Case Report
Openaccess
Diagnosis and Management of Infective
Endocarditis in Patient with Ventricular Septal
Defect: A Report of Clinical Case from Dakar,
Senegal
Mohamed Leye1, Momar Dioum2, Adama Sawadogo3*, Modibo Doumbia3, Joseph Mingou
4,Dominique Bindia2, Arame Diagne Diallo2, Magalie Kaya2, Simon Manga2, Kadia Ba2, OusmaneDieye2 and Ibrahima Bara Diop2
1Department of Cardiology, Unit of Training and Research in medical sciences, University of Thies, Senegal
2Department of Cardiology, Hospital of Fann, Cheikh Anta DIOP University of Dakar, Senegal
3Department of Thoracic and Cardiovascular Surgery, Hospital of Fann, Cheikh Anta DIOP University of Dakar, Senegal
4Department of Cardiology, Aristide Le Dantec Hospital, Cheikh Anta DIOP University of Dakar, Republic of Senegal
2Department of Cardiology, Hospital of Fann, Cheikh Anta DIOP University of Dakar, Senegal
3Department of Thoracic and Cardiovascular Surgery, Hospital of Fann, Cheikh Anta DIOP University of Dakar, Senegal
4Department of Cardiology, Aristide Le Dantec Hospital, Cheikh Anta DIOP University of Dakar, Republic of Senegal
*Corresponding author:Adama Sawadogo, MD, Department of Thoracic and Cardiovascular Surgery, Hospital of Fann, Cheikh Anta DIOP University of Dakar, Senegal E-mail:
@
Received: 16 March, 2017 ; Accepted: 22 April, 2017; Published:02 May, 2017
Citation:Adama Sawadogo, Mohamed Leye, Momar Dioum, et.al. (2017) Diagnosis and Management of Infective Endocarditis in Patient with Ventricular Septal Defect: A Report of Clinical Case from Dakar, Senegal. J Cardiovascular Thoracic Surgery 2(2):1-3. DOI: 10.15226/2573-864X/2/2/00111
Abstract
Infective Endocarditis (IE) due to Streptococcus pneumoniae
is a rare serious complication in the patients with congenital heart
diseases. The authors report a case of pneumococcal endocarditis in
a 13-year-old boy diagnosed with VSD.
Keywords: Endocarditis; Ventricular septal defect; Streptococcaceae; Antibiotic therapy
Keywords: Endocarditis; Ventricular septal defect; Streptococcaceae; Antibiotic therapy
Introduction
Infective Endocarditis (IE) is an infective inflammation
of the endocardium leading mainly to valvular damage and causing
significant mortality and morbidity. It can occur on healthy
or pathological heart [1]. Endocarditis due to Streptococcus
pneumoniae is unusual in children, accounting for 3%–7% of
all cases of childhood endocarditis. It is a serious complication
of congenital heart diseases [2,3]. We report a case of IE due to
streptococcus pneumoniae in 13-year-old boy diagnosed with
VSD.
Case Report
MT is a 13-year-old boy who presented in our
department with intermittent fever that was highest on late
afternoon associated with anorexia and worsening of his physical
status. Regarding his previous medical history, he was born from
a normal pregnancy without parental consanguinity. Then he
was diagnosed with VSD at the age of 6-year-old. The clinical
examination found a fever at 39.1°C and a purring thrill at the
palpation of the cardiac area. On auscultation, heart sounds were
regular; there was pansystolic murmur with isometric
Table 1: TTE 5-cavity apical view: 2D mode showing VSD and vegetation
(red arrows)
Table 2: TTE 5-cavity apical view: Color mode showing the same findings
with left to right shunt
Table 3: TTE Short axis parasternal view color mode showing vegetation
and shunt
Table 4: TTE 5-cavity view 2D mode: showing subaortic VSD and vegetation
handgrip. Pulmonary examination was normal. No dental or ENT
area infection was found. The chest X-rays showed a bilateral hilar
vascular overload. The electrocardiogram (ECG) showed a regular
sinus tachycardia with heart rate at 116 bpm with a right axis
heart. Transthoracic Echocardiogram (TTE) confirmed the VSD
which was perimembranous with 16 mm diameter. Vegetation
could be seen on the right side of the VSD. They were attached
to the edge of the defect and infundibulum (Figures 1 to 4). Left
Ventricle end-diastolic and end-systolic diameters were 55 and
30 mm respectively and ejection fraction was 74%. At biology,
CRP raised up to 97 mg/dL with hyperleukocytosis at 11,000
white blood cells / mm3. The test for malaria (blood smear) was
negative. Empiric antibiotic therapy was started and included
gentamicin 2.5 mg/kg for 5 days associated with ceftriaxone 50
mg/kg for 21 days before laboratory microbiological reports are
available. There was improvement of the clinical feature at the
first week with normalized temperature and drop in CRP (16
mg/dL). However, on week 3 the fever appeared again and CRP
rose to 48 mg/dL. Finally, blood cultures isolated Streptococcus
pneumonia that was resistant to penicillin and ceftriaxone
but sensitive to vancomycin, lyncomycin, pristinamycin and
imipenem. The laboratory did not determine the minimum
inhibitory concentration (MIC). Urine culture was negative.
