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Prosthetic Valve Endocarditis Caused by HACEK

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Prosthetic Valve Endocarditis Caused by HACEK Case Report Infection & https://doi.org/10.3947/ic.2017.49.4.282 Infect Chemother 2017;49(4):282-285 Chemotherapy ISSN 2093-2340 (Print) · ISSN 2092-6448 (Online) Prosthetic Valve Endocarditis caused by HACEK Organisms: a Case Report and Systematic Review of the Literature Ha Na Choi, Ki-Ho Park, Soyoung Park, Jae-Min Kim, Hyun Joon Kang, Jae Hun Park, and Mi Suk Lee Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul, Korea HACEK is a rare cause of prosthetic valve endocarditis (PVE). We describe 42-year-old male patient who presented with Aggregat- ibacter aphrophilus PVE and cerebral infarct. A. aphrophilus was isolated from his blood cultures as the sole pathogen, which was confirmed by subsequent 16S rRNA sequencing. He was treated with valve replacement surgery and an 8 week course of patho- gen-directed antibiotic therapy and followed for 20 months without recurrence. Key Words: HACEK; Aggregatibacter aphrophilus; Endocarditis; Heart valve prosthesis. Introduction [3]. A favorable prognosis with medical treatment [2, 4, 5] and a high incidence of large systemic emboli and heart failure HACEK is an acronym comprising the first letters of the ge- have been reported [6-8]. This favorable prognosis is likely neric names of the following group of bacteria: Haemophilus based on overestimation of positive outcomes due to consid- parainfluenzae, Aggregatibacter actinomycetemcomitans, Ag- erable bias towards under-reporting unfavorable cases [9]. gregatibacter aphrophilus, Aggregatibacter paraphrophilus, HACEK accounts for approximately 5–10% of native valve Cardiobacterium spp., Eikenella corrodens and Kingella spp.. community-acquired endocarditis in patients who are not in- These organisms are fastidious Gram-negative bacteria found travenous drug users [10] but is a rare cause (1.4%) of pros- in the human upper respiratory and genitourinary tracts [1, 2]. thetic valve endocarditis (PVE) [11]. Therefore, there are limit- The microorganisms are generally considered to be of low vir- ed data on the clinical characteristics and outcomes of PVE ulence and to infect structurally damaged or prosthetic cardi- caused by HACEK organisms, and the optimum treatment in ac valves . Clinically, these cases are characterized by a sub- patients with PVE due to HACEK is controversial. In this pa- acute or chronic course and often present with embolic per, we describe a patient who presented with HACEK PVE of lesions from large vegetations and congestive cardiac failure the mechanical mitral valve from whom Aggregatibacter Received: May 28, 2016 Accepted: July 21, 2016 Published online: May 25, 2017 Corresponding Author : Mi Suk Lee, M.D. Division of Infectious Diseases, Department of Internal Medicine, Kyung Hee University School of Medicine, 23, Kyungheedae-ro, Dongdaemun-gu, Seoul 02447, Korea TEL: +82-2-958-1634, FAX: +82-2-968-1848 E-mail: [email protected] This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and repro- duction in any medium, provided the original work is properly cited. Copyrights © 2017 by The Korean Society of Infectious Diseases | Korean Society for Chemotherapy www.icjournal.org www.icjournal.org https://doi.org/10.3947/ic.2017.49.4.282 • Infect Chemother 2017;49(4):282-285 283 aphrophilus was isolated as the sole pathogen. We also review able but showed moderate pulmonary hypertension. A the English-language literature on A. aphrophilus PVE. transesophageal echocardiogram (TEE) showed thrombus and vegetation in the mechanical mitral valve of a flail nature. After confirmation of the presence of vegetation by TEE, treat- Case Report ment was started with nafcillin (2 g every 4 h) and vancomycin (1 g every 12 h), based on the assumption that Gram-negative A 42-year-old male presented to our hospital with fever and bacteria are a rare cause of PVE and methicillin-resistant and jaundice. He had undergone mitral valve replacement 25 susceptible staphylococci are most common cause of PVE. On years prior because of rheumatic heart disease. He had no re- hospital day 7, the patient showed dysarthria, left-sided weak- cent history of dental manipulation or any intervention. An ness and drowsy mentality. Brain diffusion MRI showed acute initial physical examination showed fever of up to 38.2°C and cerebral infarction (Fig. 1). Non-sustained ventricular tachycar- general weakness. All of his body’s skin and sclera were yel- dia appeared, and a repeat TTE showed progression of the low. Abdominal examination did not reveal any abnormali- thrombus on the mitral valve (Fig. 2). The blood culture drawn ties. There was no peripheral sign of endocarditis. His white on the day of admission was reported on hospital day 9 to be blood cell count was 22.22 × 10³/mm3, hemoglobin was 11.6 positive for A. aphrophilus. This organism was confirmed by g/dL, and platelet count was 133 × 10³/mm3. The following subsequent 16S rRNA sequencing. Based on