Septic embolism in a patient with infective endocarditis and COVID-19: a case report and review of management
DOI:
https://doi.org/10.54844/cai.2022.0082Keywords:
COVID-19, infective endocarditis, multidrug-resistant staphylococcus aureus, diagnosis, treatmentAbstract
Background: The diagnosis and treatment of infective endocarditis (IE) is facing great challenges during the coronavirus disease (COVID-19) pandemic, especially in patients without valvular heart disease. Methods: The 39-year-old patient with no pertinent medical history presented with high fever for 14 days and positive nucleic acid test results for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) for 3 hours. He denied any trauma or IV drug use. Blood culture grew MRSA. CT revealed infectious metastases in spleen, liver, kidney and brain. Transesophageal echocardiography (TEE) was performed under safety protection finding mitral valve vegetation. His senses of smell, taste, hearing and vision were weakened temporarily. The patient was treated with daptomycin in combination with fosfomycin sodium and linezolid successively. On hospital day 10, the patient was transferred to ICU due to respiratory distress and cardiac insufficiency for 5 days with high flow oxygen noninvasive ventilation. After treatment, the patient achieved remission and was discharged from hospital. Results: We encountered a typical case of IE with multiple organ infection caused by MRSA sepsis combined with COVID-19, for which combination therapy was effective. Conclusions: Obvious risk factors of IE may be absent in many cases. A high index of suspicion is required, especially with additional findings such as embolic phenomenon, focal neurologic deficit, decompensated heart failure, or new murmurs. The purpose of this case report is to help clinicians by improving awareness of IE, particularly in patients having high suspicion despite any risk factors, during COVID-19 pandemic.
References
Pant S, Patel NJ, Deshmukh A, Golwala H, Patel N, Badheka A, et al. Trends in Infective Endocarditis Incidence, Microbiology, and Valve Replacement in the United States From 2000 to 2011. J Am Coll Cardiol 2015;65:2070–2076. DOI: https://doi.org/10.1016/j.jacc.2015.03.518
Dayer MJ, Jones S, Prendergast B, Baddour LM, Lockhart PB, Thornhill MH. Incidence of infective endocarditis in England, 2000-13: a secular trend, interrupted time series analysis. Lancet 2015;385:1219–1228. DOI: https://doi.org/10.1016/S0140-6736(14)62007-9
Olmos C, Vilacosta I, Fernández-Pérez C, Bernal JL, Ferrera C, García-Arribas D, et al. The Evolving Nature of Infective Endocarditis in Spain. J Am Coll Cardiol 2017;70:2795–2804. DOI: https://doi.org/10.1016/j.jacc.2017.10.005
Ulloa N, Cook JM, Smithson S. A Clinical Challenge in the Emergency Department: A Case of Klebsiella Infective Endocarditis Presenting With Splenic Abscess. Cureus 2020;12:e10577 DOI: https://doi.org/10.7759/cureus.10577
Havers-Borgersen E, Fosbøl EL, Butt JH, Petersen JK, Dalsgaard A, Kyhl F, et al. Incidence of infective endocarditis during the coronavirus disease 2019 pandemic: A nationwide study. Int J Cardiol Heart Vasc 2020;31:100675. DOI: https://doi.org/10.1016/j.ijcha.2020.100675
Cosyns B, Motoc A, Arregle F, Habib G. A Plea Not to Forget Infective Endocarditis in COVID-19 Era. JACC Cardiovasc Imaging 2020;13:2470–2471. DOI: https://doi.org/10.1016/j.jcmg.2020.07.027
Escolà-Vergé L, Cuervo G, de Alarcón A, Sousa D, Barca LV, Fernández-Hidalgo N, et al. Impact of the COVID-19 pandemic on
the diagnosis, management and prognosis of infective endocarditis. Clin Microbiol Infect 2021;27:660–664..
