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Cardiovascular Infections: J Korean Opthalmol Soc 52:863, 2011

1. The 38-year-old man likely has infective endocarditis based on his symptoms and physical exam findings including a heart murmur and retinal hemorrhages. He is at higher risk due to a childhood illness resembling rheumatic fever from growing up in rural Honduras. 2. Blood cultures reveal the causative organism is Streptococcus mutans, a viridans streptococcus commonly found in the oral flora that can cause endocarditis, especially in those with a history of rheumatic fever which damages heart valves. 3. Complications of infective endocarditis include heart valve damage and heart failure if not treated properly with antibiotics and potentially surgery to replace infected valves.

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73 views3 pages

Cardiovascular Infections: J Korean Opthalmol Soc 52:863, 2011

1. The 38-year-old man likely has infective endocarditis based on his symptoms and physical exam findings including a heart murmur and retinal hemorrhages. He is at higher risk due to a childhood illness resembling rheumatic fever from growing up in rural Honduras. 2. Blood cultures reveal the causative organism is Streptococcus mutans, a viridans streptococcus commonly found in the oral flora that can cause endocarditis, especially in those with a history of rheumatic fever which damages heart valves. 3. Complications of infective endocarditis include heart valve damage and heart failure if not treated properly with antibiotics and potentially surgery to replace infected valves.

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boday
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Cardiovascular Infections

Collaborative Classrooms
Friday, 12 January 2018

Case one

A 38 y.o. man presents with a 3-week history of low-grade fever, fatigue, shortness of
breath with exercise, and visual change. He migrated to the US 10 years previously, after
having grown up in a rural area outside of San Pedro Sula, Honduras.

He states that he probably would not have come to the physician’s office if he had not
developed blurred vision in his right eye. When asked about his past medical history, he
mentions that as a young child he was ill with a fever, knee pain and joint swelling, and
abnormal movements. He could not control the movements and they lasted a few months
before resolving.

On examination, his temperature is 101.4 °F, pulse rate of 94 with a forceful pulse, and
blood pressure 108/48. On skin and mucous membrane exam, he has scattered oral
mucosal petechiae, conjunctival petechiae and splinter hemorrhages in the nail beds of his
fingers (below). On exam of his oropharynx there is diffuse gingival disease. On fundoscopy
he has two retinal hemorrhages in the right eye, one in the macula and one inferior to the
macula (below). On cardiac exam, he has a prominent apical impulse and an early- to pan-
diastolic, high-pitched, decrescendo murmur heard best at the left lower sternal border.

J Korean Opthalmol Soc 52:863, 2011


Laboratory testing:

 WBC: 9,400 cells/mm3 with 76% neutrophils


 Hemoglobin: 10.3 g/dL
 Hematocrit: 33%
 Erythrocyte sedimentation rate: 104 mm

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Questions:

1. What is the most likely diagnosis that explains his current illness?

2. How would you make the diagnosis?

3. Why do you think he is at risk for this complication? Why is growing up in Honduras
relevant?

He has a trans-esophageal echocardiogram that demonstrates a 1.5 cm vegetation on the


non-coronary leaflet of his aortic value. There is moderate regurgitation during diastole.
His left ventricle is mildly enlarged.

4. List three bacterial organisms most likely to cause his disease.

He has 3 sets of blood cultures drawn. All sets grow a viridans streptococcus: Streptococcus
mutans, in both the anaerobic and aerobic bottles.

5. What characteristics of Streptococcus mutans make it suited to be a cause of


endocarditis? How does this organism differ from the types of Streptococcus that
predisposed him to rheumatic fever? Consider virulence characteristics.

6. What are additional complications of aortic valve endocarditis?

7. What are the treatment principles in endocarditis, both medical and surgical?

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Case 2

A 32-year-old woman is hospitalized for her third episode of pyelonephritis (kidney


infection) in the last two years. She presented with left flank pain, fever to 103.8 °F, and
shaking chills. She is known to have recurrent renal calculi that predispose her to
pyelonephritis.

Her urine and blood grow Escherichia coli resistant to ampicillin, sulfonamides and most
cephalosporins so she is started on meropenem to complete a two-week course.

She has a peripherally inserted central catheter (PICC) placed in her left arm for
administration of the antibiotic at home. Ten days into her therapy she develops a fever to
102.5 °F, feels poorly and is readmitted to the hospital. On examination there is pus around
the PICC site. Her blood cultures now grow Staphylococcus epidermidis.

1. What nosocomial complication has she experienced?

2. How commonly does this occur? What is the annual cost to the health system both in
terms of money spent and prolongation of hospitalization?

3. What are the infection control guidelines for prevention of infection with indwelling
catheters?

4. What are the options for treating this infection?

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