the identified or- values were also increased from normal levels: serum alanine ganism and susceptibility, antibiotic treatment was changed to transaminase, 47 U/L (normal range, 10–40 U/L); serum total intravenous ceftriaxone (2 g every 24 h) and ciprofloxacin (800 bilirubin, 17.83 mg/dL (normal range, 0.2–1.1 mg/dL); serum mg every 12 h) and continued for 8 weeks. On hospital day 12, direct bilirubin, 14.31 mg/dL (normal range, 0.2–0.5 mg/dL); the patient underwent thoracic surgery. The cultures for ordi- serum alkaline phosphatase, 209 U/L (normal range, 39–108 nary bacteria, fungi, and mycobacteria from surgical samples U/L); creatinine, 1.3 mg/dL (normal range, 0.6–1.2 mg/dL); were all negative. The infected mitral valve prosthesis and left and C-reactive protein, 16.47 mg/dL (normal range, < 0.3 mg/ upper pulmonary vein thrombus were removed during the op- dL). Microscopic hematuria was evident. eration. The patient was clinically healthy and remained afebrile, Abdominal computed tomography (CT) revealed a partial but he had only partly recovered from his neurological handicap splenic infarction within the distal splenic artery. There was and exhibited gait disturbance at 20 months after discharge. no evidence of cholangitis. A chest radiograph showed pul- monary edema. An electrocardiogram revealed atrial fibrilla- tion. A transthoracic echocardiogram (TTE) was unremark- Discussion Our review of the English-language literature revealed 7 cas- es of A. aphrophilus HACEK PVE (Table 1) [11-14]. We found that the outcome of HACEK PVE was favorable, as indicated Figure 1. MRI axial diffusion weighted image of brain shows an infarction in- volving right basal ganglia, periventricular white matter, and basal temporal lobe. Figure 2. Transthoracic echocardiography showing thrombus and vegeta- MRI, magnetic resonance imaging. tions (white arrow) on the mitral prosthetic valve diagnostic of endocarditis. 284 Table 1. Clinical features of eight patients with infections due to Aphrophilus aphrophilus Case No. Age/ Predisposing Symptom Surgical man- Primary antibiotic therapy etal. Choi HN, Prosthesis Complication Diagnosisa Outcome [Reference] Sex factor Onset (day) agement (total duration of therapy) 1 [11] 48/F MVR None 1 Cerebral infarct Possible IE None Cephalothin (42 days) Cured 2 [12] 41/F MVR ND ND None Possible IE Valve Penicillin (40 days) Cured • HACEKprostheticvalveendocarditis replacement 3 [12] 70/M AVR ND ND None Possible IE Valve Penicillin plus streptomycin Expired replacement (6 weeks) 4 [13] 69/M AVR ND ND None Possible IE Valve Penicillin (12 weeks) Cured replacement 5 [13] 48/F MVR ND ND None Possible IE None Penicillin plus streptomycin Cured (7 weeks) 6 [14] 56/F AVR Previous IE 60 None Possible IE None Amoxicillin and ofloxacin Cured (34 days) 7 [14] 55/M AVR Previous IE 330 None Possible IE None Cefixime and ofloxacin (56 days) Cured Present case 42/M MVR None 1 Cerebral infarct Definite IE None Ceftriaxone plus ciprofloxacin Cured (8 weeks) aAccording to modified Duke criteria. F, female; MVR, mitral valve replacement; M, male; AVR, aortic value replacement; IE, infective endocarditis, ND, not described. on presentation; however, the goal is targeted antimicrobial istargeted antimicrobial thegoal however, on presentation; sary with signs high-risk septic orwhoshow shock inpatients be neces may therapy with IE. Empirical inpatients of emboli ic infection. with prosthet aortic with valve 0%(0/4)ofpatients compared stroke a infection suffered prosthetic valve withmitral tients as50%(2/4)ofpa beto animportant forstroke, risk factor been IEhas reported valve cohort [15,16].Mitral Endocarditis on Collaboration International IE(8%)in the streptococcal of reported incases IE(17%)andwas with non-HACEK tis (IE)(25%)compared infective commoninHACEK endocardi more conspicuously of jor complication ma The reports. blood with culture associated delayed stroke surgery, and25%(1/8)experienced cardiac required tients (4/8)ofthepa percent of 12.5%(1/8).Fifty amortalityby rate 3. 2. 1. References Ha Na Choi Mi Suk Lee ORCID Conflicts ofInterest management. andappropriate diagnosis early to lead may entity knowledgerare of this Increased disease. PVE HACEK conclusion, isarare In regimen. antibiotic pirical em anappropriate regarding indecision-making considered ofPVE, cause they be should arare are organisms HACEK the Although failures. thetherapeutic explain may cin, which and/orclindamy ampicillin to be could resistant organisms Thisisimportant group theHACEK because ologic treatment. microbi the disturb may PVE. incubation HACEK Prolonged of be with associated stroke may report bloodDelayed culture inhibitory the minimum guidedby concentration. therapy Prompt use of antibiotics significantly reduces incidence the significantly useantibiotics of Prompt No conflictsofinterest. No Das M, Das BadleyCockerill FR,AD, Steckelberg JM, Wilson isms. Annu Rev Med 1997;48:25-33. Wormser GP, Bottone EJ. Bottone GP, Wormser fastidi and rare to due Endocarditis D. Raoult P, Brouqui ous bacteria.
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