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• W2032369989 abstract "Streptococcus agalactiae is an uncommon cause of endocarditis in the general population. Before the advent of antibiotics, group B streptococcus was occasionally found in the postpartum period, and several cases of endocarditis were reported. In the post antibiotic era, group B streptococcus is an unusual cause of infection in adults. This organism is highly virulent, often requiring cardiac surgery for treatment, despite susceptibility to penicillin, because of rapid destruction of the valves. Complications include metastatic infection, heart failure, major emboli, myocardial abscess, and complete heart block. Several reviews of endocarditis describe cases of group B streptococcal endocarditis.1-10 We describe a case of endocarditis due to group B streptococcus complicated by a myocardial abscess, ventricular septal defect, and complete heart block. This article reviews the complications, management, and outcome of S. agalactiae endocarditis. ILLUSTRATIVE CASE The patient is a 75-year-old man whose chief complaint on admission was fever as high as 102°F for 11 days. He had a productive cough, chills, and diaphoresis. As an outpatient, he was treated with a 10-day course of levofloxacin. He denied rash, diarrhea, dysuria, frequency, urgency, chest pain, and joint pain. He was short of breath with exertion, but denied orthopnea and paroxysmal nocturnal dyspnea. The patient reported dental work 6 months prior to admission and received amoxicillin prophylaxis. Past medical history included hypertension, hypercholesterolemia, stable angina, aortic regurgitation, and benign prostatic hypertrophy. In the past, he underwent a coronary angiogram for chest pain, which showed coronary artery disease. Aortic regurgitation was found on a transthoracic echocardiogram. On admission, the patient had a blood pressure of 111/57 mm Hg with a pulse of 97/min, respiratory rate of 8 per minute, and a rectal temperature of 100.5°F. On examination, the patient was a well-nourished elderly man who was resting comfortably in bed in no apparent distress. Extraocular movements were intact. Pupils were equal and reactive to light. No evidence of conjunctival hemorrhage was seen. Neck was supple without jugular venous pressure. The lung fields were clear to auscultation bilaterally with occasional expiratory wheezes. The heart examination revealed normal heart sounds with a regular rate and rhythm, and a 2/6 systolic murmur was heard at the left upper sternal border without radiation. The abdominal examination was benign. There was no cyanosis, clubbing, or edema in the extremities. The patient was alert and oriented to person, place, and time, and he had no focal neurologic deficits. Laboratory tests revealed a white blood cell count of 19.8 cells/mm3, with a differential count of 87% neutrophils, 4% lymphocytes, and 8% monocytes. Platelets were 201,000/mm3. Hemoglobin was 14 g/dL, and hematocrit was 41 g/dL. Electrolytes were as follows: sodium of 131 mEq/L, potassium of 4.0 mEq/L, chloride of 95 mEq/L, bicarbonate of 28 mEq/L, blood urea nitrogen of 22 mEq/L, and creatinine of 1.2 mEq/L. Coagulation profile was normal. Erythrocyte sedimentation rate was 46 mm/h. A urinalysis showed trace protein, 2+ blood, with 28 red blood cells, no nitrites or leukocyte esterase. The admission chest x-ray showed no cardiomegaly infiltrate or effusion. An electrocardiogram showed normal sinus rhythm at 83 beats per minute with a normal axis and a right bundle branch block (Fig. 1).FIGURE 1: EKG showing right bundle branch block.Blood cultures (2/2) drawn on admission grew group B streptococci after 24 hours. Ceftriaxone was empirically started for endocarditis. Transesophageal echocardiogram (TEE) was done 24 hours after admission. Results showed no vegetations, a normal ejection fraction, moderate aortic regurgitation, and mild left ventricular hypertrophy. An indium scan showed a collection in the retrosternal area suggestive of endocarditis. Three days after admission, the patient complained of shortness of breath at rest. There had been a decline in urine output since admission, with a rise in creatinine from baseline (0.9 as an outpatient to 1.4). A stat chest x-ray revealed pulmonary vascular congestion. An electrocardiogram showed right bundle branch block and a new first-degree atrioventricular block (Fig. 2). Arterial blood gas on 3 L of O2 per minute showed a pH of 7.47, PCO2 of 32, PO2 of 76, and a O2 saturation of 97%.FIGURE 2: EKG showing right bundle branch block and new first degree atrioventricular block.During the patient's stay in the cardiac care unit, dopamine was started for blood pressure support. Repeat chest x-rays showed worsening pulmonary vascular congestion. A repeat transesophageal echocardiogram was done and showed severe aortic insufficiency with moderate mitral regurgitation. No vegetations were seen, but an abscess was present adjacent to the aortic valve. A cardiothoracic surgery consult was subsequently requested for an aortic valve replacement. A cardiac catheterization showed moderate 2-vessel coronary artery disease involving the right coronary