Gemella Sanguinis Endocarditis: First Case Report in Taiwan and Review of the Literature

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CASE REPORT Gemella sanguinis endocarditis: First case report in Taiwan and review of the literature

Ching-Huei Yang a,*, Kuei-Ton Tsai b

a Division of Infectious Diseases, Department of Internal Medicine, Buddhist Tzu Chi General Hospital, Taipei Branch, New Taipei City, Taiwan b Division of Cardiovascular Surgery, Department of Surgery, Buddhist Tzu Chi General Hospital, Taipei Branch, New Taipei City, Taiwan

Received 13 August 2011; received in revised form 3 February 2012; accepted 5 February 2012

KEYWORDS We describe a case of infective endocarditis of the native aortic valve due to Gemella sangui- endocarditis; nis in a 67-year-old Taiwanese man who had pre-existent valvular heart disease. He was Gemella sanguinis successfully treated with aortic valve replacement accompanying a 6-week intravenous antibiotic treatment. To the best of our knowledge, this is the ﬁrst report of G sanguinis endocarditis in Taiwan. Copyright ª 2012, Elsevier Taiwan LLC & Formosan Medical Association. All rights reserved.

Introduction endocarditis. Gemella spp. are catalase-negative, faculta- tively anaerobic, Gram-positive coccoid organisms associated with low GþC content DNA that form in pairs, tetrads, Infective endocarditis (IE), a severe form of valve disease, 1 is associated with a high mortality and is mostly caused or short chains when grown in culture medium. There are by Gram-positive bacteria including Staphylococcus four species in this genus. Among them, G. morbillorum and Streptococcus. However, Gemella spp. have become had been reported to be the cause of IE in more than 40 an emerging opportunistic bacterial etiology in infective cases and G. sanguinis as a cause of IE for 4 cases from a review of the English language literature.2e6 The aortic valve tends to be the most commonly involved in G. sanguinis endocarditis. Dental disease seems not to be mandatory in patients with G. sanguinis endocarditis; Conflicts of interest: The authors have no conflicts of interest nevertheless, previous valvular heart disease should be an relevant to this article. * Corresponding author. Division of Infectious Diseases, Depart- important predisposing factor. Early surgery accompanying ment of Internal Medicine, Buddhist Tzu Chi General Hospital, an extended period of parenteral antimicrobial therapy is Taipei Branch, 289 Jianguo Road, New Taipei City 231, Taiwan. key for successful treatment. Here, we describe the E-mail address: [email protected] (C.-H. Yang). first reported case of bacterial endocarditis caused by