Then we prescribed vancomycin 15 mg/kg IV for 36 more days. On day 57, CRP was at 8 mg/dl, the control TTE found persisting vegetation. The total duration of IV antibiotics was 57 days. The patient was discharged from hospital with a good clinical condition. A surgical repair is to be planned after total sterilization of the IE.
Then we prescribed vancomycin 15 mg/kg IV for 36 more days. On day 57, CRP was at 8 mg/dl, the control TTE found persisting vegetation. The total duration of IV antibiotics was 57 days. The patient was discharged from hospital with a good clinical condition. A surgical repair is to be planned after total sterilization of the IE.
Discussion
Pneumococcal endocarditis has become uncommon
since the advent of penicillin; it now develops in less than 1% of
native heart valves and that the vast majority (91%) of children
with pneumococcal endocarditis have underlying structural
heart disease [4,5]. Rheumatic valve disease is the most common
cardiac pathology in the developing countries [3]. It is known that
VSD is the most common malformation. Some studies found that
patients with VSD were six times more likely to suffer from IE
compared to the general population [1,6]. TTE or TEE are useful
for diagnosis and follow-up of IE [7,2]. TEE is recommended in
patients with prosthetic valve or other intra-cardiac material
in case TTE is not contributive [8]. The diagnosis is based on
the modified Duke University criteria [9]. According to these
criteria, IE is certain if microorganisms are found in blood
culture or histology of vegetation or in intra-cardiac abscess.
Another diagnosis is based on the presence of vegetation or
intra-cardiac abscess associated with histological confirmation
of an evolving IE. We had isolated the streptococcus. This germ
was also preponderant in some studies such us the series of Li
et al. who found 56% Viridans streptococci in a series of 130
VSD-patients with IE [10]. No source was found over clinical
examination and other investigations but in the literature, dental
infection, ENT source, open-heart surgery, cutaneous wound and
catheterization are reported [10]. Like our patient, the treatment
of IE in case of positive blood culture is primarily based on a
targeted antibiotic therapy in monotherapy or in combination.
Practically, the intravenous route should be considered as the
reference because it ensures total bioavailability [1]. During
antibiotic treatment, disappearance of fever and the remaining
normal temperature, negative blood culture and disappearance of
biological inflammation syndrome are the best guarantee of the
efficiency of antibiotic therapy. The duration of the association
should be 2 weeks and the total duration of treatment should
last 4 weeks or up to 6 weeks in case of prolonged evolution
or complicated form. Surgical treatment remains inaccessible
for most children with congenital heart diseases in our context.
About 22% of the patients required surgery in the series of
Givner (11 patients) [4]. Although the stabilized situation of our
patient, surgical repair is to be performed as soon as possible to
avoid embolic accidents and to reduce the risk of mortality. The
purpose of this article is to discuss the prevention of IE in the
case of VSD. According to 2015 guidelines, antibiotic prophylaxis
is not recommended for high-risk cardiac diseases. The National
Institute of Excellence in Health and Care (NICE 2008) went even
further by not recommending antibiotic prophylaxis regardless
of cardiac history and procedure. In addition, antibiotic therapy
exposes the risk of anaphylaxis and the emergence of resistant
strains [11,12]. The question is whether these recommendations
can really be applied in the developing countries that are lacking
asepsis measures? The Adult Expert Panel for the Hospital
Level which is a part of the National List of Essential Medicines
Committee of South Africa recommends antibiotic prophylaxis in
Osler infections, for high-risk procedures even in patients with
acquired valve diseases [13]. The definitive answer requires
controlled randomized studies which is tricky due to the large
number of patients to include. In our opinion, it is reasonable
to apply the recommendations of international societies but
in taking into consideration the socio-economic context, the
expertise in dentistry but also the microbiological environment
of each region; the antibiotic prophylaxis in case of VSD is not
necessary [11,1].
Conclusion
IE due to streptococcus pneumoniae is a rare clinical
situation in VSD-patients that is not reported within our region
yet. In our context, echocardiogram associated with blood culture
can make the diagnosis. A well managed antibiotic therapy is a
key to stabilize the infection prior to perform surgical repair.
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