Erysipelothrix rhusiopathiae endocarditis and presumed osteomyelitis

Erysipelothrix rhusiopathiae is known to cause infections in humans following exposure to decaying organic matter or animals colonized with the organism, such as swine and fish. Invasive infections with this organism are unusual and are manifested primarily as infective endocarditis. The present report is believed to be the first to report a case of E rhusiopathiae endocarditis and presumptive osteomyelitis. E rhusiopathiae appears to have intrinsic resistance to vancomycin. Because vancomycin is often used empirically for the treatment of endocarditis, rapid differentiation of E rhusiopathiae from other Gram-positive organisms is critical. In patients with endocarditis caused by a Gram-positive bacillus and epidemiological risk factors for E rhusiopathiae exposure, empirical treatment with vancomycin should be reconsidered.Key Words: Endocarditis, Erysipelothrix rhusiopathiae, OsteomyelitisErysipelothrix rhusiopathiae is a Gram-positive bacillus that has long been recognized as a pathogen in animals, particularly swine (1). It is ubiquitous in nature and has been reported to be a colonizer of fish, shellfish, birds and even insects (2). In humans, infections with E rhusiopathiae are most commonly associated with occupational exposure to contaminated meat or fish. The majority of human infections fall into three categories: a mild cutaneous form (erysipeloid), a generalized cutaneous form and an invasive septic form (infections of the blood and/or other sterile sites). Invasive E rhusiopathiae infection, unlike the cutaneous form, is uncommon - there are approximately 60 case reports in the literature. Invasive infections with this organism are unusual and are manifested primarily as infective endocarditis. The present report is believed to be the first to report a case of E rhusiopathiae endocarditis and presumptive osteomyelitis.     

Erysipelothrix rhusiopathiae endocarditis and presumed osteomyelitis.

Erysipelothrix rhusiopathiae is known to cause infections in humans following exposure to decaying organic matter or animals colonized with the organism, such as swine and fish. Invasive infections with this organism are unusual and are manifested primarily as infective endocarditis. The present report is believed to be the first to report a case of E rhusiopathiae endocarditis and presumptive osteomyelitis. E rhusiopathiae appears to have intrinsic resistance to vancomycin. Because vancomycin is often used empirically for the treatment of endocarditis, rapid differentiation of E rhusiopathiae from other Gram-positive organisms is critical. In patients with endocarditis caused by a Gram-positive bacillus and epidemiological risk factors for E rhusiopathiae exposure, empirical treatment with vancomycin should be reconsidered.     

An autopsy case of Erysipelothrix rhusiopathiae endocarditis

A 58-year-old man was admitted to our hospital with fever. The vegetation was confirmed by echocardiography on the tricuspid valve and Erysipelothrix rhusiopathiae was isolated by blood culture. The patient died due to heart failure, and tricuspid valve vegetation was confirmed on autopsy and the sample of Gram's staining showed gram-positive microcolonies. Although about 60 cases of E. rhusiopathiae endocarditis have been reported, Japanese cases are extremely rare.     

Infective endocarditis complicating mitral valve prolapse: epidemiologic, clinical, and microbiologic aspects

Cases of infective endocarditis superimposed upon prolapsing mitral valves were first described two decades ago. In the intervening years 72 reports in the English-language literature have described 267 such cases. Men predominated numerically in cases occurring after the age of 40 years and in surgical and autopsy series. In cases with auscultatory abnormalities documented before the onset of infective endocarditis, murmurs-and not merely isolated systolic clicks--were usually present. Complications of infective endocarditis were relatively common, and at least 42 patients required valve replacement in the acute phase of illness or during convalescence. Although viridans streptococci were the most frequent etiologic agents (46% of cases), deaths occurred primarily among patients infected with other organisms and among those over 40 years of age. Mitral valve prolapse is increasingly being recognized as a precursor of infective endocarditis because of its high prevalence in the general population and the wider availability of echocardiographic diagnostic techniques. The risk/benefit and cost/benefit ratios for endocarditis prophylaxis in patients with prolapsing mitral valves remain controversial.     

