical valves due to artifacts. In these cases, blood culture is the most important finding to suspect IE. The culture-negative endocarditis which is characterized by clinical features typical of IE but with negative blood cultures are reported to comprise 10 % of all IE cases [2]. Many cases are due to the previous use of antibiotics, but are sometimes due to pathogens which are difficult to detect with blood cultures, including Bartonella, Brucella, Coxiella, Chlamydia, HACEK group, and Tropheryma whipplei [3]. Even if the patient does not fulfil Duke’s criteria, when IE cannot be ruled out, we should carefully follow up the patient to completely exclude IE. Careful history-taking, blood tests, and repeated echocardiography accounting for these difficult-to-detect pathogens are crucial for diagnosis.
J Echocardiogr Conflict of interest Izumi Sumatani, Nobuyuki Kagiyama, Chie Saito, Masaki Makanae, Hideo Kanetsuna, Kenta Ahn, Akira Mizukami, and Yuji Hashimoto declare that they have no conflict of interest. Human rights statements and informed consent All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000(5). Informed consent was obtained from all patients for being included in the study.
References 1. Habib G, Hoen B, Tornos P, et al. Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009): the Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and the International Society of Chemotherapy (ISC) for Infection and Cancer. Eur Heart J. 2009;30(19):2369–413. 2. Hoen B, Duval X. Clinical practice. Infective endocarditis. N Engl J Med. 2013;368(15):1425–33. 3. Fournier PE, Thuny F, Richet H, et al. Comprehensive diagnostic strategy for blood culture-negative endocarditis: a prospective study of 819 new cases. Clin Infect Dis. 2010;51(2):131–40.
Fig. 2 Worsening aortic regurgitation over time. a Transesophageal echocardiography (long-axis view of the aortic valve) on the 8th day of admission with trivial aortic regurgitation. b Transesophageal echocardiography (long-axis view of the aortic valve) on the 30th day of admission with moderate aortic regurgitation with paravalvular regurgitation. c Transesophageal echocardiography (long-axis view of the aortic valve) on the 38th day of admission with severe aortic regurgitation with paravalvular regurgitation
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CASE REPORT
Infective endocarditis with negative blood culture and negative echocardiographic findings Izumi Sumatani1 • Nobuyuki Kagiyama2 • Chie Saito1 • Masaki Makanae1 Hideo Kanetsuna1 • Kenta Ahn3 • Akira Mizukami4 • Yuji Hashimoto4
•
Received: 3 September 2014 / Revised: 26 January 2015 / Accepted: 6 March 2015 Ó Japanese Society of Echocardiography 2015
Abstract A 61-year-old male presented with fever. He had a history of aortic valve replacement, and infective endocarditis was suspected. The transthoracic and transesophageal echocardiography on admission could not detect vegetation, and all blood cultures obtained were negative. We concluded that infective endocarditis was not likely. However, repeated echocardiography revealed paravalvular regurgitation and paravalvular abscess. Serum antibody testing for Bartonella henselae was positive, leading to the diagnosis of blood culture-negative endocarditis. Even when blood cultures and echocardiography were negative on initial examination, careful history-taking, blood tests accounting for these pathogens, and repeated echocardiography are crucial for diagnosis. Keywords Infective endocarditis Transesophageal echocardiography Prosthetic valve Culture-negative endocarditis Paravalvular regurgitation
& Nobuyuki Kagiyama [email protected] 1
Department of Laboratory Medicine, Kameda Medical Center, 929 Higashicho, Kamogawa, Japan
2
Department of Cardiology, The Sakakibara Heart Institute of Okayama, 2-5-1 Nakaicho, Kitaku, Okayama 700-0804, Japan
3
Department of Cardiovascular Surgery, Kameda Medical Center, 929 Higashicho, Kamogawa, Japan
4
Department of Cardiology, Kameda Medical Center, 929 Higashicho, Kamogawa, Japan
Introduction Modified Duke’s criteria for the diagnosis of infective endocarditis (IE) have high sensitivity and specificity, and include positive blood culture and echocardiographic [including transesophageal echocardiography (TEE)] findings as the major criteria. Sensitivity is reported to be 95 and 86–94 %, respectively [1]. The case here is a 61-year-old male. The patient had a history of aortic valve replacement (AVR) using a 27-mm Bjo¨rk–Shiley mechanical prosthesis for aortic regurgitation at the age of 31 years. He was working in the dairy industry, with a dog and a cat as pets. He presented with fever persisting for more than 1 month, edema, and dyspnea, and was admitted to our hospital. On admission, blood culture was negative and transthoracic echocardiography (TTE) and TEE (Fig. 1a, b) did not detect any vegetation, paravalvular abscess, or valve failure. We concluded that IE was unlikely and follow-up echocardiography was not performed frequently. However, followup TTE on the 25th day revealed moderate aortic regurgitation, which was mild at admission. During this period, a total of 14 blood cultures were obtained, but all of them were negative. However, serum IgG and IgM antibody for Bartonella henselae was positive. Therefore, IE caused by Bartonella henselae was strongly suspected and antibiotics (doxycycline 400 mg/day and rifampicin 600 mg/day) were started. TEE was reperformed on the 30th day and revealed severe paravalvular aortic regurgitation with paravalvular abscess (Fig. 2), and, finally, vegetation was detected on the 38th day of admission by TEE (Fig. 1c). Since it was refractory to antibiotic therapy in spite of appropriate drug and dose, re-AVR was scheduled. Because the patient suffered cerebral infarction on the 40th day, re-AVR was deferred until the 55th day of admission.
