Unexpected source and cause of sepsis (not endocarditis)

    Authors

    Keywords

    vascular graft infection, endocarditis, echocardiography

    DOI

    https://doi.org/10.15836/ccar2024.539

    Full Text

    **Introduction:** High suspicion for infective endocarditis is driven by fever and positive blood cultures in the absence of an alternative focus of infection. (1, 2) This case underlines the importance of exploring other more obvious sources of bacteremia to avoid unnecessary tests and delays in diagnosis. In cases of inconclusive echocardiography results, imaging should be repeated. **Case report**: 59-year-old patient with diabetes and hypertension was admitted for sepsis, unilateral leg pain and plantar rash. Medical history includes aortobifemoral reparation of infrarenal aortic aneurysm 19 years ago and recurrent leg abscesses with prolonged periods of antimicrobial and probiotic therapy. Blood cultures found Lactobacillus rhamnosus and Candida glabrata. Positive blood cultures and clear Janeway lesions (**Figure 1**) indicated transesophageal echocardiography (TEE) which showed competent aortic valve with small hyperechogenic lesion (7mm X 6 mm) on base of left coronary cusp (**Figure 2**). TEE was repeated after 2 weeks of effective antimicrobial therapy, showing no change of suspected valvular lesion. Patient clinically improved and repeated blood cultures were negative. Further workup (including FDG-PET/CT) found intensive tracer uptake in the region of implanted aortic prosthesis. The surgeon opted for prolonged course of antimicrobial therapy. Unfortunately, only 4 days after completion of therapy the patient was septic with positive blood cultures. The operation was inevitable and aortointestinal fistula, graft infection and thrombosis were found. Partial graft replacement and bowel reconstruction were conducted. FIGURE 1. Unilateral Janeway lesions on the left leg. FIGURE 2. Transesophageal echocardiography image (midesophageal view, short axis) showing a nodular lesion on the noncoronay cusp of the aortic valve. **Conclusion**: Even in patients with highly specific findings for endocarditis like skin lesions and positive blood cultures, workup and therapy should be clinically guided. Bizarre blood culture isolates in our patient are easily explained when we know complete course of disease.

    Literature

    1. Delgado V, Ajmone Marsan N, de Waha S, Bonaros N, Brida M, Burri H, et al. 2023 ESC Guidelines for the management of endocarditis. Eur Heart J. 2023 October 14;44(39):3948–4042. https://doi.org/10.1093/eurheartj/ehad193
    2. Chakfé N, Diener H, Lejay A, Assadian O, Berard X, Caillon J, et al. Editor’s Choice - European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Vascular Graft and Endograft Infections. Eur J Vasc Endovasc Surg. 2020 March;59(3):339–84. https://doi.org/10.1016/j.ejvs.2019.10.016
    Cardiologia Croatica
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    Unexpected source and cause of sepsis (not endocarditis)

    Extended Abstract
    Issue11-12
    Published
    Pages539
    PDF via DOIhttps://doi.org/10.15836/ccar2024.539
    vascular graft infection
    endocarditis
    echocardiography

    Authors

    Martina Roginić*ORCIDZabok General Hospital and the Croatian Veterans Hospital, Zabok, Croatia
    Siniša RoginićORCIDZabok General Hospital and the Croatian Veterans Hospital, Zabok, Croatia
    Andrija Škopljanac MačinaORCIDMagdalena Clinic for Cardiovascular Medicine, Krapinske Toplice, Croatia
    Sandra LjubičićORCIDZabok General Hospital and the Croatian Veterans Hospital, Zabok, Croatia
    Iva ZecORCIDZabok General Hospital and the Croatian Veterans Hospital, Zabok, Croatia
    Tereza KnaflecORCIDZabok General Hospital and the Croatian Veterans Hospital, Zabok, Croatia
    Nikolina Mijač MikačićORCIDZabok General Hospital and the Croatian Veterans Hospital, Zabok, Croatia

    *Correspondence email: martina.pilko@gmail.com

    Full Text

    Introduction: High suspicion for infective endocarditis is driven by fever and positive blood cultures in the absence of an alternative focus of infection. (1, 2) This case underlines the importance of exploring other more obvious sources of bacteremia to avoid unnecessary tests and delays in diagnosis. In cases of inconclusive echocardiography results, imaging should be repeated.

    Case report: 59-year-old patient with diabetes and hypertension was admitted for sepsis, unilateral leg pain and plantar rash. Medical history includes aortobifemoral reparation of infrarenal aortic aneurysm 19 years ago and recurrent leg abscesses with prolonged periods of antimicrobial and probiotic therapy. Blood cultures found Lactobacillus rhamnosus and Candida glabrata. Positive blood cultures and clear Janeway lesions (Figure 1) indicated transesophageal echocardiography (TEE) which showed competent aortic valve with small hyperechogenic lesion (7mm X 6 mm) on base of left coronary cusp (Figure 2). TEE was repeated after 2 weeks of effective antimicrobial therapy, showing no change of suspected valvular lesion. Patient clinically improved and repeated blood cultures were negative. Further workup (including FDG-PET/CT) found intensive tracer uptake in the region of implanted aortic prosthesis. The surgeon opted for prolonged course of antimicrobial therapy. Unfortunately, only 4 days after completion of therapy the patient was septic with positive blood cultures. The operation was inevitable and aortointestinal fistula, graft infection and thrombosis were found. Partial graft replacement and bowel reconstruction were conducted.

    FIGURE 1. Unilateral Janeway lesions on the left leg.

    FIGURE 2. Transesophageal echocardiography image (midesophageal view, short axis) showing a nodular lesion on the noncoronay cusp of the aortic valve.

    Conclusion: Even in patients with highly specific findings for endocarditis like skin lesions and positive blood cultures, workup and therapy should be clinically guided. Bizarre blood culture isolates in our patient are easily explained when we know complete course of disease.

    Literature

    1. 1.
      Delgado V, Ajmone Marsan N, de Waha S, Bonaros N, Brida M, Burri H, et al. 2023 ESC Guidelines for the management of endocarditis. Eur Heart J. 2023 October 14;44(39):3948–4042.DOI
    2. 2.
      Chakfé N, Diener H, Lejay A, Assadian O, Berard X, Caillon J, et al. Editor’s Choice - European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Vascular Graft and Endograft Infections. Eur J Vasc Endovasc Surg. 2020 March;59(3):339–84.DOI