garvieae requiring valve replacement: First case in the United States T.C. Sharngoe, T.Fazili, W. Javaid, T. Endy, M. Polhemus, Department of Infectious Disease, SUNY Upstate Medical University, Syracuse, New York

Introduction Discussion Lactococcus, a gram positive organism of low virulence, is an uncommon cause of human . Infective endocarditis due to Lactococcus genus was identified in 1985. Prior to that, they were included in the Streptococcus genus. They are facultatively anaerobic, catalase-negative, gram-positive cocci that occur singly, in pairs, or in chains1. There are eight recognized Lactococcus Lactococcus is extremely rare . species, however, L. garvieae and L. lactis are the ones known to cause human infections2. L. garvieae is known to cause infective endocarditis, bacteremia, peritonitis, osteomyelitis and peritonitis of which, endocarditis Case appears to be the most common reported illness in humans2. The risk factors of infection seem to be immunosuppression, Sixty- year- old man with a history of Waldenstrom’s macroglobulinemia and intravenous immunoglobulin infusions for two underlying cardiac conditions, consumption of contaminated food such as raw fish, cheese and presence of colonic 3 years who presented to the hospital with a two-week history of fatigue, decreased appetite and worsening shortness of breath. diverticulosis . He was afebrile on admission but did report some fever and chills about two weeks prior to presentation. On examination, he Beta lactams and aminoglycosides are known to be effective in Lactococcal . In cases with penicillin allergy Vancomycin had stable vitals, diminished breath sounds at the lung bases and occasional rhonchi. His cardiac examination was negative for has been used effectively. Vancomycin resistance has yet to be found in Lactococcus species. L garvieae is resistant to 4 jugular venous distension, but had a grade three systolic murmur along the left sternal border and a grade three diastolic clindamycin and that has been used to differentiate it from L lactis . murmur over the aortic area and an S3. White cell count was slightly elevated at 12.1/cumm, his chemistries were normal There have been sixteen cases of L. garvieae infective endocarditis that have been reported so far. Three of the cases have no and BNP was elevated at 616. Chest radiograph showed findings consistent with interstitial pulmonary edema. A information available on them. Of the remaining thirteen, six (46%) were males, four (30%) of them had prosthetic valves, four transesophageal echocardiogram showed a mobile echodensity on the aortic valve extending into the left ventricular outflow (30%)of them had significant history of fish consumption, five (38%) had history of gastrointestinal disorders (two colonic polyps tract along with leaflet perforation and severe aortic regurgitation. Two-thirds of the aortic valve leaflets were essentially and two gastrointestinal ulcers. They were all treated with long-term (4-12 weeks), antibiotics (either beta lactam/vancomycin 3,5,6 destroyed. Blood cultures drawn grew Lactococcus garvieae. He was treated with vancomycin and for two weeks with or without aminoglycosides), five (38%)of them required valve replacement surgeries . initially followed by ceftriaxone for a total of six weeks. He underwent aortic valve replacement with a bovine pericardial valve 2 weeks after he was started on empiric antibiotics. He did well post-operatively. A follow up transthoracic echocardiogram Conclusion showed a normally functioning bioprosthetic aortic valve. Lactococcus garvieae infections in humans are uncommon, however, infective endocarditis is the most common presentation, when it does occur. Beta lactams appear to be the antibiotics of choice and the prognosis is favorable. Lactococcal infections appear to be increasing in the recent past, but it could be due to improved identifying methods and awareness amongst physicians.

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