Group B Streptococcus Endocarditis Associated with Multiple Pulmonary
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Clinics and Practice 2011; volume 1:e7 Group B streptococcus tality. With the documentation of endocarditis with complication of multiple septic emboli Correspondence: Carlos G. Teran, endocarditis associated with secondary to tricuspid valve vegetations in this 1855 Putnam Ave. Apt 2L, Ridgewood, NY, 11385, multiple pulmonary septic elderly woman, we hope to add more knowl - USA. Tel. +1.347.455.6402. emboli edge on this issue since little documentation E-mail: [email protected] has been done on it. Key words: Group B streptococcus, endocarditis, Carlos G. Teran, 1,2 Ariel O. Antezana, 3,4 septic emboli. Jerome Salvani, 3,4 Deborah Abaitey 1,2 Contributions: CGT, manuscript writing and liter - 1 Woodhull Medical and Mental Health Case Report ature searching; AOA, data collection, clinic Center, Brooklyn, New York; 2New York overview and manuscript editing; JS, manuscript University, School of Medicine, New York, An 87 year old female with history of hyper - critical revision; DA, manuscript revision and editing. New York; 3University Hospital tension and heart failure was admitted to the of Brooklyn, Brooklyn, New York; hospital because of two weeks history of fever, Conflict of interest: the authors report no con - 4 SUNY Downstate Medical Center, chills, loss of appetite and abdominal discom - flicts of interest. Brooklyn, New York, USA fort. She denied cough, dyspnea, chest pain, palpitations or diaphoresis. Two weeks prior Received for publication: 11 March 2011. admission she visited her primary care physi - Accepted for publication: 25 March 2011. cian with the same complaints and was pre - scribed oral cefuroxime. The patient complied This work is licensed under a Creative Commons Abstract Attribution 3.0 License (by-nc 3.0). with taking of the mediation but had no improvement in her condition. She had a his - Endocarditis is a rare presentation of group B ©Copyright C.G. Teran et al., 2011 tory of atrial fibrillation and hypothyroidism Licensee PAGEPress, Italy streptococcal infection. Its association with pul - and received prophylactic warfarin and Clinics and Practice 2011; 1:e7 monary septic embolism was only barely studied levothyroxine for treatment of the respective doi:10.4081/cp.2011.e7 and limited data is available up to date. Multiple conditions. Sick sinus syndrome was diag - septic emboli is a common complication of bac - nosed ten year prior to presentation and peace - terial endocarditis, but only a few cases have maker was placed for control. She had no his - Treatment for suspected pneumonia was been documented in relation to group B strepto - tory of alcohol intake, smoking or use of intra - initiated with azythromycin and Ceftriaxone. coccus. We present the case of an 87 year old venous drugs. She lived with 24 hours home Levothyroxine, furosemide, metoprolol and female patient with multiple underlying condi - aid. On examination she had a temperature of simvastatin were continued for the manage - tions that predisposed the development of bac - 104°F, blood pressure 195/64, the pulse 75 ment of hypothyroidism, cardiac failure, hyper - terial endocarditis secondary to group B strepto - beats per minute, the respiratory rate was 19 tension and hypercholesterolemia respectively. coccus and subsequently multiple pulmonary cycles per minute and the oxygen saturation The blood culture results was positive for septic emboli. The patient was treated with cef - was 99% while the patient was breathing ambi - Group B streptococcus, sensitive to penicillin, triaxone and azythromycin with good response ent air. cephalosporins, quinolones and macrolides. and complete recovery without any further com - At general examination she was in mild res - The presence of the murmur, fever and the plications. In the event of a diagnosed case of piratory distress and oriented in person, place blood culture raised the suspicion of the possi - group B streptococcus endocarditis, there and person. Pallor was noted on inspection of bility of endocarditis. Transthoracic and trans - should be a low threshold for the suspicion of the mucous membranes and the skin and the esophageal echocardiogram were ordered and septic pulmonary emboli especially in cases presence of a pacemaker generator noted on these showed a left ventricle that was moder - with right valves involvement. the left anterior chest. Auscultation of the ately dilated with severe left ventricular sys - chest revealed an irregular rhythm and a non tolic dysfunction. The left ventricular ejection radiated grade II/VI holosystolic murmur best fraction was estimated to be 25%. The right heard in mitral and tricuspid areas. Basal ventricle appeared severely dilated and hypoki - Introduction