artery (50% distal lesion) and the left circumflex artery (50% midlesion), and 4+ aortic insufficiency was seen. An EKG was performed and showed a new third-degree atrioventricular block, and a transcutaneous pacemaker was placed at the bedside (Fig. 3). A repeat transesophageal echocardiogram was done intraoperatively, which confirmed the preoperative findings. There was an abscess below the commissure of the right noncoronary cusp extending into the right atrium with a ventricular septal defect caused by a myocardial abscess. There was also a pseudoaneurysm present causing disruption of the mitral valve to the aortic annulus in the area of the noncoronary cusp. The abscess and pseudoaneurysm were debrided; a bovine valve was inserted, and a permanent pacemaker was placed.FIGURE 3: EKG showing third-degree heart block.DISCUSSION Several case reviews have reported cases of group B streptococcal endocarditis in the literature.1-10 Sambola et al reported 30 cases during 1975 to 1988 from 4 Spanish teaching hospitals.6 Twelve cases were described between 1974 and 1985 at the Presbyterian Hospital in New York, and 7 cases were identified between 1980 and 1985 at St. Elizabeth Hospital Medical Center in Ohio.4,5 Lerner et al reported 5 cases during a 7-year period, 1970 to 1976, and 7 more cases were reported in Youngstown, OH, between 1980 and 1984.3 The characteristic demographics of patients with group B streptococcus endocarditis have changed over the years. The mortality rate, although still high, has decreased. Before the antibiotic era, most cases were found in postpartum women, and the mortality rate was about 84% to 100%. The mortality rate is now about 44%.3 Over the past 40 years, reviews have shown S. agalactiae endocarditis to occur in mostly older patients. The average age is 54 years, with an increasing number of cases occurring in older age groups, between the sixth and ninth decade of life.3 Men and women are equally affected. There is a known association between group B streptococcus endocarditis and chronic systemic diseases, such as alcoholism, diabetes mellitus, liver cirrhosis, malignancy, intravenous drug use, and human immunodeficiency virus.3-6 In the review of the literature, the overall mortality rate is still high, even with the use of cardiac surgery. A potential explanation may be the late decision to perform surgery. The highest mortality, 90%, is seen in patients with prosthetic valve endocarditis. Group B streptococcus has been rarely reported in patients with prosthetic heart valves. In the literature review, only 10 cases of prosthetic valve endocarditis secondary to Group B streptococcus were reported between 1962 and 1988. Staphylococci or gram-negative bacilli are most often the pathogens involved in early prosthetic valve endocarditis, less than 2 months postoperative, with a mortality rate of about 73%. Streptococcus is associated with late prosthetic valve endocarditis and has a mortality rate of about 45%. Therefore, it is not surprising that most cases of group B streptococcus are late onset.6,11,12 Serious complications of group B streptococcus endocarditis are common. In our review, 34% of patients had major emboli, 28% had congestive heart failure, 2% had local abscess formation, and 3% had heart block. Emboli are often the initial manifestation of endocarditis, which leads to its diagnosis. The frequency of emboli probably relates to the large size of the vegetations, which is characteristic of group B streptococcus infections.13-18 Surgery and autopsy confirmed the large size of the vegetations found with this disease. These large vegetations contribute to the virulence of group B streptococcus, because the organism persists for long periods within the fibrin clot material, despite adequate antibiotic therapy. Therefore, cardiac surgery with valve replacement is often necessary.2-5,19 Most cases of S. agalactiae were susceptible to penicillin with a minimum inhibitory concentration of <0.1 μg/mL. Tolerant and penicillin-resistant strains have been described in the literature.6,20-22 Combining a β-lactam antibiotic with an aminoglycoside provides synergy against tolerant, penicillin-sensitive and penicillin-resistant cases of S. agalactiae. Therefore, most authorities recommend penicillin G or ceftriaxone for 4 to 6 weeks, with an aminoglycoside for the first 2 weeks.1-6 Vancomycin is an alternate choice for patients with penicillin/cephalosporin allergies.4-6 From an analysis of our case and a literature review, it seems that group B streptococci are more virulent than other streptococci. Because of its aggressiveness and potential complications, group B streptococcal endocarditis may be viewed clinically as equivalent to Staphylococcus endocarditis. Complications of S. agalactiae endocarditis, such as emboli and abscesses, are common, which suggests that surgery should be considered at an early stage." @default.
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• W2032369989 title "Streptococcus agalactiae (Group B Streptococcus) Infective Endocarditis Complicated by Myocardial Abscess and Heart Block" @default.
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