Bacteremia due to Staphylococcus epidermidis: microbiologic, epidemiologic, clinical, and prognostic features

Staphylococcus epidermidis was established as the causal agent of true bacteremia on the basis of microbiologic, epidemiologic, clinical, and prognostic data on 65 episodes of S. epidermidis bacteremia (SEB) recorded in the Hospital Covadonga of Oviedo, Spain, during 1982-1986. All isolates were susceptible in vitro to vancomycin, mercury, silver, cadmium, and malachite green, and 95.2% of isolates were susceptible to cephalothin; a dominant biotype, four resistotypes (ion-dye resistance patterns), and four antibiotypes (antibiotic resistance patterns) were found. A high percentage of isolates (76.7%) produced slime, and several potentially toxic exoproteins were detected in various and generally lower proportions. The main clinical features of SEB were high frequency in male patients greater than 40 years of age, fever, leukocytosis, anemia, and phlebitis. Indwelling devices were the most common portal of entry. The overall death rate was 36.9%. Underlying disease, hemodynamic status, predisposing factors, and treatment were statistically significant parameters in relation to mortality.     

Imported rickettsial disease: clinical and epidemiologic features

PURPOSE AND METHODS: The rickettsioses continue to constitute major health problems in many parts of the world. With increasing international travel, recognition of rickettsial diseases by physicians is becoming more important. The clinical features of four cases of rickettsial disease imported into Canada over a five-year period are presented; two patients with tick typhus (Rickettsia conorii), one patient with scrub typhus (R. tsutsugamushi), and one patient with murine typhus (R. typhi). We also present the North American data over the past 10 years from the Centers for Disease Control (CDC) (Atlanta). RESULTS: Since 1983 in the United States, three cases of imported scrub typhus, all after travel to India, were confirmed, as well as six cases of murine typhus after travel to southeast Asia. At the CDC, 67 imported cases of tick typhus have been confirmed by indirect fluorescent antibody test since 1976; most illnesses occurred after travel to Africa. CONCLUSION: Rickettsial diseases are underrecognized by physicians, who should consider these diagnoses in travelers returning from endemic areas. Since effective treatment is available, prompt diagnosis and treatment are important. In all cases, specific serologic confirmation should be obtained.     

Mitro-aortic infective endocarditis produced by Erysipelothrix rhusiopathiae: case report and review of the literature

Endocarditis produced by Erysipelothrix rhusiopathiae is an uncommon disease in humans. This bacterial species is found worldwide as a commensal or a pathogen in many animals. Infection in humans is usually due to occupational exposure. The case is reported of a 43-year-old male parrot breeder with native aortic and mitral valve endocarditis and NYHA class II heart failure at six months after wound infection. The patient was discharged after six weeks' treatment with intravenous penicillin G and replacement of the mitral and aortic valves due to severe regurgitation. At one year after surgery the patient was asymptomatic and infection-free.     

Multiple-valve infective endocarditis: clinical, microbiologic, echocardiographic, and prognostic profile

Whether infection in more than 1 valve worsens the prognosis for endocarditis remains untested. We conducted the current study to determine the profile of multiple-valve endocarditis, compare multiple-valve endocarditis with single-valve endocarditis, and determine predictors of outcome. We conducted a prospective and observational study including 680 episodes of infective endocarditis consecutively diagnosed at 3 tertiary centers. Multiple valve involvement was present in 115 episodes (17%), and single valve involvement in 530 (78%). In the remaining 35 cases, valvular involvement could not be documented. Mean age of patients with multiple valve endocarditis was 58 years. Clinical complications were frequent (heart failure 65%, renal failure 44%, systemic embolisms 24%). The microorganism most frequently isolated was Staphylococcus aureus (22%).Factors predictive of in-hospital mortality in the univariate analysis were septic shock, prosthetic endocarditis, heart failure, and persistent infection. In the multivariate analysis, we detected heart failure (odds ratios [OR], 4.7; 95% confidence interval [CI], 1.6-13.8) and persistent infection (OR, 4.3; 95% CI, 1.7-10.8) as predictors of in-hospital mortality. Compared to single-valve endocarditis, multiple-valve disease was associated more frequently with heart failure (65% vs. 50%, p = 0.03), perivalvular complications (41% vs. 21%, p < 0.001), and heart surgery (70% vs. 54%, p = 0.002). Despite these differences, in-hospital mortality was similar (28% vs. 30%, p = 0.647). In conclusion, multiple-valve endocarditis has a poor clinical course. Mortality is similar to that of single-valve endocarditis, probably in relation with aggressive therapy including surgery in many patients. Heart failure and persistent infection are independent predictors of death.     

