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Case R eport
REVISTA PAULISTA DE MEDICIN AMusculoske le tal manife stations
of bacte rial e ndocarditis
Universidade Federal de São Paulo / Escola Paulista de Medicina, São Paulo, Brazil
a b s t r a c t
CO N TEX T: The incidence o f staphylo co ccal infectio n has been
in-creasing during the last 2 0 years.
O BJECTIV E: Repo rt a case o f staphylo co ccal endo carditis preceded
by musculo skeletal manifestatio ns, which is a rare fo rm o f clinical presentatio n.
DESIGN : Case repo rt.
CASE REPO RT: A 4 5 -year-o ld-man, witho ut addictio ns and witho ut kno wn previo us cardio pathy, was diagno sed as having definitive acute bacterial endo carditis due to Staphylo co ccus aureus. Its etio l-o gy was cl-o mmunity-acquired, arising frl-o m a nl-o n-apparent primary fo cus. In additio n, the musculo skeletal sympto ms preceded the infec-tive endo carditis (IE) by abo ut 1 mo nth, which o ccurred to gether with o ther sympto ms, e.g. myco tic aneurysms and petechiae. Later, the patient sho wed perfo ratio n o f the mitral valve and mo derate mitral insufficiency with clinical co ntro l.
KEY W O RDS: Bacterial endo carditis. Musculo skeletal sympto ms. Staphylo co ccal infectio n.
• Érika Bevilaqua Rangel • Álvaro Nagib Atallah
INTRODUCTION
There has been a gro wing trend fo r the number o f bo th co mmunity-acquired and ho spital-acquired staphylo co ccal infectio ns to increase o ver the past 20 years. The incidence o f staphylo co ccal endo carditis acco unts fo r 25-35 percent o f cases and is character-ized by a rapid o nset, high fever, frequent invo lvement o f no rmal cardiac valves, and the absence o f physical stigmata o f the disease o n initial presentatio n. In pa-tients witho ut addictio ns, the endo carditis is o ften left-sided and in 50% o f cases there are embo lic and neu-ro lo gical co mplicatio ns.1
CASE REPORT
A 45-year-o ld man was admitted to the ho spital because o f daily fever (38 to 40º C) fo r 20 days, chills and lumbar pain, which wo rsened with mo vements. He had no histo ry o f smo king, alco ho l abuse, recent travel, pro miscuity, blo o d transfusio n o r endo veno us drug addictio n. There was no histo ry o f previo us car-dio pathy o r skin lesio ns.
The patient appeared acutely ill. The tempera-ture was 38ºC, the pulse was 116, and the respiratio n was 24. The blo o d pressure was 120/70 mm Hg. The results o f a physical examinatio n were no rmal, except fo r a lumbar pain and tenderness. Labo rato ry tests sho wed hemato crit 33%, erythro cyte sedimentatio n rate 58 mm/hr, white cell co unt 17100/mm3 with no rmal
dif-ferential co unt, platelet co unt 317000/mm3, creatinine
1.6 mg/dl, so dium 130 mEq/l, po tassium 4.7 mEq/l, to -tal bilirubin 0.5 mg/dl, gluco se 110 mg/dl, aspartate
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no transferase 17 U/l, alanine amino transferase 38 U/l, alkaline pho sphatase 361 U/l, gamma-glutamyl-trans-ferase 247 U/l. The urine was no rmal. Fo ur specimens o f blo o d were o btained fo r culture. A urine culture was sterile. Ceftriaxo ne was given intraveno usly (2 g daily). Sero lo gical tests fo r B and C hepatitis and fo r AIDS were negative. An electro cardio gram revealed sinusal tachy-cardia. Tho racic radio graphy and abdo minal ultraso no g-raphy examinatio ns were no rmal. Lumbar radio gg-raphy sho wed a lytic lesio n in the L4 vertebral bo dy. A mag-netic reso nance imaging scan o f the lumbar spine dis-clo sed mild pro trusio n o f the intervertebral disc be-tween L4 and L5.
The fever persisted and o n the third ho spital day, the patient sho wed acute mental co nfusio n, right hemiparesis, meningeal signs and hypo tensio n (80/ 40 mmHg). A co mputed to mo graphy scan o f the brain was no rmal and the liquo r sho wed 120 cells with 80 neutro phils and 8 lympho cytes. On the eighth ho spi-tal day, a grade 2 systo lic murmur was present in the mitral area. Cardiac ultraso no graphy examinatio n, in-cluding a transeso phageal study, revealed a left ven-tricular ejectio n fractio n o f 83% and mitral vegetatio n o f 12 mm with mo derate mitral regurgitatio n. There were also petechiae in the feet. The blo o d culture yielded Staphylococcus aureus (3 o f the 4 specimens o
b-tained o ver a perio d lo nger than 12 ho urs). Oxacillin (12 g daily) and Amikacin (1.5 g daily) were started. A magnetic reso nance scan o f the brain revealed my-co tic aneurysms in the area o f the left inner capsule. The patient’s co nditio n impro ved co nsiderably. On the 19th ho spital day, a cardiac ultraso no graphy exami-natio n sho wed a decrease in mitral vegetatio n size to 10 mm with a perfo ratio n o f 5 mm clo se to it. Digitalis was started. The vegetatio n co mpletely disappeared o n the 32nd ho spital day and a mo derate mitral
insuf-ficiency develo ped. The patient was discharged fro m the ho spital 6 weeks later.