Habib G, Erba PA, Iung B, Donal E, Cosyns B, Laroche C, et al. Clinical presentation, aetiology and outcome of infective endocarditis.
Results of the ESC-EORP EURO-ENDO (European infective endocarditis) registry: a prospective cohort study. Eur Heart J 2019;40:3222–3232.
Kirkpatrick JN, Mitchell C, Taub C, Kort S, Hung J, Swaminathan M. ASE Statement on Protection of Patients and Echocardiography
Service Providers During the 2019 Novel Coronavirus Outbreak: Endorsed by the American College of Cardiology. J Am Soc Echocardiogr 2020;33:648–653. DOI: https://doi.org/10.1016/j.echo.2020.04.001
Skulstad H, Cosyns B, Popescu BA, Galderisi M, Salvo GD, Donal E, et al. COVID-19 pandemic and cardiac imaging: EACVI recommendations on precautions, indications, prioritization, and protection for patients and healthcare personnel. Eur Heart J Cardiovasc Imaging 2020;21:592–598. DOI: https://doi.org/10.1093/ehjci/jeaa072
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Septic embolism in a patient with infective endocarditis and corona virus disease 2019: a case report and review of management
Jingbo Wang1, Haitao Wang2, Wei Wu3, Huijun Suo1
1Department of Infectious Disease, The Sixth People’s Hospital of Shenyang, Shenyang 110006, Liaoning Province, China
2Department of General Surgery, The Second Affiliated Hospital of Shenyang Medical College, Shenyang 110001, Liaoning Province, China
3Department of Intensive Critical Medicine, The Sixth People’s Hospital of Shenyang, Shenyang 110006, Liaoning Province, China
ABSTRACT
Background: The diagnosis and treatment of infective endocarditis (IE) is facing great challenges during the corona virus disease 2019 (COVID-19) pandemic, especially in patients without valvular heart disease. Methods: The 39-year-old patient with no pertinent medical history presented with high fever for 14 d and positive nucleic acid test results for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) 3 h ago. The patient denied any trauma or IV drug use. Eight samples, including two sets of both upper and lower limbs, were collected in the morning and afternoon respectively on the first day of hospitalization. And multidrug-resistant staphylococcus aureus (MRSA) were positive in all blood cultures for 4 d. Computed tomography (CT) revealed infectious metastases in spleen, liver, kidney and brain. Transesophageal echocardiography (TEE) was performed under safety protection finding mitral valve vegetation. The patient’s senses of smell, taste, hearing and vision were weakened about 3 d. The patient was treated with daptomycin in combination with fosfomycin sodium and linezolid successively. On hospital d 10, the patient was transferred to intensive care unit (ICU) due to respiratory distress and cardiac insufficiency for 5 d with high flow oxygen noninvasive ventilation. After treatment, the patient achieved remission and was discharged from hospital. Results: This patient was a typical case of IE with multiple organ infection caused by MRSA sepsis combined with COVID-19, for which combination therapy was effective. Conclusions: Obvious risk factors of IE may be absent in many cases. A high index of suspicion is required, especially with additional findings such as embolic phenomenon, focal neurologic deficit, decompensated heart failure, or new murmurs. The purpose of this case report is to help clinicians by improving awareness of IE, particularly in patients having high suspicion despite any risk factors, during COVID-19 pandemic.
Key words: COVID-19, infective endocarditis, multidrug-resistant staphylococcus aureus, diagnosis, treatment
Address for correspondence:
Dr. Huijun Suo, Department of Infectious Disease, The Sixth People’s Hospital of Shenyang, 85 Heping South Street, Shenyang 110006, Liaoning Province, China. E-mail: 1662647300@qq.com
Submitted: 18-03-2022 Revised: 09-06-2022
Accepted: 04-07-2022 Published: 29-07-2022
For reprints contact: reprints@sppub.org
INTRODUCTION
The corona virus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome corona virus 2 (SARSCoV-2), has emerged as a critical public health challenge. Infective endocarditis (IE) is a serious bacterial infection of the endocardium and/or heart valves with high mortality rate.[1,2,3] Patients often do not demonstrate risk factors or specific symptoms, which makes the diagnosis difficult, especially during current COVID-19 pandemic.[4,5] Until now, reports on COVID-19 patients with IE are limited. Here, this study reported the first confirmed case of COVID-19 with IE presenting MRSA bacteremia and multiple organ embolism, ultimately achieved remission.