Cardiobacterium hominis: review of microbiologic and clinical features

Cardiobacterium hominis, like other fastidious, opportunistic gram-negative bacilli, including Actinobacillus actinomycetemcomitans, Haemophilus aphrophilus, and Eikenella corrodens, is increasingly recognized as a cause of human disease. In this review the microbiologic and clinical features of C. hominis are discussed. The findings are based on observations of two infected patients (the case history of one was reported previously) and on reports in the literature of 32 others. Microbiologically, the chief distinguishing features of C. hominis are its characteristic colonial morphotype and its production of indole. Infection with C. hominis is clinically distinctive because of its chronic course (averaging 169 days among patients with endocarditis), the absence of documented infection outside of the bloodstream, and the high degree of responsiveness to treatment with penicillin.     

Shigellosis in adults: epidemiologic, clinical, and laboratory features

One hundred and sixteen cases of adult patients hospitalized for shigellosis have been reviewed. The most common presentation included diarrhea (most frequently watery), fever, and abdominal pain, while dysentery has been less frequent. S. flexneri infection, as compared to S. sonnei, was more common in elderly patients and in males, and was characterized by a more prolonged clinical course. Abnormalities of serum electrolytes and hepatic enzymes were the most common laboratory complications, most often seen in elderly patients. Most isolates exhibited susceptibility to the common antimicrobial agents used in shigellosis therapy.     

The occurrence and epidemiologic features of alcohol-related occupational injuries

This paper presents a review of published literature on alcohol-related occupational injuries. Based on the information presented the true magnitude of the problem of alcohol- and work-related injuries has not been accurately assessed and the epidemiologic features of this problem have not been properly evaluated. There is some evidence, albeit incomplete, that alcohol contributes to work-related injuries, but the extent is not known. Further, the risk of injury by specific industry and occupation has not yet been elucidated. Analytic studies which include control groups and which assess confounding variables are needed so as to aid in the design of effective countermeasure strategies. Even when alcohol is detected, its role in the causal pathway from the worker-energy interaction to injury onset (or exacerbation) has not been studied.     

Pacemaker-related endocarditis: clinical features and treatment

BACKGROUND AND AIM OF THE STUDY: Removal of the entire infected system is the traditionally indicated management of pacemaker lead endocarditis (PLE), based on expert recommendations. Herein is described the present authors' experience with this condition. METHODS: Between 1987 and 2004, all consecutive patients with PLE treated at a tertiary referral university hospital and a community hospital were prospectively selected. Clinical features, management and outcome were analyzed. RESULTS: Thirteen cases of PLE were diagnosed. Surgery was performed in 10 cases, and medical treatment alone in three (due to advanced age in two cases and because of terminal colon cancer in one case). Four subjects died before discharge: three deaths occurred after surgery (one patient died due to refractory ventricular arrhythmia and two from persistent sepsis), and one unoperated patient died from sepsis and severe renal failure. No deaths or late surgeries were observed after a mean follow up period of 37 +/- 14 months. Both patients who survived hospitalization and underwent only medical treatment were free from late complications after 30 and 60 months follow up, respectively. CONCLUSION: Some patients with PLE present a good evolution without surgery, suggesting that surgical treatment is not mandatory in this situation. However, an indication for surgery may be similar to that for other cases of infective endocarditis.     

Campylobacter enteritis: clinical and epidemiologic features.

Campylobacter fetus subspecies (ssp.) jejuni has been recently recognized to cause diarrheal disease in man. To assess its importance as an enteric pathogen, we prospectively studied 514 patients with diarrhea. Campylobacter fetus ssp. jejuni was isolated from the feces of 26 patients (5%) and seven of 11 of their symptomatic household contacts. This organism was isolated from the feces of only one of 18 asymptomatic household contacts and not at all from 157 other healthy persons. Seventeen of 20 patients from whom C. fetus ssp. jejuni was isolated from fecal culture showed at least a fourfold rise in specific IgG titers. Review of 35 cases of campylobacter enteritis identified a typical clinical syndrome with acute onset of diarrhea, abdominal pain, fever, and constitutional symptoms. Stool examination revealed blood in 60% and polymorphonuclear leukocytes in 78% of patients. Epidemiologic investigation strongly suggested an external source for the infection in 22 of 35 patients.     

