Open Access

Prosthetic valve endocarditis due to Streptococcus pneumoniae

  • Ayman Natsheh1,
  • Michal Vidberg2,
  • Reuven Friedmann3,
  • Eli Ben-Chetrit4, 5,
  • Amos M Yinnon4, 5Email author and
  • Shoshana Zevin1
SpringerPlus20143:375

https://doi.org/10.1186/2193-1801-3-375

Received: 20 May 2014

Accepted: 15 July 2014

Published: 22 July 2014

Abstract

Introduction

In the pre-antibiotic era up 10% of cases of infective endocarditis were due to Streptococcus pneumoniae, but this association is currently exceedingly rare.

Case description

Since 1997 we have diagnosed three patients, all aged >70, with endocarditis due to S. pneumoniae. One of these three cases involved a prosthetic valve, another a prosthetic ring. All three patients completely recovered with antibiotic treatment only.

Discussion and evaluation

During the same period there were 1694 cases of pneumococcal bacteremia, of whom 395 (23%) after age 70. Therefore, after age 70 the prevalence of endocarditis out of all cases of pneumococcal bacteremia was 0.7%. A literature review detected another 16 cases of pneumococcal PVE. The mean age of these 17 patients was 64±14; 10 were female and 7 male. In most instances, symptom duration was short, < 6 days. Valve surgery was performed in 5 cases (29%) and 13 patients (76%) survived.

Conclusions

Endocarditis due to S. pneumoniae is rare in the antibiotic era; even in patients with prosthetic valves its course is evidently not more virulent than with other low-virulent organisms.

Keywords

Infective endocarditisProsthetic valve endocarditis Streptococcus pneumoniae Mitral valve replacement

Introduction

In the pre-antibiotic era up to 15% of all cases of infective endocarditis (IE) were due to S. pneumoniae, but currently <1%, almost all involving native valves. Recent data have demonstrated a relative increase in the incidence of prosthetic valves as a predisposing factor for IE, from ±13% in the 1970s and 1980s to presently 22-31% (Fefer et al. 2002). We describe three patients with pneumococcal endocarditis diagnosed since 1997, one of whom had prosthetic valve endocarditis (PVE) which is the focus of the current paper and review 16 similar patients, previously published (Killen et al. 1970, Bruyn et al. 1990, Ugolini et al. 1986, Aguado et al. 1993, Hanson et al. 1993, Cunningham and Sinha 1995, Lefort et al. 2000, Collazos et al. 1996, Claes et al. 2000, O'Brien et al. 2011).

Patient #1

In March 2013, an 80-year old female patient presented because of an unexpected fall. She underwent mitral valve replacement 13 years earlier with a St Jude mechanical valve. She denied fever or any other complaint. Oral temperature was 37.6°C, mechanical heart sounds were heard, as well as a 2/6 apical systolic murmur. The physical examination was otherwise unremarkable.

Laboratory tests revealed a leucocyte count of 10.800/μL, hemoglobin 10.5 gm/dL, and normal liver and kidney function tests. Because of unexplained fever, three blood cultures were obtained, which grew Streptococcus pneumoniae, with a minimal inhibitory concentration (MIC) of <0.1 μg/mL. A trans-esophageal echocardiogram (TEE) revealed a 1.1 cm sized vegetation attached to the prosthetic mitral valve. In spite of the large vegetation and its presence on a mechanical valve it was decided not to operate, because of the patient's fragility. The patient was treated with intravenous ceftriaxone for six weeks, and she attained complete clinical and microbiological cure.

Patient #2

In February 2006, an 81 year old fully alert woman was admitted because of swelling, erythema, local heat and pain in her left knee, which started several days after she fell. One year earlier she had undergone mitral valve repair because of severe mitral incompetence: after quadrangular resection annuloplasty was performed with a 30 mm ring. Physical examination revealed a temperature of 38°C, a 1/6 pan-systolic murmur at the apex, while the left knee was swollen, red and hot. The physical examination was otherwise unremarkable. The peripheral blood count was 9.400/μL, hemoglobin was 9.9 gm/dL and biochemistry was normal. Streptococcus pneumoniae was isolated from two blood cultures and from joint fluid; MIC was 0.02 μg/mL. The TEE demonstrated two vegetations < 1 cm in size attached to the posterior repaired mitral valve and ring. The patient received a six weeks course of ceftriaxone and completely recovered.