CASE REPORT
The patient was a 39-year-old male who presented with fever for 14 d and positive nucleic acid test results for SARS-CoV-2 for 3 h. On December 24, 2020, the patient developed fever (body temperature >39℃) and treated with moxifloxacin and ceftriaxone successively at a fever clinic. On January 6, 2021, SARS-CoV-2 nucleic acid test revealed positive, the patient immediately transferred to the COVID-19 treatment center. The patient had no chronic diseases history and denied any trauma or IV drug use.
On admission (January 6, 2021), temperature 39.5℃, blood pressure 129/74 mmHg, oxygen saturation (SO2) 97% (nasal cannula, oxygen 3 L/min), petechiae on the left little and ring fingers with maximal diameter of 3 mm, and apical systolic grade II/III murmur. Eight samples including two sets of both upper and lower limbs were collected in the morning and afternoon respectively, and blood cultures were performed. Laboratory investigations were as followed: white blood cells (WBC) 15.8×109/L, lymphocytes (L) 1.0×109/L, neutrophils (N) 13.4×109/L, C-reactive protein (CRP) 185 mg/L, interleukin (IL)-6 34.3 pg/mL, procalcitonin (PCT) 1.36 ng/mL, D-dimer (D-D) 2.72 mg/L (Table 1). Arterial blood gas analysis yielded the following findings: pH=7.523, partial pressure of oxygen (PO2) 66.4 mmHg, partial pressure of carbon dioxide (PCO2) 29.3 mmHg, lactate 1.5 mmol/L, oxygenation index (OI, PO2/ fraction of inspired oxygen [FiO2]) 201 mmHg. Lung computed tomography (CT) revealed patchy ground-glass opacities in the right lung (Figure 1A). The patient was diagnosed with COVID-19 (moderate type), high probability of IE.
| Date | clinical type | WBC (×109/L) | LC (×109/L) | CRP (mg/L) | IL-6 (pg/mL) | PCT (ng/mL) | LDH (U/L) | D-dimer (mg/L) | FIB (g/L) | ALT (U/L) | BIL (μmol/L) | PO2 (mmHg) | blood culture | O/N | daptomycin | fosfomycin | linezolid | oxygen therapy mode |
| 6 Jan | Moderate | 15.8 | 1 | 185 | 34.3 | 1.36 | 716 | 2.72 | 5.31 | 111 | 47.6 | 66.4 | 31/31 | nasal cannula | ||||
| 7 Jan | 10 | 0.8 | 225 | 112 | 1.02 | 684 | 3.26 | 4.98 | 71 | 33.9 | 80.7 | MRSA | 28/28 | 0.8g Qd | 8g 12h | nasal cannula | ||
| 8 Jan | 8.1 | 0.6 | 208 | 1075 | 4.62 | 4.71 | 57 | 21.3 | 0.8g Qd | 8g 12h | nasal cannula | |||||||
| 10 Jan | 10 | 1.1 | 211 | 168 | 0.83 | 1005 | 3.47 | 3.15 | 65 | 19 | 73.1 | (-) | 33/32 | 0.8g Qd | 8g 12h | nasal cannula | ||
