Infective Endocarditis Due to Unusual or Fastidious Microorganisms

doi:10.4065/72.6.532

Mayo Clinic Proceedings

Volume 72, Issue 6, June 1997, Pages 532-542

https://doi.org/10.4065/72.6.532 Get rights and content

Infective endocarditis due to fastidious microorganisms is commonly encountered in clinical practice. Some organisms such as fungi account for up to 15 % of cases of prosthetic valve infective endocarditis whereas organisms of the HACEK group (Haemophilus parainfluenzae, H. aphrophilus, and H. paraphrophilus, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae) cause 3% of community-acquired cases of infective endocarditis. Special techniques are necessary to identify these microorganisms. A history of contact with mammals or birds may suggest infection caused by Coxiella burnetii (Q fever), Brucella species, or Chlamydia psittaci. A nosocomial cluster of postsurgical infective endocarditis may be caused by Legionella species or Mycobacterium species. If risk factors that are commonly associated with fungal infections (cardiac surgical treatment, prolonged hospitalization, indwelling central venous catheters, and long-term antibiotic use) are present, fungal endo- carditis is possible. Patients with endocarditis and a history of periodontal disease or dental work in whom routine blood cultures are negative might have infection due to nutritionally variant streptococci or bacteria of the HACEK group. Communication between the microbiologist and the clinician is of crucial importance for identification of these microorganisms early during the course of the infection before complications such as embolization or valvular failure occur. In this article, we review the microbiologic and clinical features of these organisms and provide recommendations for diagnosis and treatment.

Section snippets

GRAM·NEGATIVE BACTERIA

HACEK Group.- The fastidious gram-negative bacteria of the HACEK group are Haemophilus parainfluenzae, H. aphrophilus, and H. paraphrophilus, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae. In a previously reported study, these organisms caused approximately 3% of cases of infective endocarditis in a geographically defined population.³ In Olmsted County, Minnesota, the incidence of HACEK endocarditis is estimated to be about 0.32 per

ACKNOWLEDGMENT

We thank Dr. Walter R. Wilson for his expert advice and helpful suggestions.