123
J Echocardiogr Fig. 1 Formation of paravalvular abscess over time. a, b There was no obvious abscess or vegetation on the prosthesis according to the short- and long-axis views on the 8th day of admission. c Transesophageal echocardiography (short-axis view of the aortic valve) on the 38th day of admission. Paravalvular echo-free space was observed with valvular instability. d Operative picture with a large paravalvular abscess around LCC and NCC (cranial side up, caudal side bottom)
Intraoperative examination revealed vegetation at the prosthetic valve, with infection extending to the paravalvular structure (Fig. 1d). Polymerase chain reaction (PCR) performed with the tissue obtained was positive for Bartonella henselae, and the diagnosis was confirmed.
Discussion In this case, none of the major criteria of Duke’s criteria were fulfilled at initial examination. But repeated echocardiography and serum antibody lead to the appropriate diagnosis. Prosthetic valve endocarditis is reported to have low detection sensitivity with TTE, and concomitant TEE is recommended. However, even with TEE, it is sometimes challenging to detect vegetation at
123
mechanical valves due to artifacts. In these cases, blood culture is the most important finding to suspect IE. The culture-negative endocarditis which is characterized by clinical features typical of IE but with negative blood cultures are reported to comprise 10 % of all IE cases [2]. Many cases are due to the previous use of antibiotics, but are sometimes due to pathogens which are difficult to detect with blood cultures, including Bartonella, Brucella, Coxiella, Chlamydia, HACEK group, and Tropheryma whipplei [3]. Even if the patient does not fulfil Duke’s criteria, when IE cannot be ruled out, we should carefully follow up the patient to completely exclude IE. Careful history-taking, blood tests, and repeated echocardiography accounting for these difficult-to-detect pathogens are crucial for diagnosis.
J Echocardiogr Conflict of interest Izumi Sumatani, Nobuyuki Kagiyama, Chie Saito, Masaki Makanae, Hideo Kanetsuna, Kenta Ahn, Akira Mizukami, and Yuji Hashimoto declare that they have no conflict of interest. Human rights statements and informed consent All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000(5). Informed consent was obtained from all patients for being included in the study.
References 1. Habib G, Hoen B, Tornos P, et al. Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009): the Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and the International Society of Chemotherapy (ISC) for Infection and Cancer. Eur Heart J. 2009;30(19):2369–413. 2. Hoen B, Duval X. Clinical practice. Infective endocarditis. N Engl J Med. 2013;368(15):1425–33. 3. Fournier PE, Thuny F, Richet H, et al. Comprehensive diagnostic strategy for blood culture-negative endocarditis: a prospective study of 819 new cases. Clin Infect Dis. 2010;51(2):131–40.
Fig. 2 Worsening aortic regurgitation over time. a Transesophageal echocardiography (long-axis view of the aortic valve) on the 8th day of admission with trivial aortic regurgitation. b Transesophageal echocardiography (long-axis view of the aortic valve) on the 30th day of admission with moderate aortic regurgitation with paravalvular regurgitation. c Transesophageal echocardiography (long-axis view of the aortic valve) on the 38th day of admission with severe aortic regurgitation with paravalvular regurgitation
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