| 13 Jan | 5.7 | 1.6 | 140.8 | 37.4 | 783 | 5.82 | 4.15 | 56 | 15.4 | 83 | (-) | -/- | 0.8g Qd | 8g 12h | nasal cannula | |||
| 15 Jan | Severe | 5 | 1.2 | 97.69 | 70.1 | 0.28 | 760 | 7.52 | 4.71 | 45 | 13.1 | -/- | 0.8g Qd | 8g 12h | noninvasive assisted ventilation | |||
| 16 Jan | 5.3 | 1.3 | 92.06 | 0.26 | 792 | 8.74 | 4.59 | 47 | 15.3 | 61.1 | (-) | 0.8g Qd | 8g 12h | noninvasive assisted ventilation | ||||
| 17 Jan | 5.2 | 1.4 | 92.07 | 53.5 | 0.1 | 779 | 9.5 | 4.84 | 43 | 17.2 | 56.2 | (-) | 0.8g Qd | 0.6 12 | noninvasive assisted ventilation | |||
| 18 Jan | 6.8 | 1.2 | 66.81 | 29 | 0.14 | 660 | 7.45 | 6.6 | 35 | 16 | 0.8g Qd | 0.6 12 | noninvasive assisted ventilation | |||||
| 19 Jan | 7.5 | 1.3 | 59.7 | 41 | 0.11 | 626 | 5.87 | 5.87 | 63 | 19 | 74.1 | (-) | 0.8g Qd | 0.6 12 | noninvasive assisted ventilation | |||
| 20 Jan | Moderate | 7.7 | 1.4 | 68.66 | 27.1 | 0.13 | 616 | 5.33 | 7.41 | 152 | 20.8 | 0.8g Qd | 0.6 12 | nasal cannula | ||||
| 28 Jan | 7.9 | 2.2 | 44.58 | 19.7 | 0.18 | 475 | 2 | 4.59 | 39 | 15.4 | -/- | 0.8g Qd | 0.6 12 | nasal cannula | ||||
| 29 Jan | 7.7 | 2.2 | 29.1 | 15 | 0.15 | 393 | 1.79 | 6.6 | 35 | 15.4 | 0.8g Qd | 0.6 12 | nasal cannula | |||||
| 30 Jan | 7.9 | 1.9 | 21.87 | 9.8 | 0.1 | 399 | 1.99 | 5.87 | 27 | 12.9 | 0.8g Qd | nasal cannula | ||||||
| 17 Feb | 6.8 | 2.5 | 2.28 | 1.5 | 0.05 | 388 | 0.99 | 3.59 | 29 | 9.8 | (-) | -/- | Stop | |||||
| 20 Feb | Discharge | 6.8 | 2.1 | 3.57 | -/- | |||||||||||||
| WBC: white blood cells, LC: lymphocytes, CRP: C-reactive protein, IL-6: interleukin-6, PCT: procalcitonin, LDH: lactate dehydrogenase, FIB: Fibrinogen, ALT: alanine amiotransferase, BIL: bilirubin, PO2: partial pressure of oxygen, O: open reading frame 1ab gene (ORF 1ab), N: nucleoprotein gene. | ||||||||||||||||||
Figure 1: CT image. (A,B,C) The ground glass opacity of both lungs increased from a small amount to a patchy one with thickened blood vessels, and then to the inflammatory lesions. (D) Multiple splenic infarcts with the maximum diameter of 5.1 cm×3.6 cm and the tip pointed to splenic hilum. (E,F) Left parietal lobe hemorrhage and left occipital lobe infection with peripheral edema. (G) Low density necrosis in liver. (H) Low density small infarct in right kidney. (I) Necrosis of distal pinkie of left hand. Transoesophageal echocardiogram: (J) Vegetations in the heel of the left atrium near the posterior lobe of the mitral valve. (K) Mitral valve prolapse. Transthoracic echocardiogram: (L) Mitral valve regurgitation.