Patient #3

A 74 year male patient was admitted in 1996 because of an acute febrile illness. There were no localizing symptoms and physical examination was negative except a 2/6 systolic murmur. Streptococcus pneumoniae (MIC = 0.01 μg/mL), was isolated from two blood cultures. A TEE indicated moderate mitral regurgitation, exactly as found in a routine echocardiogram obtained two years earlier. The patient received two weeks of intravenous penicillin and completely recovered. During the subsequent six months he developed exertional dyspnea without fever. Echocardiography showed significantly worsened mitral regurgitation, but no vegetations were detected. He underwent an uneventful valve replacement with a biological prosthesis. Routine histologic examination revealed an ulcerated mitral valve, with fibrinous vegetation and inflammatory infiltrate. The patient was treated with ceftriaxone for four weeks and attained complete cure. In retrospect, it seems this patient suffered from pneumococcal endocarditis, partially treated with two weeks of intravenous penicillin and subsequently developed latent endocarditis and worsening mitral insufficiency (Shapiro et al. 2004).

Discussion

Pneumococcal endocarditis in the antibiotic era is rare and generally manifests acutely, similar to staphylococcal endocarditis, although rare instances of a more insidious course have been described. In several series of pneumococcal bacteremia in the antibiotic era the prevalence rate of endocarditis was reported, which ranges from 0.3%- 3.4% (Bruyn et al. 1990, Cunningham and Sinha 1995).

In our hospital 1694 patients have been diagnosed with pneumococcal bacteremia since 1997 (Table 1). During this period only three patients, all aged >70, were diagnosed with endocarditis, constituting 0.18% of all cases of pneumococcal bacteremia. Of these 1694 cases, 395 (23%) occurred after age 70. Therefore, after the latter age the prevalence of endocarditis out of all cases of pneumococcal bacteremia was 0.7%.
Table 1

Patient specific episodes of S. pneumoniae bacteremia, by age (1997–2013)

Year

Age groups (years)

S. pneumoniae/All positive

 

1-20

21-70

71-110

UA

Total (n, %)

All positive2

     

S. pneumoniae 1

 

1997

36

13

13*

 

62 (1.4)

439

1998

42

39

22

 

62 (0.7)

848

1999

43

33

18

 

94 (1.3)

708

2000

40

27

20

 

87 (1.7)

523

2001

41

15

22

 

78 (0.9)

891

2002

52

21

11

2

84 (1)

876

2003

73

12

13

 

98 (1.1)

888

2004

46

14

21

 

81 (1)

789

2005

48

34

37

 

119 (1.3)

891

2006

62

46

24*

 

132 (1.4)

951

2007

66

33

19

1

118 (1.1)

1029

2008

63

39

47

2

149 (1.5)

997

2009

89

28

31

 

148 (1.4)

1087

2010

54

25

24

 

103 (0.9)

1176

2011

60

20

30

 

110 (0.9)

1191

2012

45

19

31

 

95 (0.8)

1205

2013

11

10

12*

 

33 (0.3)

839

Total

871

428

395

5

1694 (1.0)

16515

UA, unavailable; each asterix* indicates one patient diagnosed that particular year with S. pneumoniae endocarditis.

The difference in incidence of S. pneumoniae endocarditis between age 1–20 (0/871), adults aged 21–70 (0/428) and elderly (3/395 or 0.8%) was statistically insignificant.

All patient-specific blood isolates of S. pneumoniae1 (n, and as % of all patient-specific true-positive blood isolates2 (i.e. excluding contaminants).

One of our three pneumococcal endocarditis cases involved a prosthetic valve, another a repaired mitral valve and ring, possibly suggesting a higher propensity of S. pneumoniae to infect prosthetic rather than natural valves. This trend has not previously been reported: the Bruyn et al. reported five patients with pneumococcal endocarditis of whom one had PVE Bruyn et al. (1990)), and Lefort et al. (2000) reported 30 cases with pneumococcal endocarditis, collected in a nation-wide survey of whom 4 (13%) had PVE.