G. sanguinis in Taiwan, and the fifth known case in the aortic stenosis and mild to moderate aortic regurgitation, English literature. He was successfully treated with and no definite mobile vegetation; however, there was an medical-surgical management. The relevant literature is increasing echo density of aortic valve and an echolucent reviewed. space around paravalvular area with a suspicious paravalvular abscess. In addition, mild mitral regurgitation, atrial fibrillation, and a small amount of pericardial effu- Case report sion were found in this examination. Shortly thereafter, antibiotic therapy was adjusted to penicillin (3 106 U A 67-year-old man was admitted to hospital with a 1-week every 4 hours) and the surgeon was consulted. The patient history of fever, chills, and generalized weakness and subsequently underwent surgery with a successful aortic malaise. Initially he had received treatment for a common prosthetic valve replacement. At surgery, the operative cold the at outpatient clinic; however, symptoms pro- findings included a congenital calcified bicuspid aortic valve gressed. Medical history was significant for rheumatic heart and a large periannular abscess, which extended downward disease diagnosed by a cardiovascular specialist in the to the interventricular septum and upward to the aortic outpatient clinic and gouty arthritis for many years. There root. Thus the previous diagnosis of rheumatic heart was no evidence of dental problems. His blood pressure disease in this patient was absent. After excision of remained lower, around 100/70 since he was young. The diseased aortic valve and radical debridement of this root patient had a right inguinal hernia repair as a teenager. abscess, the abscess cavity was exteriorized with a piece of Physical examination revealed temperature on admission of autologous pericardium to reconstruct left ventricular 39C, heart rate 94 beats/min, respiratory rate 22 breaths/ outflow tract continuity. A 23 mm SJM mechanical valve (St min, and blood pressure 110/77 mmHg. Basal rhonchi and Jude Medical Inc., St Paul, MN, USA) was then implanted crackles were noticed on lung auscultation. Cardiac onto this newly repaired aortic annulus. Pathological find- auscultation revealed Grade III aortic and pulmonary valve ings showed leukocytic infiltrate, focal necrosis, and foci of pansystolic murmur and Grade II early systolic crescen- calcification consistent with the diagnosis of acute endo- doedecrescendo and diastolic murmur at left middle and carditis. He continued to receive intravenous penicillin lower sternal border. The other physical examination was treatment for 6 weeks and was discharged with a stable not remarkable. condition. There was no evidence of recurrence after 3 Significant laboratory investigations on admission months of evaluation. revealed a total white blood cell count 17.3 109/L with neutrophilia (neutrophils 90%; lymphocytes 5%); hemo- globin 12.0 g/dL [reference range (rr) 13e18 g/dL); platelet Discussion count 282 109/L (rr 120e245 109/L); fibrinogen 456.2 mg/dL (rr 200e400 mg/dL) and D-dimer 1260.94 ng/ Gemella spp. belongs to a genus of Gram-positive, a non- mL (rr 0e500 ng/mL); C-reactive protein 22.39 (rr faecalis and nonfaecium enterococcus with facultative 0e0.33 mg/dL); lactate dehydrogenase 273 (rr 85e227 IU/ anaerobic bacteria, primarily found in the mucous L); and albumin 2.3 g/dL (rr 3.4e5.0 g/dL). Urinary analysis membranes of humans, particularly in the oral cavity and was normal. A chest radiograph on admission showed upper digestive tract as normal commensals.1 Because of increasing bilateral infiltrate in the lungs. An abdominal the similarities, it was difficult to differentiate Gemella ultrasound revealed no significant abnormality. Electro- spp. from Streptococcus spp. before 1988, when, the genus cardiography demonstrated normal sinus rhythm at 89 of Gemella was identified by its genetic analysis and its beats/minute. physiologic characteristics, which are quite different from Treatment was initially started with moxifloxacin Streptococcus spp.1,2 It rarely causes infection in humans. (400 mg intravenously every day) and ceftriaxone (2.0 g Study has shown that they thrive best at high partial pres- 1 every day) for tentative diagnosis of severe community- sure of CO2. Most strains of these species are pyrrolidonyl acquired pneumonia. Two blood cultures on admission arylamidase and leucine aminopeptidase positive, catalase were all shown to be positive for Gram-positive cocci, so and oxidase negative, and produce colonies on blood agar treatment was switched after 1 day to vancomycin (1.0 g that resemble those of viridans streptococci, characterized every 12 h) and gentamicin (1 mg/kg every 8 h) to provide by pairs, tetrads, or short chains.1 Four species, G. hae- coverage against both methicillin-susceptible and molysans, G. morbillorum, G. bergeriae, and G. sanguinis methicillin-resistant Staphylococcus aureus. Blood cultures are recognized, with G. sanguinis being the latest species were later shown to be positive for G. sanguinis with identified: in a 1998 report,3 where it was found to be a penicillin MIC of 4.0 mg/L. The colonies of G. sanguinis responsible for IE in a 69-year-old man. However, no further were tiny ovoid, nonsporing, nonpigmented, and trans- relevant data were reported in that patient. G. sanguinis lucent cocci that grew in pairs or short chains on blood agar. differs from other Gemella spp. by the fact that it can Identification was confirmed by VITEK 2 System (bio- produce acid from mannitol, sorbitol, and sucrose and also Me´rieux, Marcy l’Etoile, France) and API-20 NE substrate- alkaline phosphatase, acid phosphatase, and ester lipase utilization test panel kit, Phoenix 100 System (Beckson C8.1,2 Although Staphylococcus or Streptococcus have been Diagnostic Instrument Systems, Sparks, MD, USA). In addi- the leading pathogens in IE, Gemella spp. may have tion, the organism was susceptible to vancomycin, eryth- become an emerging bacterial etiology. G. morbillorum romycin, clindamycin, linezolid, ampicillin, levofloxacin, had been reported to be the cause of IE for more than ceftriaxone, and cefepime. A transthoracic echocardiog- 40 cases and G. sanguinis for four cases.2e6 The exact raphy (TTE) showed a calcified aortic valve with severe cause for a lower case number of G. sanguinis IE than 564 C.-H. Yang, K.-T. Tsai