Day 2, transthoracic echocardiography (TTE) revealed mild mitral valve prolapse (Figure 1K) with regurgitation (Figure 1L) and left ventricular ejection fraction (LVEF) of 56.4%. CT revealed infectious foci in spleen (Figure 1D), kidney (Figure 1H), liver (Figure 1G) and intracranium with small hemorrhage in the left frontal lobe (Figure 1E). Blood cultures grew multidrug-resistant Staphylococcus aureus (MRSA). He was treated with daptomycin (0.8 g/d, 10 mg/kg/d) combined with fosfomycin sodium (16 g/d). Day 5, blood cultures were negative. Day 8, his senses of smell, taste, hearing and vision were weakened, and Osler's nodes appeared in the left little finger (Figure 1I). Repeat CT revealed progressive inflammation in both lungs (Figure 1B) and obvious edema around intracranial infarct focus (Figure 1F). Nucleic acid test result for SARS-CoV-2 was negative. Day 10, the patient experienced diarrhea, vomiting, headache, shortness of breath with SO2 88%, then was transferred to intensive care unit (ICU). Noninvasive assisted ventilation (FiO2 50%) was used to the patient whose SO2 increased to 94%–98%. Day 11, the patient was examined by transesophageal echocardiography (TEE) which found an additional isoechoic mass (1.2 cm × 1.2 cm × 0.8 cm) on the root of mitral valve (Figure 1J). A definitive diagnosis of IE was reached. Day 12, fosfomycin sodium was replaced by linezolid (1.2 g/d) due to the temperature was still beyond 39.0°C. Day 15, the temperature decreased to normal. CT revealed gradually absorbed pulmonary consolidation in both lungs (Figure 1C). Day 23, vegetation reduced to 1.2 cm × 0.3 cm × 0.5 cm. Day 25, linezolid was stopped while daptomycin continued. Day 43, daptomycin was stopped. Day 46, the patient was discharged.
This study was reviewed and approved by the Ethics Committee of the Sixth People’s Hospital of Shenyang (KY-LW-2021-02-01).
DISCUSSION
In the case described herein, IE was complicated by COVID-19. The COVID-19 pandemic has resulted in a decline in IE diagnosis approaching 35%.[6,7] Patients with IE are at a higher risk than ever before, and in addition, IE mortality has exceeded 20% under normal conditions.[8] To date, there is limited knowledge about COVID-19 combined with IE. The role played by viruses in the course of IE is complex, and no reports have directly described viruses as initiating factors.
In this case, IE was not considered due to the lack of any risk factors at the early stage. A high suspicion was made when the patient had additional presentations such as prolonged fever, positive blood culture, multiple embolic phenomenons, and focal neurologic deficit. Until vegetation visualized on TEE studies, the diagnosis of IE was more sufficient. The experience remained clinicians that IE should be highly alert to the patient with a high index of suspicion such as embolic phenomenon, focal neurologic deficit, decompensated heart failure, or new murmurs, despite any risk factors, just like this case.
MRSA was the pathogenic bacterium of IE in our report. According to drug sensitivity test, daptomycin was selected to control bloodstream infection for 42 d. Fosfomycin sodium and linezolid were successively combined with it for 10 d and 13 d, respectively, to treat intracranial and organ infection. The combination therapy was obviously effective. The blood culture was negative four days later, and body temperature was normal after one week. The size of vegetation decreased from 1.2 cm × 1.2 cm × 0.8 cm to 1.2 cm × 0.3 cm × 0.5 cm within two weeks. The infectious foci and Osler nodes were absorbed gradually.
Echocardiography (TTE and TEE) is an important tool for the diagnosis of IE. According to the American Society of Echocardiography (ASE) and the European Association of Cardiovascular Imaging recommendations,[9,10] TEE should be performed if a definitive diagnosis cannot be reached based on TTE findings when there is a high clinical suspicion for IE, despite the risk of infection. In this case, the vegetation was located on the posterior mitral leaflet near the base of the valve, which was not easily detected by TTE, and a definitive diagnosis was finally reached based on TEE performed under safety protection. TEE is also an important assessment modality to guide treatment. After 23 d combined treatment, vegetation was significatly reduced. On this basis, Fosfomycin sodium and linezolid were successively discontinued, only daptomycin lasted for 42 d. Surgical treatment was not required for the patient because the mitral valve structure was not severely damaged.