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Chlamydia psittaci endocarditis: A case report and literature review
2023, Infectious Diseases Now
Blood-culture-negative infective endocarditis (BCNE) is found in 2 to 48% of cases of infective endocarditis (IE) (Houpikian and Raoult, 2005) [1]. IE and vertebral osteomyelitis due to Chlamydia sp. are difficult to diagnose.
A case report of Chlamydia psittaci IE is provided, associated with a literature review.
We report the first case of Chlamydia psittaci IE, revealed by a spondylodiscitis. Questioning of the patient, imaging, serologies and PCR techniques on valves confirmed the diagnosis.
C. psittaci IE is rare but probably underdiagnosed. In case of negative blood cultures, questioning patients with IE about their contacts with animals is relevant. PCR techniques are reference tools for diagnosis confirmation when valve or vertebral samples are available.
The complexity and obscurity of Infective Endocarditis
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Analysis of the frequency of bacteraemia of dental origin implicated in infective endocarditis in patients requiring valve surgery
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Understanding the frequency of bacteraemia of dental origin that is implicated in severe infective endocarditis (IE) will further our understanding of the disease’s pathoaetiology and help us take steps to reduce its prevalence. A total of 78 patients from the Royal Papworth Hospital, Cambridge, who had valve surgery due to IE (as confirmed by the Modified Duke Criteria) were included. Case notes were retrospectively reviewed for microorganisms that were implicated in the bacteraemia and IE. Associated factors were also recorded to determine whether they were different if a dental or non-dental pathogen was inoculated. A dental pathogen was implicated in 24 of the patients with IE; 20 had non-dental pathogens, and 30 were culture negative. This was not deemed statistically significant (p = 0.54). Of the associated factors, only smoking was statistically significant with a greater proportion of non-smokers having bacteraemia of dental origin (p = 0.03). No other associated factor was appreciably different based on the aetiology of the microorganism. Our results indicate that dental pathogens are not more likely to cause severe IE. We therefore advocate the stance adopted by the current national guidance on the judicious prescription of antibiotic prophylaxis for IE with regard to dental procedures.
A case of recurrent Corynebacterium jeikeium endocarditis: Unanswered questions for the treatment of chronic endovascular infections
2019, IDCases
Citation Excerpt :
These biofilms can contribute to antimicrobial resistance and have been the probable cause of many recurrent implant-associated infections [1]. The Corynebacterium species was traditionally classified as culture contaminants, but have become associated with life-threatening infections in immunocompromised hosts [2,3]. Our case highlights many of the challenges with treating recurrent endovascular infections.
A 53-year-old woman with end-stage renal impairment on hemodialysis was evaluated for recurrent episodes of Corynebacterium jeikeium bacteremia and endocarditis. Her recurrences occurred despite surgical debridement and extended courses of culture-directed antimicrobial therapy. The clinical course was complicated by the requirement of various endovascular prostheses for vascular access. To our knowledge this degree of relapse with guideline medical and surgical therapy is rare and challenges current practice and understanding of this group of infection.
HACEK infective endocarditis: Epidemiology, clinical features, and outcome: A case–control study
2018, International Journal of Infectious Diseases
The study aimed to describe the epidemiological, microbiological, and clinical features of a population sample of 17 patients with HACEK infective endocarditis (HACEK-IE) and to compare them with matched control patients with IE caused by viridans group streptococci (VGS-IE).
Cases of definite (n = 14, 82.2%) and possible (n = 3, 17.6%) HACEK-IE included in the Infective Endocarditis Hospital Clinic of Barcelona (IE-HCB) database between 1979 and 2016 were identified and described. Furthermore, a retrospective case–control analysis was performed, matching each case to three control subjects with VGS-IE registered in the same database during the same time period.
Seventeen out of 1209 IE cases (1.3%, 95% confidence interval 0.69–1.91%) were due to HACEK group organisms. The most frequently isolated HACEK species were Aggregatibacter spp (n = 11, 64.7%). Intracardiac vegetations were present in 70.6% of cases. Left heart failure (LHF) was present in 29.4% of cases. Ten patients (58.8%) required in-hospital surgery and none died during hospitalization. In the case–control analysis, there was a trend towards larger vegetations in the HACEK-IE group (median (interquartile range) size 11.5 (10.0–20.0) mm vs. 9.0 (7.0–13.0) mm; p = 0.068). Clinical manifestations, echocardiographic findings, LHF rate, systemic emboli, and other complications were all comparable (p > 0.05). In-hospital surgery and mortality were similar in the two groups. One-year mortality was lower for HACEK-IE (1/17 vs. to 6/48; p = 0.006).
HACEK-IE represented 1.3% of all IE cases. Clinical features and outcomes were comparable to those of the VGS-IE control group. Despite the trend towards a larger vegetation size, the embolic event rate was not higher and the 1-year mortality was significantly lower for HACEK-IE.
Generation of a recombinant Aggregatibacter actinomycetemcomitans RTX toxin in Escherichia coli
2018, Gene
A leukotoxin (LtxA) that is produced by Aggregatibacter actinomycetemcomitans (Aa) is an important virulence determinant in an aggressive form of periodontitis in adolescents. Understanding the function of this protein at the molecular level is critical to elucidating its role in the disease process. To accomplish genetic analysis of the protein structure and relating these observations to toxin function, we have developed an E. coli expression system for the generation and rapid purification of LtxA. Cloning the structural toxin gene, ltxA, from Aa strain JP2 under control of T7 promoter-1 of pCDFDuet-1 vector resulted in expression of a 114 KDa protein which could be easily purified by the presence of a carboxy-terminal engineered double hexahistidine (double–His₆) tag and was immunologically reactive with an anti-LtxA monoclonal antibody, but was not cytotoxic. Cloning a second gene, ltxC, an acyltransferase gene, into the vector under control of T7 promoter-2, resulted in expression of the biologically active LtxA. The toxin was extracted from E. coli inclusion bodies, purified by immobilized metal affinity chromatography, and refolded by dialysis. When compared by circular dichroism (CD) spectroscopy analysis, acylated recombinant LtxA has a secondary structure consistent with wt LtxA, while variations in α-helical structure of nonacylated LtxA were observed. No modifications in α-helix were found upon the toxin's binding with liposome-incorporated cholesterol. Our results suggest that pure, biologically active recombinant LtxA can be isolated by a one-step affinity chromatography from E. coli. The toxic and structural properties of the recombinant LtxA are similar to its wt counterpart.

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Subspecialty Clinics: Infectious DiseasesInfective Endocarditis Due to Unusual or Fastidious Microorganisms

Section snippets

GRAM·NEGATIVE BACTERIA

ACKNOWLEDGMENT

AmJMed

Am J Med

Lancet

Am J Med

Infect Dis Clin North Am

IntJCardiol

Med Hypotheses

Am J Med Sei

Semin Arthritis Rheum

Hum Pathol

Diagn Microbiol Infect Dis

Ann Thorac Surg

Am J Med

J Infect

Am J Med

The medical treatment of culture-negative infective endocarditis

Eur Heart J

Culture-negative endocarditis

Mayo Clin Proc

Infective endocarditis caused by HACEK microorganisms

AnnuRevMed

Analysis of 281,797 consecutive blood cultures performed over an eight-year period-trends in microorganisms isolated and the value of anaerobic culture of blood

Clin Infect Dis

Gram-negative bacterial endocarditis

Unusual bacterial causes of endocarditis

Endocarditis due to gram-negative bacteria: report of 56 cases

Mayo Clin Proc

Antibiotic treatment of adults with infective endocarditis due to streptococci, enterococci, staphylococci, and HACEK microorganisms

JAMA

Chronic Q fever: ninety-two cases from France, including 27 cases without endocarditis

Arch Intern Med

Q fever endocarditis

Eur Heart J

Serological differentiation between actue (late control) and endocarditis Q fever

JClinPathol

Isolation of Coxiella burnetii from heart valves of patients treated for Q fever endocarditis

J Clin Microbiol

Conventional viral cultures and shell vial assay for diagnosis of apparently culture-negative Coxiella burnetii endocarditis

Eur J Clin Microbiol Infect Dis

An unusual case of Q fever endocarditis

Cardiology

Q fever endocarditis on porcine bioprosthetic valves: clinicopathologic features and micro-biologic findings in three patients treated with doxycycline, cotrimoxazole, and valve replacement

Ann Intern Med

Ciprofloxacin in a case of Q fever endocarditis [letter]

NEnglJMed

Brucella endocarditis: the role of combined medical and surgical treatment

Rev Infect Dis

Brucella melitensis endocarditis: successful treatment of an infected prosthetic mitral valve

Thorax

Prosthetic valve endocarditis caused by Brucella melitensis: a report of four cases successfully treated with tetracycline, streptomycin, and sulfamethoxazole and trimethoprim plus valve replacement

Arch Intern Med

Brucella endocarditis: report of one case and review of the literature

J Cardiovasc Surg

Management of Brucella endocarditis with aortic root abscess

Chest

Quinolones in treatment of human brucellosis: comparative trial of ofloxacin-rifampin versus doxycycline-rifampin

Antimicrob Agents Chemother

Prosthetic valve endocarditis caused by Legionella pneumophila

Ann Intern Med

Legionella prosthetic-valve endocarditis

N Engl J Med

Subspecialty Clinics: Infectious Diseases
Infective Endocarditis Due to Unusual or Fastidious Microorganisms