Correspondence
Intraaortic Vegetations and Infective Endocarditis
N Engl J Med 2007; 356:2430-2431June 7, 2007
- Article
To the Editor:
The mobile aortic thrombus described by Adam et al. (Feb. 22 issue)1 as suggestive of intraaortic endocarditis does not even warrant a diagnosis of possible endocarditis, according to the Duke criteria.2 At admission, the patient had definite enterococcal endocarditis, meeting two major criteria: echocardiographic evidence of vegetations and the presence of a typical endocarditis pathogen. The fever initially responded to antibiotics but then relapsed. This is common during treatment of endocarditis, for numerous reasons. The suggestion that the relapse was due to a second pathogen seems unlikely. For unexplained reasons, the supposed aortic vegetation was not examined microscopically during the operation, making it impossible to diagnose it definitively as a mural vegetation. The finding of a mixture of coagulase-negative staphylococci casts further doubt on the conclusion that these bacteria were causing the infection. Mixtures of such bacteria, even from operative sites, usually indicate contamination from skin. The reporting of highly speculative cases serves only to confuse the clinical picture of endocarditis.
2 ReferencesJames Greig, M.R.C.Path.
Plymouth Hospitals National Health Service Trust, Plymouth PL6 8DH, United Kingdom
james.greig@phnt. swest. nhs. uk 1
Adam O ,Kramm T ,Klein HH ,Schafers H-J . Intraaortic vegetations as a manifestation of infective endocarditis. N Engl J Med 2007;356:874-875
Full Text | Web of Science | Medline2
Baddour LM ,Wilson WR ,Bayer AS , et al. Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America. Circulation 2005;111:e394-e434[Erratum, Circulation 2005;112:2373, 2007;115:e408.]
CrossRef | Web of Science | Medline
To the Editor:
Adam et al. report a case of intraaortic vegetations as a manifestation of infective endocarditis. Although they reference the 1998 guidelines of the American College of Cardiology and the American Heart Association for the care of patients with valvular heart disease, their chosen treatment does not conform to current recommendations of the American Heart Association and the Infectious Diseases Society of America with regard to diagnosis and management of infective endocarditis.1 The patient initially received piperacillin and ciprofloxacin. (Minimum inhibitory concentrations of gentamicin and streptomycin for the isolated Enterococcus faecalis are not reported.) The failure of this combination would not be unexpected. The subsequent switch to imipenem monotherapy is not advocated by the guidelines either. Failure with this antibiotic would not be unexpected.
From the standpoint of a microbiologic diagnosis, Adam et al. report that the patient had E. faecalis endocarditis but then also report that the valve and aortic material were infected with two types of coagulase-negative staphylococci (i.e., mixed staphylococci). Either the case represents E. faecalis infective endocarditis plus infection with coagulase-negative staphylococci or, more likely, contamination of the aortic-tissue specimen (and perhaps the valve-tissue specimen) by coagulase-negative staphylococci after excision — raising the question of whether the “floating” aortic lesion was infected at all. Histologic examination of the excised material might resolve the matter.
1 ReferencesCathal E. O'Sullivan, M.B.
Barts and the London National Health Service Trust, London E1 2ES, United Kingdom
osullivan.ce@gmail. com 1
Baddour LM ,Wilson WR ,Bayer AS , et al. Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America. Circulation 2005;111:e394-e434[Erratum, Circulation 2005;112:2373, 2007;115:e408.]
CrossRef | Web of Science | Medline
Author/Editor Response
Greig and O'Sullivan question the infectious nature of the intraaortic vegetation and apparently the diagnosis of endocarditis as well. We do not agree.
Since the patient had fever, valve destruction, valve vegetations, and microbiologic proof of the presence of pathogens, the standard criteria for infectious endocarditis were fulfilled. On initial transesophageal echocardiography, the aorta was normal, and 6 weeks later, the intraaortic vegetation was visible. Microscopical examination of the intraaortic mass showed neutrophils and gram-positive staphylococci. Two types of staphylococci, with identical susceptibility patterns, were found on mitral valve, aortic valve, and intraaortic vegetation. These facts make the probability of contamination negligible. Although there is a small but residual degree of uncertainty regarding differentiation between an infected intraaortic thrombus and a primary vegetation, the presence of 2 cm3 of infected material seems clinically relevant. We believe that it is important for the practicing clinician to consider unusual presentations of life-threatening diseases, even if they are not part of a standard classification.
Oliver Adam, M.D.
University Hospital Homburg, 66421 Homburg, GermanyHermann Hubert Klein, M.D., Ph.D.
Municipal Hospital, 55743 Idar-Oberstein, GermanyHans-Joachim Schäfers, M.D., Ph.D.
University Hospital Homburg, 66421 Homburg, Germany
