A Case Of Polymicrobial Endocarditis In An Intravenous Drug Abuser Due To Anaerobes

A Case Of Polymicrobial Endocarditis In An Intravenous Drug Abuser Due To Anaerobes

LEARNING OBJECTIVES:  1. Gain awareness of Infective Endocarditis (IE) due to anaerobic organisms 2. Compare IE in intravenous drug abusers (IVDA) from other cases 3. Recognize that peculiar habits of IVDA can result into unusual polymicrobial IE.
CASE:  A 33-year-old white male presented to our hospital with a two-week history of subjective fevers, chills, and rigors. He had history of intravenous drug abuse and a habit of licking the needle to the dorsum of the tongue before injection into his arm. Blood cultures grew Actinomyces odontolytica, Veillonella species, and Prevotella melaninogenica. CT of the thorax showed multiple cavitary lesions in both lungs and echocardiogram showed vegetations on the tricuspid valve. The patient was treated with a six-week course of penicillin G and metronidazole. He responded well with complete resolution of symptoms.
DISCUSSION:  Endocarditis in intravenous drug users are usually right sided and of the tricuspid valve. Right-sided endocarditis presents with a syndrome of persistent fever and pulmonary symptoms due to septic emboli including cough, dyspnea, and hemoptysis. The peripheral stigmata of endocarditis are not classically found in right-sided endocarditis. Although the most common organism isolated is Staphlococcus aureus, it is important to consider other more fastidious causes of infection in this population including those of endogenous origin. Anaerobes are predominant components of normal human skin and mucous membranes and are an uncommon cause of endocarditis. Most cases are caused by anaerobic cocci, Propionibacterium acnes and Bacteroides fragilis group. Actinomyces odontolytica, Veillonella species, and Prevotella melaninogenica reside predominantly in saliva and the dorsum of the tongue as compared to other organisms. We believe that his peculiar habit of licking the needle to the dorsum of the tongue to gauge the strength of the injection, subjected our patient to infection by these particular anaerobes. Polymicrobial endocarditis is a rare entity that is found almost exclusively in intravenous drug abusers. Although uncommon, it is important to consider since it carries a mortality rate exceeding 30%. There are documented cases in which cultures from the vegetations grew more organisms than the blood cultures, further exemplifying the fastidious nature of the organisms causing endocarditis in intravenous drug users. Therefore, some authors recommend empiric coverage of both skin and oral flora when endocarditis is suspected in this population. Penicillin G or other bactericidal agents appear to be the treatment of choice for these three organisms. Metronidazole is often added due to the growing resistance of anaerobes towards penicillins.
A CASE OF POST-OBSTRUCTIVE PNEUMONIA SECONDARY TO BRONCHOLITHIASIS.S.E. Luckhaupt1; L. Coberly1. 1University of Cincinnati, Cincinnati, OH. (Tracking ID #115743)
LEARNING OBJECTIVES:  1) Distinguish post-obstructive pneumonia from uncomplicated community acquired pneumonia 2) Recognize broncholithiasis as a cause of bronchial obstruction 3) Manage bronchial obstruction to prevent recurrent pneumonia.
CASE:  A 54-year-old male smoker with an unremarkable past medical history presented with a 2-week history of shortness of breath, cough, purulent sputum, pleuritic chest pain, and orthopnea. On exam, he had a temperature of 101.4, respirations of 28 and a pulse ox of 89% on room air. Chest exam revealed bibasilar rhonchi and intermittent wheezing over the left lung base. Initial laboratory data: WBC 20.5 with 12% bands, Hb 15.6. ABG on room air: pH 7.44, pCO2 36, pO2 64. A chest x-ray suggested left lower lobe consolidation with pleural effusion. Despite treatment with iv antibiotics, his oxygen requirement increased and serial x-rays showed increasing infiltrate and effusion. A CT on hospital day #3 revealed extensive loculated left pleural effusion with a compressed lower lobe, possibly caused by calcified left hilar lymph nodes. An ultrasound was negative for free-flowing fluid, so chest tubes were placed, and t-PA was used to assist in drainage. A repeat CT showed improvement in the effusion, but compression of the left lower lobe persisted. Bronchoscopy ultimately revealed obstructing broncholiths. The broncholiths could not safely be removed, so left lower lobectomy was performed. Pathology showed four hard tan-gray stones measuring 0.4 cm to 1.5 cm in diameter and lymph nodes with necrotizing granulomas, negative for neoplasia. No fungi, acid fast bacilli, or other organisms were identified in the pathology specimens or in the pleural fluid.
DISCUSSION:  This patient’s presentation provided several clues that he did not have a typical case of community acquired pneumonia. Despite having an unremarkable medical history, he was very ill on presentation with hypoxemia, which progressed even after treatment with antibiotics. Localized wheezing raised suspicion for bronchial obstruction and concern about the possibility of carcinoma. Broncholithiasis is a less common cause of bronchial obstruction, which usually presents with hemoptysis (from erosion of pulmonary vessels), wheezing, shortness of breath, or chronic cough. It is often associated with fungal infection, such as histoplasmosis, or tuberculosis. The cause of broncholithiasis in this case was unclear. The diagnosis can usually be confirmed by bronchoscopy, but bronchoscopic removal carries a high risk of bleeding, so surgical resection is often required to relieve obstruction.
