Pimpawan Boapimp, MD

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INFECTIOUS DISEASES CASE CONFERENCE
Pimpawan Boapimp, MD Wake Forest Baptist Medical
Center March 1, 2004
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HPI

• 78 y/o WM
• PMH of Austrians syndrome (pneumococcal
  endocarditis, pneumonia, and meningitis)
• 3 months PTA and had completed 4 week course of
  ceftriaxone
• F/U TEE one week PTA showed severe MR, MV
  vegetation- same size compared to one in 11/03

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HPI

• Pt denies any F/C, N/V, diarrhea, poor appetite
• Was admitted for MVR
• Underwent radical reconstruction of MV by using
  patch and ring annuloplasty
• Radical debridement of vegetation from anterior
  leaflet of MV
• excision of Lt atrial appendage

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• Post-op no F/C, no leukocytosis
• ID was consulted for proper ATBs management

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Physical Examination

• T 99 F , P 130 , RR 19 , BP 102/59
• PO 97 3LNC
• GA alert, awake, afebrile, NAD
• Chest CTA bilaterally, midline Sx wound-
  healing
• well, no signs of inflammation
• Heart tachycardia
• Abd benign
• Ext no edema, PICC at LUE - OK
• NS no focal deficit

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Laboratory Data

• WBC 12.3 Hb 10.1 Hct 29.7 Plt 143
• No bands
• BMP WNL
• CXR increased pleural effusions with lower lung
  volumes and worsening bibasilar atelectasis

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Operative note

• Mitral valve - heavy shaggy exudate on
• the anterior leaflet and a perforation in the
  body of the anterior leaflet
• This area was radically debrided leaving a large
  defect in the anterior leaflet up to the right
  fibrous trigone. We took a piece of Shelhigh
  pericardium and created an oval patch which
  corresponded to the residual defect in the
  anterior leaflet.

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CULTURE

• MITRAL VALVE
• TISSUE FROM OR
• GRAM STAIN () WHITE BLOOD CELLS
• GRAM STAIN 2
• GRAM POSITIVE COCCI

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CULTURE

• 2 Coagulase Negative staphylococci
• Methicillin resistant

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Pathology

• LEFT ATRIAL APPENDAGE, RESECTION
• Sections consistent with atrial appendage with
  no significant histological abnormality.

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TREATMENT
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• Clinical utility of cardiac valve Gram stain and
  culture in patients undergoing native valve
  replacement
• Arch Pathol Lab Med. 1998 May122(5)412-5.
• Chuard C, Antley CM, Reller LB

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• Case series
• Reviewed all pts with native valve C/S result
  over 18 months (1992-1993)
• and pts with a Dx of IE and a positive valve C/S
  over a 5-year period (1998-1992)
• Microbiologic, histopathologic, and clinical data
  were analyzed
• Tissue slides were reviewed

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• Evidence of postop prosthetic valve endocarditis
  within 3 months was sought

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(No Transcript)
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Rare lt1/oilfield 1 (1-4/oilfield) 2
(5-9/oilfield) 3 (10-24/oilfield)
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Rare lt1o col 1 (lt10 col) 4 (lt10 col)
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• From 1989-1992, 7 cases of native valve IE with
  positive valve C/S were diagnosed
• Among 13 pts in whom IE was recognized before
  surgery and was treated
• -Clinical criteria were met in 11 cases
• -BC positive in 12 cases
• One case was unsuspected -73y/o man with MR for
  15 years, no clinical symptoms of infection but
  Gram stain and C/S were positive

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• Compared 13 diagnosed pts , 1 unsuspected case,
  and 34 pts without IE
• Gram stain- the number of WBC did not
  differentiate pts with clinically recognized and
  partially treated IE from those with clinically
  unsuspected and untreated or those with no IE
• Specificity and PPV of organisms seen on Gram
  stain was 100 for IE
• Negative did not rule out the Dx in treated pts

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• Valve C/S results
• Quantity of growth did not differentiate between
  pts with partially treated IE and those without
  IE
• Most pts with partially treated IE showed scanty
  growth, as did those without IE
• Positive valve C/S resulting from contamination
  grew normal skin flora ( CoNS, Propionibacterium
  species, diphtheroids, or Bacillus species ) in
  94 of cases
• A single case of unsuspected IE grew CoNS but
  growth was heavy

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• Histopathology correlated better with the
  presence or absence of IE than did microbiology
• Acute inflammation, microorganisms, or both were
  seen in all cases of IE and in none of pts
  without IE

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• Presence of acute inflammation is a clue to IE
  when no organisms seen
• There was considerable overlap in Gram stain and
  C/S when pts with IE treated before Sx were
  compared with those without IE
• Only the presence of bacteria or yeasts on Gram
  stain was predictive for IE, both treated and
  untreated

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• Second most accurate predictor was the identity
  of organism with a strong association between
  normal flora and contaminants
• Routine microbiologic examination of excised
  heart valves to detect rare pts with clinically
  unsuspected IE is not warranted

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• Evaluation of the practice of routine culturing
  of native valves during valve replacement surgery
  
• Ann Thorac Surg. 2000 Feb69(2)548-50
• Campbell WN, Tsai W, Mispireta LA

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Result

• 32 of 222 (14.4) pts had positive valve C/S
• CoNS most common isolate
• Only 1 of 32 (3) developed postop PVE with CoNS
• Mean F/U of 23 months

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Conclusion

• The incidence of false-positive native valve
  culture is high.
• Positive C/S did not predict the occurrence of
  PVE sufficiently to justify obtaining them

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• Gram stain, culture, and histopathological
  examination findings for heart valves removed
  because of infective endocarditis
• Clin Infect Dis. 2003 Mar 1536(6)697-704. Epub
  2003 Mar 04
• Arthur J. Morris

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• Retrospective chart review
• 480 patients who underwent a total of 506 valve
  replacements or repair procedures for IE
• When valves were removed before the end of Tx,
• -Gram stain in micro lab organism seen 231 of
  285 (81)
• -Gram-stained from histopath lab organism seen
• 140 (67) of 208 specimens
• P .0007

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• Gram-positive cocci were either cultured from or
  observed in excised valve tissue in 42 (67) of
  63 episodes involving negative preop BC
• Positive Gram stain results for microbiological
  specimens should be reintroduced into the
  definite pathological criteria for IE

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• When deciding on how long to continue
  antimicrobial therapy after valve replacement IE,
  valve culture results should be the only
  laboratory finding taken into account, because it
  takes months for dead bacteria to be removed from
  sterile vegetations

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• Pt will receive Vancomycin and Rifampin for total
  of 6 weeks.