Pasteurella multocida Endocarditis with Septic Arthritis: Case Report and Review of the Literature

Background: There is a paucity of evidence regarding optimal management of Pasteurella spp. endocarditis. The authors report the first case of Pasteurella spp. endocarditis with septic arthritis and review the literature. Case Description: A 79-year-old patient with significant comorbidities, including prosthetic aortic valve, was admitted with left knee swelling, fever, and confusion, having been scratched by a cat 2-weeks prior. At presentation, there was a metallic click, a Grade 3 pan-systolic murmur and Grade 1 flow murmur audible on auscultation. Blood and synovial fluid cultures both isolated Pasteurella multocida, identified by matrix-assisted laser desorption ionisation–time of flight, which was sensitive to penicillin according to the European Committee on Antimicrobial Susceptibility Testing (EUCAST); minimum inhibitory concentration: 0.094). The patient underwent joint washout and received intravenous piperacillin/tazobactam for 3 days before switching to benzylpenicillin once sensitivities were known. Due to continued pyrexia, a transthoracic echocardiogram was obtained, which revealed a small mobile mass on a thickened mitral valve suspicious for a vegetation. On review by the Infective Endocarditis team, conservative management was deemed best, given the presence of comorbidities. Despite requiring further joint washout due to persistent knee pain, the patient was successfully treated with 8 weeks of antibiotic therapy (24 days of benzylpenicillin monotherapy, 2 weeks of benzylpenicillin and ciprofloxacin, and 15 days ciprofloxacin monotherapy). Discussion: Previous literature reviews report a higher mortality of Pasteurella spp. endocarditis when managed without cardiac surgery, thus recommending surgery in all cases. The authors found these to have confounding factors, including inadequate duration of antimicrobials, aortic root abscess, and rapid progression to death. The authors’ case of Pasteurella spp. endocarditis, complicated by septic arthritis, showed successful therapy without cardiac surgery.

Aortic root abscess – a deadly complication of UTI-induced infective endocarditis

Aortic root abscess and endocarditis should be suspected in patients with bradycardia and sepsis. We present a case of a 76 year old male who presented with urinary tract infection and sepsis and developed bradycardia and ventricular stand still during hospital admission. Transthoracic echocardiogram was unrevealing; transesophageal echocardiogram showed prosthetic valve dehiscence and aortic root abscess, intracardiac fistula, and tricuspid valve endocarditis. This case highlights the importance of suspecting endocarditis in patients with sepsis and known source of infection, especially if blood cultures do not clear or conduction abnormalities develop.

Acute posteromedial papillary muscle rupture secondary to aortic valve endocarditis: a case report

Background Acute papillary muscle rupture due to infective involvement has been recognized as a complication of infective endocarditis. However, there is very limited literature describing the rupture of the posteromedial papillary muscle in primary aortic valve endocarditis without aortic root abscess. This report highlights the etiology of the papillary muscle rupture in the setting of primary aortic valve endocarditis and the importance of a multidisciplinary approach. Case summary An 81-year-old man without any heart failure symptoms presented with fever and loss of vision in his left eye. Initial echocardiography revealed moderate aortic valve regurgitation due to a perforated right coronary cusp without aortic root abscess, and his blood cultures were positive for Group G Streptococci. During adequate antibiotic therapy, he developed acute severe mitral regurgitation secondary to posteromedial papillary muscle rupture. Following emergent aortic and mitral valve replacement using bioprosthetic valves, he made excellent progress on a 6-week course of intravenous antibiotics. Discussion The echocardiography and the histological findings suggested that the main cause of papillary muscle rupture was most likely a metastatic focus of infection from the aortic valve via a regurgitant jet. Successful treatment of this fatal complication includes early diagnosis and prompt surgical intervention by a multidisciplinary approach.

Back to basics: a rare and aggressive case of Aggregatibacter aphrophilus endocarditis

ABSTRACT We present the case of a 25-year-old with a history of bicuspid aortic valve and ascending aortopathy who was successfully treated for infective endocarditis (IE) due to Aggregatibacter aphrophilus. His clinical course was complicated by a large aortic root abscess not initially visualised on transthoracic echocardiography or computerised tomography. The cardinal feature of progressive prolongation of the PR interval on serial electrocardiograms was the only sign associated with clinical deterioration and was the trigger for rapid investigation and urgent management. Our case emphasises the importance of simple bedside tests to identify dynamic clinical scenarios and the requirement for early further imaging in the management of IE.