A CASE OF RAPIDLY FATAL ASPERGILLOSIS IN AN IMMUNOCOMPETANT PATIENT.F.K. Salahuddin1; S. Chitavellue2; K. Karamchandanni3. 1University of Illinois at Peoria,SFMC., Peoria, IL; 2University of Illinois College of Medicine,@Peoria,SFMC, Peoria, IL; 3University of Illinois College Of Medicine,@Peoria, Peoria, IL. (Tracking ID #117272)
LEARNING OBJECTIVES:  1. Diagnosis of massive hemoptysis. 2. Aspergilloma as a cause of hemoptysis. 3. Management of life threatening hemoptysis using various means.
CASE:  A 60 year old male was admitted into the hospital because of pleuritic chest pain, hemoptysis, fever, lethargy and significant weight loss. He was a retired janitor in a school. At the time of presentation, he was in respiratory distress and examination revealed bilateral crackles and wheezes. Chest X-ray and CT scan showed consolidation and cavitation of right upper lobe (Figure below). He underwent diagnostic flexible bronchoscopy which confirmed the bleeding from right upper lobe without any intra-bronchial pathology. Bronchoalveolar lavage grew aspergillious. Patient was treated with Amphotericin B because of massive hemoptysis. He continued to have massive hemoptysis which required mechanical ventilatory support with double lumen endotracheal intubation. Patient was sent for an emergent bronchial arteriogram and had control of bleeding with coiling. After 24 hours patient developed another episode of maasive hemoptysis which lead to his demise. Autopsy confimed the angioinvasive aspergillosis.
DISCUSSION:  Angioinvasive pulmonary aspergillosis is commonly seen as a serious complication in immunosupressed individuals such as patients with AIDS and leukemia. It is rare to encounter angioinvasive aspergillosis in immunocompetant individuals. Aspergillosis can develop as a fungal ball in preexisting pulmonary cavities causing lifethreatening massive hemoptysis. Routine surgical recection of aspergillious is not recommended but should be reserved for patients with recurrent severe refractory hemoptysis. Pleuro-pneumonectomy should be avoided. Lung necrosis can result from invasion of fungus into the vasculature, leading to vascular thrombosis and hemorrhage. Massive hemoptysis can be managed with mechanical ventilation using double lumen endotracheal tube, bronchial artery embolization and or surgery. Prognosis in immunocompetant patients is usually good with above therapies.
A CASE OF RHODOCOCCUS EQUI PNEUMONIA IN A RENAL TRANSPLANT PATIENT.T.S. Bischof1; J. Hariharan1; M. Graham1. 1Medical College of Wisconsin, Milwaukee, WI. (Tracking ID #116015)
LEARNING OBJECTIVES:  (1) To recognize the clinical presentation of atypical pneumonia in transplant patients. (2) To educate the clinician on the presentation, radiography, pathology, and treatment of Rhodococcus equi pneumonia.
CASE:  A 48 y/o male with IgA nephropathy and 4 renal transplants presented with a one week history of nausea, vomiting, and diarrhea. He related dehydration, weakness, low-grade fevers, night sweats, and weight loss. He denied chest pain, shortness of breath or cough. The patient was taking immunosuppressive and antihypertensive medicines. Physical exam revealed an afebrile, normotensive, cachectic male in no acute distress. Exam was within normal limits, and lungs were clear. BMP was normal except for Bun/Cr of 37 mg/dL and 2.0 mg/dL. WBC was 9.0, Hgb 11.9 g/dL, and urinalysis revealed no proteinuria or white cells. Blood, urine and stool cultures were negative. Patient was hydrated, and CXR revealed a new opacity in the left lung. A chest CT revealed a 4.5 × 2.3-cm consolidation in the left lower lobe, but was negative for bony lesions and lymphadenopathy. A bronchoscopy and CT guided biopsy were done, and cultures from both subsequently grew Rhodococcus equi. On directed questioning, it was found the patient lives near a farm with routine exposures to horses and had a new dog. Therapy with moxifloxacin and azithromycin was planned until the lesion cleared on repeat CT scan.
DISCUSSION:  Rhodococcus equi is a gram-positive coccobacillus that usually causes infections in grazing animals. Infection in humans is rare, but over 100 cases have been reported. Rhodococcus is often overlooked in cultures as a non-pathogenic organism and its insidious onset often leads to delays in diagnosis. Pulmonary infection is the most common, and symptoms include fever, cough, and weight loss. On radiography, the superior lobes are mainly involved, and cavitation is frequent, as well as effusion and empyema. Diagnosis is based on positive culture. Most isolates are susceptible to erythromycin, ciprofloxacin, and aminoglycosides. Oral and parenteral combinations of the above are used for treatment for at least two months. This patient was treated for 5 months and repeat CT 3 months later showed decreased consolidation. It is well known that immunocompromised patients are more prone to atypical infections. This case represents a rare cause of a treatable bacterial infection in a transplant patient and the value of social and personal history in medical management. It is important to recognize that when patients present with vague complaints and lack of physical signs, a good history and continually pursuing identification of treatable causes is important. Rhodococcus equi pneumonia is rare but understanding the nature of its presentation is highlighted in this case.

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