DISCUSSION
The diagno sis o f definitive infective endo cardi-tis (IE) was based o n the criteria o f Durack et al in Duke University.2 Thus, two majo r criteria were
in-cluded, i.e. po sitive blo o d cultures and endo cardiac invo lvement, and two mino r o nes, i.e. fever greater than 38º C and vascular events. Meningitis was also present.
Acco rding to Bayer, et al.3, 26% o f infective
en-do carditis en-do es no t sho w previo us valve lesio ns no r a histo ry o f drug addictio n, as seen in the present case. And 77% o f patients with a diagno sis o f definitive
in-fective endo carditis had bacteremia as a majo r crite-rio n and 57% o f these had 2 majo r criteria and 43% had 1 majo r criterio n and 3 mino r criteria. Further-mo re, 57% o f cases o f definitive IE sho wed vegetatio n and 82% o f tho se had 2 majo r criteria and 18% had 1 majo r criterio n and 3 mino r criteria. On the o ther hand, the vegetatio n co uld o nly be seen by transeso phageal cardiac ultraso no graphy examinatio n in 41% o f the patients with definitive infective endo carditis and with the presence o f vegetatio n.3
In the same way, Heiro , et al. repo rted that the vegetatio n was a majo r criteria in 72% o f infective en-do carditis cases.4 Mo reo ver, the mo st co mmo n etio
l-o gy was Staphylococcus aureus (23%) and Streptococcus viridans (17%) in a gro up o f patients witho ut addictio ns.
These autho rs stated that there had been a tempo ral trend fo r the etio lo gy o f infective endo carditis to change o ver the past 30 years, and thus staphylo co c-cal infectio n had increased fro m abo ut 15% to 30%,4,5
altho ugh there was a bias inso far as the cases were repo rted mo re co mmo nly in referral ho spitals than in co mmunity o nes. Also , so me patients died befo re di-agno sis due the severity o f the case.5
The sensitivity o f transtho racic cardiac ultra-s o no grap hy e xam inatio n iultra-s 50 to 60% and transeso phageal abo ut 90%. The latter is mo re sensi-tive fo r the diagno sis o f vegetatio n smaller than 5 mm and fo r pro sthetic valves.5 Vegetatio n bigger than 1 to
2 cm in the left valve is related to co mplicatio ns, e.g. cardiac insufficiency and embo lic events.5 And 50% o f
the patients with mitral regurgitatio n can develo p co n-gestive cardiac insufficiency.6 The fo rmer and latter
events happened in the present case.
Acco rding to Willco x, co mmunity-acquired bac-teremia due to S. aureus co mprised 40% o f the
bacter-emia and tended to be mo re severe than when ho spi-tal-acquired.7 Mo reo ver, 58% o f the patients with
bac-te re mia b ut witho ut addictio ns did no t have an apparent primary fo cus, and 17% o f these develo ped infective endo carditis with 68% mo rtality. The risk o f infective endo carditis after S. aureus bacteremia can
range fro m 5 to 60% and the mo rtality can reach 70%.7
To sum up, ro ughly 20% o f patients with co mmunity-acquired S. aureus bacteremia and witho ut a clinical
diagno sis o f infective endo carditis have presented hid-den valvular vegetatio n o r previo us valvular lesio ns.5
Regarding the musculo skeletal manifestatio ns in infective endo carditis, the lumbar pain usually o c-curs in subacute infective endo carditis and is seco nd-ary to either the embo lizatio n o r direct invo lvement o f the disc space with septic necro sis. Besides, it is advisable to lo o k fo r a no n-cardiac fo cus fo r an
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tio n during o r after the treatment in attempt to avo id the o ccurrence o f bacteremia later, i.e. o steo myelitis, septic arthritis o r paraspinal abscess.8 Thus, it seems
that the present case sho wed an embo lizatio n o f the intervertebral disc with subsequent bacteremia.
Churchill et al repo rted o n 192 patients with a diagno sis o f bacterial infective endo carditis, 29 (15%) o f who m had o nly musculo skeletal invo lvement as the first sympto m o f IE and their sympto ms included: ar-thralgia (38%), arthritis (31%), lumbar pain (23%), dif-fuse muscle pain (19%) and disc infectio n (6%). On the o ther hand, 84 patients (44%) also had muscu-lo skeletal invo lvement during the co urse o f the dis-ease and in 52 o f these (62%) the invo lvement was present amo ng o ther sympto ms at the diagno sis and included: arthralgia (35%), lumbar pain (29%), diffuse muscle pain (23%), lo cal muscle pain (11.5%) and disc infectio n (8%).9
These autho rs also described ho w the diagno -sis o f infective endo carditis was preceded by lumbar pain fo r abo ut 1.5 mo nths, ranging fro m 1 to 4 mo nths and by disc infectio n fo r abo ut 4 mo nths, ranging fro m
1.5 to 8 mo nths.9 The present case had a perio d o f
less than o ne mo nth befo re the diagno sis o f infective endo carditis. Ho wever, the mo st co mmo n infectio n was strepto co ccal (65%) rather than staphylo co ccal (15.5%).
