Infectious endocarditis with streptococcus gallolyticus

Introduction: Viridans streptococcus are the most important causative agents for native valve infective endocarditis (IE) in nondrug-addicted patients. Streptococcus gallolyticus, subspecies gallolyticus, formerly referred as Streptococcus bovis biotype I, is a member of group D streptococci, and is estimated to be incriminated in 24% of streptococcal endocarditis. Based on genetic, physiologic and phylogenetic criteria, Schlegel et al. proposed the reclassification of Streptococcus bovis biotype I as Streptococcus gallolyticus. In Southern Europe, the proportion of endocarditis which is caused by Streptococcus gallolyticus has increased duringrecent years. Hoenet al. documented that Streptococcus gallolyticus is responsible for an important proportion of streptococcal IE cases: 58% in France, 9.4% in other European countries and 16.7% in USA.
Case presentation: We present you a 45-year-old patient, known for hypertension. The patient was admitted with the following symptoms: marked fatigue, asthe-nia, weight loss (2 months to 20 kg), febrile syndrome. From the history of the disease we find that the patient was hospitalized in another hospital with suspicion of pharyngitis with the following accusations: fever, swea-ting, asthenia, dysphagia, odinophagia and he received antibiotic treatment for 5 days. Symptomatology resu-mes for a while, so that the accusations will reappear later. Under these conditions, the patient addresses the pneumology clinic with a suspicion of pneumonia, but from here he is referred to the cardiology clinic with the recommendation of an echocardiographic exam where the current diagnosis has been established. The patient did not undergo any recent invasive bleeding or recent dental extraction. The patient denies intraveno-us drug use and has no history of rheumatic or dege-nerative valvular heart disease. Clinical examination at admission reveals: altered general condition, facies pa-lid, febrile temperature=39°C, sinus rythm, tachycar-dic, 100 b/min, well trapped, systolic blast in the IV / VI mitral focal point, diastolic bloating in the aortic outbreak, 120/70 mmhg, respiratory rate 20/min. No pulmonary rallies. The abdominal examination reveals moderate splenomegaly. Laboratory tests demonstra-te an inflammatory syndrome (VSH=90 mm/), hypo-chromic anemia, neutrophil growth and leukocytes are at the upper limit of normal. On the electrical route, the sinus rhythm is recorded, with no active ischemic changes. Chest radiography is normal. Echocardiography shows aortic valve ventricular ventricle – a floating hyperecogenic formation=1.7/1.9 cm, mitral regurgitation grade 2, aortic regurgitation grade 2, left ventricle diameters in normal range, and left ventricular ejection fraction (>50%). Hemocultures were positive for Step-tococcus Gallolyticus and the antibiogram showed high sensitivity to Ampicillin and Clindamycin. Thus antibi-otic therapy with Ampicillin 16g daily was started. The response to treatment was a good one, with lowering of the temperature, improvement of siptomatology and general improvement of the patient’s condition. After 5 weeks of treatment, the patient is transferred to the Cardiovascular Surgery Clinic. Intraoperatively, the aortic bicuspid valve and atrial septal defect (DSA) are observed at the inspection. Thus, the replacement of the mitral valve with Jude Master 27 mm mechani-cal prosthesis, replacing the aortic valve with the Jude Regent 23 mm mechanical prosthesis, closing the DSA with Prolene 5.0 wire. Postoperatively, the patient con-tinues the antibiotic treatment for another 3 weeks. Evolution is favorable.
Case particularity: S. gallolyticus endocarditis is diffe-rent from other endocarditis, because it is highly sus-ceptible to intravenous antibiotics and is therefore con-sidered as benign. Even then it affects valves of patients who are not known to have cardiac valvular abnorma-lities . In our patient, a previously normal aortic valve and normal valve mitral was damaged by S. gallolyticus endocarditis. The predilection of infection is the aortic valves, but the mitral as well as the tricuspid valves may also be affected, singly or in combination. The vegeta-tions tend to be larger than those produced by other organisms and were noted in our patient. Colonoscopy is indicated in the context of S. gallolyticus bacteremia or endocarditis to look for colonic neoplastic chan-ges. If the examination is normal, a repeat colonosco-py should be scheduled in 4 to 6 months, with regular surveillance subsequently. The patient should also be evaluated for liver disease and possibly extra colonic malignancy.
Conclusions: T he presented case informs the physicians about the risk of spontaneous infective endo-carditis in non-drug-addicted patients, without a history of congenital or acquired valvular heart disease. Immunedepression, as well as nutritional habitssuch as frequent consumption of uncooked meat and fresh milk products, might have an impact on S. gallolyticus intestinal colonization and subsequent bacteremia and IE. Bacterial endocarditis prophylaxis with antibiotics remains compulsory in all cases undergoing any type of surgery or other procedures carrying potential risk of septicaemia (dental extractions, urinary catheterizations etc). Anticoagulant treatment requires, periodic Quick time check, for maintaining coagulation parameters (INR between 2.5-3.5 and prothrombin index between 15-30%).

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)