Native valve endocarditis due to coagulase-negative staphylococci. Clinical and microbiologic features

Twenty-one patients with native valve endocarditis caused by coagulase-negative staphylococci were studied; 14 had pre-existing valvular or congenital heart disease. Although commonly subacute in presentation, complications of endocarditis were frequent: arterial emboli in five patients, new electrocardiographic conduction system abnormalities in nine, congestive heart failure in eight, annular or myocardial abscesses in five, and disruption of valve leaflets in three. Cures were achieved in 10 of 12 patients treated medically and seven of nine treated surgically. In microbiologic studies of 16 coagulase-negative staphylococci from patients with endocarditis, only eight were identified as Staphylococcus epidermidis. All isolates were susceptible to vancomycin. Antibiotic resistance (methicillin, four isolates; gentamicin, two isolates; rifampin, one isolate) was usually associated with nosocomial acquisition of endocarditis. Rather than representing contamination, coagulase-negative staphylococci in blood cultures may indicate life-threatening endocarditis. However, with careful attention to the selection of antibiotics for therapy and to the occurrence of heart failure due to intracardiac complications, treatment of this form of endocarditis is frequently successful. Organisms must always be tested for cryptic resistance to beta-lactam antibiotics. Valve replacement may be required frequently.     

Adenovirus bronchiolitis in Manitoba: epidemiologic, clinical, and radiologic features

We reviewed our experience with 41 children hospitalized from 1974 to 1978 for adenovirus (ADV) bronchiolitis. Thirty-two patients (78 percent) were native Indians between four and 12 months old. In 18 of the 41 patients (43.9 percent) acute complications developed. The five fatal cases (12.2 percent) were confined to native children. The initial chest roentgenograms showed lobar consolidation in 35 patients (85.4 percent). Atelectasis developed in five (12.2 percent) during hospitalization. Sixteen of 25 patients (64 percent) with adequate radiologic follow-up examination had subsequent pneumonias or showed residual chronic changes. The reasons for the predilection of ADV bronchiolitis in native Indian children and the precise effect on subsequent airway function in survivors are unknown and require further study. We emphasize the importance of ADV as a cause of bronchiolitis in native Indian children. Furthermore, this report focuses attention on the contribution of this disease to the spectrum of chronic pulmonary disorders in the pediatric group.     

The United States National Prospective Hemolytic Uremic Syndrome Study: microbiologic, serologic, clinical, and epidemiologic findings

The frequency of Shiga toxin-producing Escherichia coli (STEC) serotypes associated with postdiarrheal hemolytic uremic syndrome (HUS) cases among children and adults in the United States and the proportion with IgM or IgG lipopolysaccharide antibodies to E. coli O157 were determined by use of a nationwide sample from January 1987 through December 1991. Among 83 patients, STEC were isolated from 30 (43%) of 70 whose stool cultures yielded bacterial growth (25 E. coli O157 isolates and 5 non-O157 STEC isolates). Fifty-three (80%) of 66 patients with serum samples had positive O157 lipopolysaccharide antibody titers. Of the 83 patients, 60 (72%) had evidence of STEC infection, including 6 of 8 adults whose illnesses also met criteria for thrombotic thrombocytopenic purpura. Data from a subset of patients suggest that E. coli O157 was the cause of > or = 80% of the STEC infections. All 3 women who were postpartum had evidence of E. coli O157 infection. STEC infection should be considered the likely cause for all persons with postdiarrheal HUS.     

A hospital food-borne outbreak of diarrhea caused by Bacillus cereus: clinical, epidemiologic, and microbiologic studies.

An outbreak of diarrhea involving 28 patients occurred in two wards of a chronic disease hospital. The illness was characterized by abdominal cramps and watery diarrhea without vomiting or fever. An epidemiologic investigation suggested food-borne intoxication and incriminated turkey loaf served at the preceding evening meal as the source of the outbreak. Bacillus cereus was isolated both from the stool of all 14 symptomatic patients who were cultured and from turkey loaf. No other enteropathogens were found. The isolate of B. cereus was shown to elaborate an enterotoxin that caused fluid secretion in assays in the rabbit ileal loop and suckling mice and that also caused a positive response in the Y-1 adrenal cell assay. B. cereus is an enteropathogen that should be sought in outbreaks of food-related gastroenteritis. This organism affects the gastrointestinal tract probably by the elaboration of enterotoxins.