A literature review detected another 16 cases of PVE with this organism (Table 2). The mean age of these 17 patients was 64 ± 14; 10 were female and 7 male. In most instances, symptom duration was short, < 6 days. Valve surgery was performed in 5 cases (29%) and 13 patients (78%) survived.
Table 2

Reported patients with prosthetic valve endocarditis associated with Streptococcus pneumoniae

No, [ref]

Year

Sex, age

Valve

PMH

Days of symptoms

Source of infection

Diagnostic method

Valve surgery

Outcome

1 [Killen et al. 1970]

1970

M, 24

Aortic

NA

5

NA

NA

Yes

Died

2 [Killen 1970]

1970

F, 51

Tricuspid

NA

3

NA

NA

No

Died

3 [Buyn 1990]

1982

F, 71

Mitral

CHF

NA

Lung

No vegetations

No

Cure

4 [Ugolini et al. 1986]

1986

M, 50

Aortic

DM

5

Sinusitis

Clinical suspicion

No

Cure

5 [Bruyn et al. 1990]

1990

F, 71

Mitral

None

1

Lung

Clinical suspicion

No

Cure

6 [Aguado et al. 1993]

1993

M, 53

Aortic

NA

NA

Na

NA

Yes

Cure

7 [Aguado et al. 1993, 1993]

1993

F, 74

Mitral

None

1

Dental procedure

TEE

No

Cure

8 [Cunningham and Sinha 1995]

1994

M, 63

Aortic + mitral

Previous IE

14

-

Clinical suspicion

No

Cure

9 [Lefort 2000]

1994

F, 80

Aortic + mitral

Alcoholism DM

30

Unknown

TEE

Yes

Cure

10 [Lefort et al. 2000]

1994

F, 79

Aortic + mitral

None

NA

Lung

No vegetation

No

Cure

11 [Lefort et al. 2000]

1995

M, 73

Aortic

None

21

Lung

TEE

Yes

Died

12 [Cunningham and Sinha 1995]

1995

M, 63

Mitral

None

7

Unknown

Clinical suspicion

No

Cure

13 [Lefort et al. 2000]

1996

M, 58

Mitral

Alcoholism

46

Lung

TEE

No

Died

14 [Collazos et al. 1996]

1996

F, 61

Mitral

None

6

Unknown

TEE

No

Cure

15 [Claes et al. 2000]

1999

F, 61

Aortic + mitral

Atrial fib

NA

Lung

TEE

Yes

Cure

16 [O'Brien et al. 2011]

2011

F, 63

Aortic

Previous IE

-

-

Roth spots + BCs

No

Cure

17 Present patient #1

2013

F, 80

Mitral

None

NA

Unknown

TEE

No

Cure

Atrial Fib, atrial fibrillation; BC, blood cultures; CHF, congestive heart failure; DM, diabetes mellitus; NA: data not available; PMH, past medical history; Present 1/2, Present case 1/2; TEE, transesophageal echocardiogram; Valve, infected mechanical or biological prosthetic valve. Patient no. 2 had endocarditis from both Staphylococcus aureus and Streptococcus pneumoniae.

In conclusion, in the antibiotic era endocarditis due to Streptococcus pneumoniae is rare. Importantly, even in patients with pneumococcal PVE its course may be insidious and not more aggressive than with other low-virulent organisms.

Declarations

Authors’ Affiliations

(1)
Department of Medicine B, Shaare Zedek Medical Center
(2)
Department of Medicine A, Shaare Zedek Medical Center
(3)
Department of Geriatrics, Shaare Zedek Medical Center
(4)
Infectious Disease Unit, Shaare Zedek Medical Center
(5)
Division of Internal Medicine, Shaare Zedek Medical Center, affiliated with The Hebrew University-Hadassah Medical School

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Copyright

© Natsheh et al.; licensee Springer. 2014

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited.