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Salmonella prosthetic valve endocarditis

1996; Elsevier BV; Volume: 112; Issue: 3 Linguagem: Inglês

10.1016/s0022-5223(96)70075-2

1097-685X

Norihide Fukushima, Namiko Ishikawa, Yasuhisa Shimazaki, Kazuhiro Taniguchi, Masahiro Tanemura, Akihumi Matsuyama, Yūji Matsuzawa, H Matsuda,

Infectious Aortic and Vascular Conditions

Salmonella endocarditis has been characterized by its destructive process and malignant clinical course.1Cohen PS Maguire JH Weinstein L. Infective endocarditis caused by Gram-negative bacteria: a review of the literature, 1945-1977.Prog Cardiovasc Dis. 1980; 22: 205-242Abstract Full Text PDF PubMed Scopus (118) Google Scholar Although an increasing number of such infections have been evident in recent years, Salmonella prosthetic valve endocarditis (PVE) is still rare.2Yamamoto N Magidson O Posner C Mendez MA Zubiate P Kay JH Probable Salmonella endocarditis treated with prosthetic valve replacement: a case report.Surgery. 1974; 76: 678-681PubMed Google Scholar, 3Choo PW Gantz NM Anderson C Maguire H Salmonella prosthetic valve endocarditis.Diagn Microbiol Infect Dis. 1992; 15: 273-276Abstract Full Text PDF PubMed Scopus (15) Google Scholar, 4Lee Y Lai L Shyu K Kuan P Lien W Salmonella prosthetic valve endocarditis: a case report.J Vasc Dis. 1994; 45: 245-247Google Scholar Only seven case reports have appeared in the English literature up to now. Because of its rarity and unusual clinical course, we describe the eighth case of Salmonella PVE in a patient who underwent rereplacement of the aortic and mitral prosthetic valves and simultaneous cholecystectomy. We also review the previous cases reported in the literature. A 58-year-old man was admitted on an emergency basis on October 1, 1994, with fever, chills, and weakness of 3 days' duration. He had undergone aortic and mitral replacement, tricuspid annuloplasty, and closure of an atrial septal defect in 1981 at 45 years of age. He had two brothers who had died of enteric typhus. On admission, his temperature was 42.0º C and blood pressure was 86/60 mm Hg. He had normal regular prosthetic valve sounds at 76 beats/min. The white blood cell count was 12,100/mm3 with 61% segmented polymorphonuclear white cells and bands of 15% but with no eosinophils. The chest x-ray film showed moderate cardiomegaly and the electrocardiogram showed incomplete right bundle branch block with normal sinus rhythm. After intravenous antibiotics were given, the white blood cell count decreased, the eosinophil count increased, and spiking fevers disappeared. Because clinical examinations showed no evidence of infectious endocarditis, antibiotics were discontinued on day 28 after admission. Five days later, his body temperature elevated again with chills. The white blood cell count increased and the eosinophil count decreased. Salmonella typhimurium was isolated from the blood three times after recurrent fever. A transesophageal echocardiogram (TEE) revealed a highly mobile echo mass attached to the anulus of the mitral prosthetic valve and an immobile echo mass on the subvalvular position of the aortic valve. After 66 days of hospitalization, he underwent rereplacement of the aortic and mitral prosthetic valves and simultaneous cholecystectomy. The aortic prosthetic valve did not appear grossly infected but had moderate sized subvalvular pannus formation. A vegetation was found on the anterior anulus of the mitral valve. The mitral and aortic prostheses were replaced with a CarboMedics bileaflet prosthesis (29 mm in diameter; CarboMedics, Inc., Austin, Tex.) and a St. Jude Medical prosthesis (25 mm in diameter; St. Jude Medical, Inc., St. Paul, Minn.). After closure of the chest, the gallbladder was removed in the usual fashion. Gall stones were found in the gallbladder, but intraoperative choledochography revealed no choledochal stones. The patient was moved to the intensive care unit in a stable hemodynamic condition. Microscopic examination of the tissue surrounding the mitral prosthetic valve showed diffuse infiltration of lymphocytes and neutrophils with clusters of micrococci. The gallbladder showed mild cellular infiltration. Culture of the vegetation and bile grew Micrococcus but no Salmonella. The concentrations of sulbactam and cefoperazone in the serum, the wall of the gallbladder, and the bile in the gallbladder were four times higher than the minimum inhibitory or bactericidal concentration for S. typhimurium, resulting in a failure to isolate Salmonella from these specimens. Imipenem, to which not only Salmonella but Micrococcus was sensitive, was given intravenously for 6 weeks after the operation. A TEE on postoperative day 35 revealed no vegetation, and he was discharged on postoperative day 36. He had no evidence of recurrent infection during 1 year of follow-up. Endocarditis resulting from Salmonella is rare but has a high mortality rate even when treated with intravenous administration of antibiotics.1Cohen PS Maguire JH Weinstein L. Infective endocarditis caused by Gram-negative bacteria: a review of the literature, 1945-1977.Prog Cardiovasc Dis. 1980; 22: 205-242Abstract Full Text PDF PubMed Scopus (118) Google Scholar Seven cases of Salmonella PVE have been reported in the English literature (Table I)2Yamamoto N Magidson O Posner C Mendez MA Zubiate P Kay JH Probable Salmonella endocarditis treated with prosthetic valve replacement: a case report.Surgery. 1974; 76: 678-681PubMed Google Scholar, 3Choo PW Gantz NM Anderson C Maguire H Salmonella prosthetic valve endocarditis.Diagn Microbiol Infect Dis. 1992; 15: 273-276Abstract Full Text PDF PubMed Scopus (15) Google Scholar, 4Lee Y Lai L Shyu K Kuan P Lien W Salmonella prosthetic valve endocarditis: a case report.J Vasc Dis. 1994; 45: 245-247Google Scholar Many types of Salmonella were isolated from the blood, valve, and aortic wall (Table I). All six patients were treated with intravenous antibiotic therapy that achieved an adequate serum bactericidal level for 34 to 100 days; however, rereplacement of valves was considered in all and three died before the operation. Four patients underwent rereplacement of the prosthetic valve and only two survived the operation (Table II). No patient underwent simultaneous cholecystectomy. Our patient represents the eighth reported case of Salmonella prosthetic valve infection and only the third to have survived. Because of high mortality and recurrence rates of Salmonella PVE, early surgical intervention should be considered. For a diagnosis of PVE, transthoracic echocardiography did not disclose a vegetation before the operation in five of seven cases of Salmonella PVE, whereas TEE could detect a vegetation in both cases in which TEE was done. TEE should be done if PVE is suspected.Table ICharacteristics of the previous and present cases of preoperative Salmonella PVECaseAuthorYearAge sexSalmonella speciesPreexisting heart diseasePreexisting prosthetic valve (position of valves)Duration from the first replacement to onset of endocarditis (yr)Antibiotic therapyTotal duration of antiobiotic therapy (days)1Weinstein196544, MS. schwarzengrundR (M and A)Hufnagel (A)4CP272Fraser196756, FS. hirschfeldiiR? (A)Bahnson (A)4PC, CP, ABPC, SM,Unknown3Yamamoto197450, FS. choleraesuis S. enteritidis (groupD)R (M)Unknown (M)3ABPC, TC544Shanson197752, MS. enteritidisS (A)Starr-Edwards (A)3GM, CEZ, CP, ABPC, mecillinam485Bassa1989NA, NAS. nontyphiNANANANANA6Choo199262,FS. heidelbergR (M and T)Hancock (M and T)9 and 7CTX, ABPC, GM817Lee199442, MGroup BR (M and A)Björk-Shiley (M and A)19VCM, netilmi cin, CTX>1008Present case199649, MS. typhimuriumR (M and A)Björk-Shiley (M and A)13PIPC, SBT/CPZ, GM ABPC64R, Rheumatic; M, mitral; A, aortic; S, syphilitic; T, tricuspid; NA, not available; CP, chloramphenicol; PC, penicillin; SM, streptomycin; ABPC, ampicillin; MC, minocycline; TC, tetracycline; GM, gentamicin; CEZ, cefazolin; VCM, vancomycin; CTX, ceftriaxone; PIPC, piperacillin; SBT, sulbactam; CPZ, cefoperazone. Open table in a new tab Table IISurgical treatment and outcome of the previous and present cases of Salmonella PVECaseSurgical treatmentNew Prosthetic valves (position of valves)Vegetation (position of valves)Postop. antibiotic therapyDuration of postoperative antibiotics therapy (days)ComplicationsOutcome1NoneAortic abscessNone48Dissecting aneurysmDied (preop.)2Re-AVRMcGovern (A)Yes (A)None45Cerebral emboli (preop.)Died (POD1)3Re-MVRKay-Shiley (M)Yes (M)ABPC, SM120Cerebral emboli (preop.); fever and isolation of Salmo- nella from stool postop.Alive4.Re-AVRBjörk-Shiley (A)Yes (A)NANACerebral emboli, pancytopeniaDied5NoneYes (?)NANANoneDied (preop.)6AVR,Re-MVR, Re-TVRSt. Jude Medical (A, M and T)Yes (T)CTX, CPFX102NoneAlive7NoneYes (A and M)NonenoneNoneDied (preop.)8Re-AVR, Re-MVRSt. Jude Medical (A), CarboMedics (M)Yes (M)IPM, BAC, DFLX156NoneAliveAVR, Aortic valve replacement; MVR, mitral valve replacement; TVR, tricuspid valve replacement; A, aortic; M, mitral; T, tricuspid; NA, not available; ABPC, ampicillin; SM, streptomycin; CTX, ceftriaxone; CPFX, ciprofloxacin; IPM, imipenam; BAC, sulfamethoxazole and trimethaprim; DFLX, difloxacin. Open table in a new tab R, Rheumatic; M, mitral; A, aortic; S, syphilitic; T, tricuspid; NA, not available; CP, chloramphenicol; PC, penicillin; SM, streptomycin; ABPC, ampicillin; MC, minocycline; TC, tetracycline; GM, gentamicin; CEZ, cefazolin; VCM, vancomycin; CTX, ceftriaxone; PIPC, piperacillin; SBT, sulbactam; CPZ, cefoperazone. AVR, Aortic valve replacement; MVR, mitral valve replacement; TVR, tricuspid valve replacement; A, aortic; M, mitral; T, tricuspid; NA, not available; ABPC, ampicillin; SM, streptomycin; CTX, ceftriaxone; CPFX, ciprofloxacin; IPM, imipenam; BAC, sulfamethoxazole and trimethaprim; DFLX, difloxacin. In Salmonella PVE with a possible infectious origin of the gallbladder, it is still controversial to perform simultaneous operations. The previous patients did not undergo simultaneous cholecystectomy. Salmonella species can persist in the gastrointestinal system, especially in the gallbladder, in carriers who are symptom-free. It is difficult to eradicate Salmonella in patients with gallstones or scarring of the biliary tree even after intravenous antibiotics.5Neil MA Opal SM Heelan J et al.Failure of ciplofloxacin to eradicate convalescent fecal excretion after acute salmonellosis: experience during an outbreak in health care workers.Ann Intern Med. 1991; 114: 195-199Crossref PubMed Scopus (109) Google Scholar Some patients with Salmonella infection resistant to intravenous antibiotic therapy required cholecystectomy to eradicate the carrier state.5Neil MA Opal SM Heelan J et al.Failure of ciplofloxacin to eradicate convalescent fecal excretion after acute salmonellosis: experience during an outbreak in health care workers.Ann Intern Med. 1991; 114: 195-199Crossref PubMed Scopus (109) Google Scholar One of two patients who survived after surgery for Salmonella PVE had recurrent fever after the operation, and Salmonella was isolated from his stool on the fifth postoperative day. In the Japanese literature, one patient with Salmonella PVE who survived after rereplacement of two prostheses had cholecystitis after the operation. Therefore simultaneous cholecystectomy should be considered in Salmonella PVE, especially in case of bile duct infection or gallstones, as in the present patient. In summary, we described the eighth case of Salmonella PVE. Rereplacement of the aortic and mitral prosthetic valves and simultaneous cholecystectomy were done, without recurrence of the infection during 1 year of follow-up.