Table 1 Clinical features of 5 cases with Gemella sanguinis endocarditis in the reported literature. Case Case 1 Case 2 Case 3 Case 4 Present case Year 1988 2002 2009 2011 2011 Age (y)/Sex 69/M 69/M 23/F 26/F 67/M Risk factors for Unknown 1. Periodontal 1. Repaired ventricular 1. Dental caries Rheumatoid infective endocarditis disease septal defect 2. Rheumatic heart disease heart disease 2. Tooth abscess 2. Regurgitated 3. Prosthetic valve s/p aortic valve (status post) bivalvular 3. Oral ulcers replacement (aortic and mitral valves) 4. Diabetes mellitus Comorbidity Unknown Old stroke Behc¸et’s disease Nil Nil Involved valve Unknown Mitral valve Aortic valve Aortic valve Aortic valve Perivalvular abscess Unknown Unknown þ þ Antibiotic use Unknown Vancomycin þ Ceftriaxone þ Ceftriaxone Penicillin gentamicin gentamicin Valve replacement Unknown þ þ þ Outcome Unknown Survived Died Survived Survived Reference Collins et al3 Shukla et al4 Almaghrabi et al5 Gundre et al6

G. morbillorum IE is unknown, but this could be because or difficult-to-treat microorganisms. Perivalvular abscess G. sanguinis had not been recognized until 1988, and as was found in Case 46 and this reported case, and both survived a result most of the isolated strains might have been after medicalesurgical treatment. Despite the negative regarded as G. morbillorum before that time.3 However, finding of valvular vegetation in TTE, it was crucial that the we still do not know whether G. morbillorum is more TTE findings of paravalvular abscess with periannular virulent because there is no relevant report about the extension in the aortic valve that prompted the early surgical comparison of virulence between Gemella spp. in the intervention for successful treatment in our case.8,9 Although literature. Most of the cases with IE due to Gemella spp. most G. sanguinis is susceptible to penicillin G or ampicillin, had previous cardiac abnormalities and/or dental lesions as successful treatment in the complicated cases of G. sanguinis an infectious source.1,2 The current case had no obvious IE seems to require not only appropriate antimicrobial dental lesion at presentation. However, as G. sanguinis is therapy, but also a multidisciplinary approach, with surgery most commonly found in oral mucosa, the occult injury in necessary in 75% of reported cases. In addition, an extended the patient’s oral cavity could be the possible infectious period of parenteral antimicrobials in treating G. sanguinis IE route. Subsequently this microorganism adhered to his after surgical repair is needed. congenitally calcified bicuspid aortic valve and led to the In conclusion, this case illustrates a rare example of severe infection. infectious endocarditis caused by G. sanguinis that was The diagnosis of G. sanguinis endocarditis in this case successfully treated with an extended period of intrave- was based on the cardiac ultrasonography, the isolation of nous antibiotic combined with early surgical intervention. the bacteria from blood culture, the operative findings, and This is the first case reported in Taiwan of infective endo- the definite pathologic results that fulfilled the Duke’s carditis due to G. sanguinis. criteria.7 This case has been successfully treated by a long course of intravenous antibiotics (6 weeks) and early surgery (aortic prosthetic valve replacement). To the best References of our knowledge, this report is the first case reported in Taiwan and the fifth in the world. The three cases published 1. Ruoff KL. Miscellaneous catalase-negative, Gram-positive cocci: in the English literature, excluding the case who had no emerging opportunists. J Clin Microbiol 2002;40:1129e33. 3 relevant data for analysis, plus this reported case are 2. Al-Hujailan G, Lagace´-Wiens P. Mechanical valve endocarditis reviewed in Table 1, and we discuss the best clinical caused by Gemella morbillorum. J Med Microbiol 2007;56: management of this type of endocarditis. All 4 cases had 1689e91. either pre-existent dental diseases and/or valvular heart 3. Collins MD, Hutson RA, Falsen E, Sjo¨den B, Facklam RR. diseases. The aortic valve was involved in 3 cases and mitral Description of Gemella sanguinis sp. nov. isolated from human valve in another one. All of the patients had received clinical specimens. J Clin Microbiol 1998;36:3090e3. appropriate antibiotic therapy. Of the 4 patients, 3 (75%) 4. Shukla SK, Tak T, Haselby RC, McCanuley CS, Reed KD. Second case of infective endocarditis caused by Gemella sanguinis. survived and received valve replacement. The patient who WMJ 2002;101:37e9. had not received surgery died of hypercoagulable state, 5 5. Almaghrabi R, Halim M, Fadel B, Alsheikh A, Kherallah M. A case probably related to his Behçet’s disease. of infective endocarditis caused by Gemella sanguinis. Clin The main indications of surgical treatment in infective Microbiol Infect 2009;15:5679e725. endocarditis are heart failure due to valvular regurgitation 6. Gundre P, Pascal W, Abrol S, Kupfer Y, Tessler S. Prosthetic and uncontrolled infection because of periannular extension valve endocarditis caused by Gemella sanguinis: Gemella sanguinis endocarditis 565

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