All in all, the frequency o f embo lizatio n is time dependent,5,10 i.e. it decreases fro m 17 events/1000
patients/year during the first week o f adequate treat-ment to less than 5 events/1000 patients/year during the seco nd and third weeks o f treatment.10
Finally, Vuielle, et al.10 described ho w ro ughly
70% o f the vegetatio n do es no t decrease in size after adequate treatment and 12% may even increase due to fibrin and platelet depo sits, valvular aneurysm o r perivalvular abscess. Co nversely, the decrease o r reso -lutio n o f the vegetatio n can co rrespo nd to an embo lic event o r healing. The latter happened with present case. And the definitive structural valvular lesio ns, as sho wn by the mitral insufficiency, were related to car-diac insufficiency and thus so metimes valvular re-placement co uld be necessary.
1. Lo wy FD. Stap hylo c o c c us aure us infe c tio ns. Ne w Eng J Me d 1998;339(8):520-32.
2. Durack DT, Lukes AS, Bright DK, et al. New criteria fo r diagno sis o f infective endo carditis: utilizatio n o f specific echo cardio graph findings. Am J Med 1994;96:200-6.
3. Bayer AS, Ward JI, Ginzto n LE, Shapiro SM, et al. Evaluation of new clinical criteria for the diagnosis of infective endocarditis. Am J Med 1994;96:211-19.
4. Heiro M, Niko skelainen J, Hartiala JJ, Saraste NK, Ko tilainen PM. Diagno sis o f infective endo carditis. Arch Intern Med 1998;158:18-24.
5. Bayer AS. Infective endo carditis. Clin Inf Dis 1993;17:313-20.
6. Weinstein L. Life-threatening co mplicatio ns o f infective endo carditis
and their management. Arch Intern Med 1986;146:953-7.
7. Willco x PA, Rayner BL, Whitelaw DA, et al. Co mmunity-acquired Staphylo co ccus aureus bacteremia in patients who do no t abuse intraveno us drugs. Quart J Med 1998;91:41-7.
8. Heimens PA. The clinical manifestatio ns o f infective endo carditis. Mayo Clin Pro c 1982;57:15-21.
9. Churchill MA, Geraci JE, Huder GG, et al. Musculoskeletal manifestations o f bacterial endo carditis. Ann Intern Med 1977;87:754-9.
10. Vuielle C, Nirdo f M, Weyman AE, Picard MH. Natural histo ry o f vegetatio n during successful medical treatment o f endo carditis. Am Heart J 1994;128(6):1200-9.
REFERENCES
r e s u m o
CO N TEX TO : A inc id ê nc ia d a Infe c ç ã o e sta filo c ó c ic a ve m
aumentando durante o s último s 2 0 ano s.
O BJETIV O : Relatar um caso de infecção estafilo có cica precedida
po r sinto mas músculo -esquelético s, o que é uma fo rma rara de apresentação clínica.
TIPO DE ESTUDO : Relado de caso .
RELATO DO CASO : Paciente de 45 anos, sexo masculino, sem
co-morbidades, não usuário de drogas endovenosas e com diagnóstico de endocardite bacteriana estafilocócica em válvula mitral, adquirida na comunidade e sem foco primário aparente. O diagnóstico foi precedido por dor lombar em cerca de 20 dias e complicada com eventos vasculares e petéquias, além de insuficiência mitral abordada apenas clinicamente.
PALAV RAS-CH AV E: Endo cardite bacteriana. Sinto mas músculo
-esquelético s. Infecção estafilo có cica.
Érika Be vilaqua Range l, MD. Medical resident, Nephro lo gy Divisio n, Universidade Federal de São Paulo / Esco la Paulista de Medicina, São Paulo , Brazil.
Álvaro Nagib Attalah, MD, PhD. Asso ciate Pro fesso r, Universidade Federal de São Paulo / Esco la Paulista de Medicina, São Paulo , Brazil.
Source s of funding: No t declared
Conflict of inte re st: No t declared
Last re ce ive d: 29 No vember 1999
Acce pte d: 20 December 1999
Addre ss for corre sponde nce :
Érika Bevilaqua Rangel
Universidade Federal de São Paulo /Esco la Paulista de Medicina Departamento de Nefro lo gia
Rua Bo tucatu, 740
São Paulo /SP – Brazil - CEP 04023-062 E-mail: erika-nefro @ pesquisa.epm.br
p u b lis hin g in fo r m a t io n