crackles were heard bilaterally on lung auscul - netic and a large vegetation was found in the tation. No peripheral edema, jugular venous Streptococcus agalactiae, also known as distention, Osler’s nodes, splinter hemorrhag - group B Streptococcus (GBS) is a gram posi - es or janeway’s lesions were noticed. The rest tive, facultative anaerobic bacteria associated of the physical exam was within normal limits. with infections in three different populations: A chest X ray was done showing car - i) Newborns : GBS is the main cause of sepsis diomegaly and perihilar infiltrates bilaterally and meningitis; ii) Pregnant woman: It is an (Figure 1). important etiologic agent of chorioammnioni - An electrocardiogram revealed atrial fibrilla - tis, endometritis, septic abortion and bac - tion with 2 to 3 paced beats and without teremia 1 and iii) Healthy individuals: GBS ischemic changes. rarely causes infection in this group and when A complete blood cell count showed impor - it occurs is almost always associated to under - tant leucocytosis (26.2xmm 3) with 83% lying disease like diabetes mellitus, cardiovas - neuthropils and normocytic anemia (hemoglo - cular disease, malignancy and immunodepres - bin 8.6 g/dL and MCV 85fL). Liver and basic sion. 2-4 metabolic profile within normal limits. The incidence of endocarditis secondary to Prothrombin time was 47 seconds and 3.8 of GBS is still considered a rare, especially when INR. Blood was drawn for culture and sent to Figure 1. A Chest X displaying cardiomegaly associated with severe disease and high mor - microbiology laboratory. and perihilar infiltrates bilaterally. [Clinics and Practice 2011; 1:e7] [page 11 ] Case Report tricuspid valve arising from its annulus meas - management but has not been proven clinical - uring 1.2 cm in its greatest dimension. ly. Most of the cases reported in literature com - A computerized tomograph of the chest bined at least one natural penicillin or showed the presence of multiple sizes, scat - cephalosporin with an aminoglycoside as ini - tered lesions in the right lung; some with spic - tial treatment, therefore, no protocol exist for ulations and cavitation. These lesions were the use of antibiotics in the rare cases of GBS mostly in the peripheral regions of the lungs, endocarditis and most of the guidelines are with the largest in the apex of the right lung based on the experience and outcomes of (Figure 2, 3). reported cases. The diagnosis of acute endocarditis second - Septic pulmonary embolism (SPE) is an ary to Group B Streptococcus associated with uncommon condition that generally presents multiple pulmonary septic emboli was then with an insidious onset of fever, respiratory done. symptoms, and lung infiltrates. Actually, SPE is The antibiotic regimen was continued and especially associated with the use of Figure 2. Chest computerized tomography after three days of treatment the fever started indwelling catheters, immunodeficiencies and scan displaying bilateral, nodular, scattered to settle and the rest of symptoms to improve. IV drug use, pelvic thrombophlebitis, as well as opacities in the peripheral zone of the The white blood cell count decreased to nor - suppurative processes. 4,8 lungs; speculations and cavitation is noted mal levels by the fourth day of hospitalization The association of septic pulmonary emboli in the right lesion. and the patient was discharge, completely and endocarditis is well recognized especially asymptomatic on the seventh day of hospital - when the right chambers of the heart are ization. Oral antibiotics were prescribed to involved. complete 4 weeks of treatment. The diagnosis is usually made with radiolog - ic investigations; the most helpful diagnostic procedure is the computerized tomography (CT) scan, typically showing cavitations or gas Discussion in nodular peripheral lesions regardless of the primary cause of the emboli. 9 Endocarditis is a rare, severe presentation This case followed the typical radiologic pat - of GBS infection. It accounts for only a minori - tern on CT scan but the clinical signs and ty of all cases of bacterial endocarditis (1.7%) symptoms were barely manifested. Group B and is mainly found in patients with history of streptococcus is known for the large extent of alcoholism, cirrhosis, diabetes and cancer. 2-4 metastatic emboli formation in relation to In the last 45 years, more than 150 cases were endocarditis, but there is limited information Figure 3. Chest computerized tomography reported in English and Spanish literature in the electronic literature of cases presenting scan displaying speculated nodular lesion in with only a minority (5 cases) in the last with septic pulmonary emboli. the apex of the right lung. decade. It has been described in all age groups In the largest case series study published in with