In summary, here this study reported the diagnosis and treatment of IE with COVID-19. The purpose of this report is to help clinicians by improving awareness of IE, particularly in COVID-19 patients.
Source of funding
Nil.
Ethics approval and consent to participate
This study was reviewed and approved by the Ethics Committee of the Sixth People’s Hospital of Shenyang (KY-LW-2021-02-01).
Conflict of interest
Nil.
REFERENCES
- Pant S, Patel NJ, Deshmukh A, Golwala H, Patel N, Badheka A, et al. Trends in Infective Endocarditis Incidence, Microbiology, and Valve Replacement in the United States From 2000 to 2011. J Am Coll Cardiol 2015;65:2070–2076. DOI: 10.1016/j.jacc.2015.03.518
- Dayer MJ, Jones S, Prendergast B, Baddour LM, Lockhart PB, Thornhill MH. Incidence of infective endocarditis in England, 2000-13: a secular trend, interrupted time series analysis. Lancet 2015;385:1219–1228. DOI: 10.1016/S0140-6736(14)62007-9
- Olmos C, Vilacosta I, Fernández-Pérez C, Bernal JL, Ferrera C, García-Arribas D, et al. The Evolving Nature of Infective Endocarditis in Spain. J Am Coll Cardiol 2017;70:2795–2804. DOI: 10.1016/j.jacc.2017.10.005
- Ulloa N, Cook JM, Smithson S. A Clinical Challenge in the Emergency Department: A Case of Klebsiella Infective Endocarditis Presenting With Splenic Abscess. Cureus 2020;12:e10577 DOI: 10.7759/cureus.10577
- Havers-Borgersen E, Fosbøl EL, Butt JH, Petersen JK, Dalsgaard A, Kyhl F, et al. Incidence of infective endocarditis during the coronavirus disease 2019 pandemic: A nationwide study. Int J Cardiol Heart Vasc 2020;31:100675. DOI: 10.1016/j.ijcha.2020.100675
- Cosyns B, Motoc A, Arregle F, Habib G. A Plea Not to Forget Infective Endocarditis in COVID-19 Era. JACC Cardiovasc Imaging 2020;13:2470–2471. DOI: 10.1016/j.jcmg.2020.07.027
- Escolà-Vergé L, Cuervo G, de Alarcón A, Sousa D, Barca LV, Fernández-Hidalgo N, et al. Impact of the COVID-19 pandemic on the diagnosis, management and prognosis of infective endocarditis. Clin Microbiol Infect 2021;27:660–664. DOI: 10.1016/j.cmi.2020.11.022
- Habib G, Erba PA, Iung B, Donal E, Cosyns B, Laroche C, et al. Clinical presentation, aetiology and outcome of infective endocarditis. Results of the ESC-EORP EURO-ENDO (European infective endocarditis) registry: a prospective cohort study. Eur Heart J 2019;40:3222–3232. DOI: 10.1093/eurheartj/ehab724.1710
- Kirkpatrick JN, Mitchell C, Taub C, Kort S, Hung J, Swaminathan M. ASE Statement on Protection of Patients and Echocardiography Service Providers During the 2019 Novel Coronavirus Outbreak: Endorsed by the American College of Cardiology. J Am Soc Echocardiogr 2020;33:648–653. DOI: 10.1016/j.echo.2020.04.001
- Skulstad H, Cosyns B, Popescu BA, Galderisi M, Salvo GD, Donal E, et al. COVID-19 pandemic and cardiac imaging: EACVI recommendations on precautions, indications, prioritization, and protection for patients and healthcare personnel. Eur Heart J Cardiovasc Imaging 2020;21:592–598. DOI: 10.1093/ehjci/jeaa072
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