ISSN : 1301-5680
e-ISSN : 2149-8156
TURKISH JOURNAL OF
THORACIC AND
CARDIOVASCULAR SURGERY
Turkish Journal of Thoracic and Cardiovascular Surgery     
Mitral and aortic valve endocarditis due to a rare microorganism: Abiotrophia defectiva and literature review
Özlem Aydemir1, Hüseyin Hatipoğlu2, Kerem Yılmaz2, Mehmet Koroğlu2, İbrahim Kara3, Tayfur Demiray1
1Clinical Microbiology Laboratory, Sakarya University Training and Research Hospital, Sakarya, Turkey
2Department of Medical Microbiology, Sakarya University Faculty of Medicine, Sakarya, Turkey
3Department of Cardiovascular Surgery, Sakarya University Training and Research Hospital, Sakarya, Turkey
DOI : 10.5606/tgkdc.dergisi.2017.14721

Abstract

Abiotrophia defectiva belongs to the nutritionally variant streptococci group and can colonize in oropharyngeal, gastrointestinal and genitourinary systems. Abiotrophia defectiva rarely causes infective endocarditis while infections caused by Abiotrophia defectiva have high morbidity and mortality rates. In this case report, we present a case of infective mitral and aortic valve endocarditis caused by Abiotrophia defectiva.

Introduction

Abiotrophia defectiva (A. defectiva) was first identified by Freckle and Hirsch back in 1961, and then included in nutritionally defective streptococci group.[1] A. defectiva is difficult to isolate on standard media, it grows more easily in Columbia agar containing L-cysteine and pyridoxal hydrochloride when inoculated with Staphylococcus aureus strain.[2] A. defectiva can colonize in oropharyngeal, gastrointestinal and genitourinary systems.[2] It can cause local and systemic infections like wound infections, bacteremia, septic arthritis, pancreatitis and meningitis.[3] A. defectiva rarely causes infective endocarditis (IE). However, infections caused by A. defectiva have high morbidity and mortality rates.[4] Nutritionally defective streptococci cause 4-8% of all IE cases.[5,6]

The mortality and relapse rates in IE cases caused by A. defectiva are higher when compared to other streptococci due to complications such as valve insufficiency.[2,6,7] In this article, we present a case of infective mitral and aortic valve endocarditis caused by A. defectiva, which was isolated in a 26-year-old male patient.

Case Presentation

A 26-year-old male patient attended to emergency service with deterioration and dyspnea. Patient’s history revealed that he had fatigue, fever and weight loss for two months. He did not have any chronic disease. He did not receive any medical treatment. He stated that his tooth was broken but he did not receive any dental intervention. Vital signs at admission were as follows: body temperature 37.8 °C, heart rate 98 beats per minute, arterial blood pressure 80/130 mm/Hg and respiratory rate 24/minute. Systolic and diastolic murmurs, decrease in pulmonary sounds and basal rales in right lung were present at auscultation. White blood cells: 23,100K/μL, neutrophil-to-lymphocyte ratio: 17.35, erythrocyte sedimentation rate: 21 mm/30 minutes, 69 mm/60 minutes, creatinine: 1.33 mg/dL, urea: 30 mg/dL, C-reactive protein: 116 mg/L (<5 mg/L), and procalcitonin: 1.67 ng/mL (<0.5 ng/mL) were the prominent laboratory findings; other laboratory parameters were within normal ranges. There was sign of pleural effusion at posteroanterior pulmonary X-ray, which led the clinician to the diagnosis of pulmonary edema. Then, the patient was hospitalized in cardiology clinic. Transesophageal echocardiography revealed severe mitral insufficiency and mitral valve vegetations were detected on mitral valve. According to the Duke’s criteria, the patient was diagnosed as IE with two major (vegetation at transesophageal echocardiography and new murmur) and zero minor criteria.[8] Vancomycin 2¥1 gand ceftriaxone 2¥1 g via intravenous route were administered as an empirical treatment. Two sets of blood culture samples with two hour-intervals were drawn from the patient and the culture bottles were incubated in BacT/ALERT 3D (Biomerieux, France) automated blood culture instrument. Intraoperative native culture was not cultured. At the fourth day of incubation, positive signal was received and pleomorphic chain forming gram-positive cocci were detected on Gram stain. Samples from blood culture bottles were inoculated on blood agar base and eosin methylene blue agar plates and incubated for 18-24 hours at 35±2 °C. After the incubation period, alpha hemolytic tiny colonies were seen on the blood agar plate. Catalase test was negative. The isolate was identified as A. defectiva by the VITEK 2® ( Biomerieux, F rance) a utomated identification system. Disc diffusion method and gradient test strips were used for antimicrobial susceptibility testing. Penicillin, gentamycin, linezolid, clindamycin and quinolone and macrolide group antibiotics were tested for susceptibility. The results were evaluated according to Clinical and Laboratory Standards Institute 2015 criteria. The isolate was found to be susceptible to all antibiotics tested. A written informed consent was obtained from the patient.

Vancomycin and ceftriaxone, which were started empirically, were continued to the patient. On the second day of treatment, the patient was admitted to the cardiovascular surgery clinic with severe mitral regurgitation, pulmonary edema and endocarditis. He was urgently taken under surgery for mitral valve replacement (Carbomedics 33 mm, Carbomedics Inc., Austin, Texas, USA) on the same day. Aortic valve replacement (Mosaic® bioprosthesis number 23, Medtronic, Inc. MN, USA) was also performed due to vegetation on the aortic valve detected during surgery. The patient recovered and was discharged at the third week after surgery. The treatment was completed in four weeks.

Discussion

Abiotrophia defectiva is a member of the normal human microbiota, which may colonize at the oral cavity, genitourinary and intestinal tracts. Rate of oral colonization is approximately 11.8% in healthy people and it is suggested that infections usually originate from that part of the body.[9]

Abiotrophia defectiva rarely causes IE leading to high mortality and morbidity rates.[9] Recently, A. defectiva has been identified as a causative agent in IE following dental interventions.[10] There was a history of tooth break in our case but no dental intervention was accomplished. The difficulties in culturing the bacterium and lack of typical colony morphology may cause problems in identification. So, in culturenegative IE cases, this bacterium should be kept in mind and not be overlooked in treatment planning.[3] It has been reported that the incidence of complications in IE cases caused by A. defectiva is higher than in other viridans streptococci. Deaths usually develop due to congestive heart failure or systemic embolism.[3] The aortic and mitral valves are generally affected in IE cases due to A. defectiva. The vast majority of patients have underlying cardiac disease, valvular replacement, or recent history of dental treatment.[9-12] However, these risk factors were not present in our case. The American Heart Association suggests that enterococcal endocarditis treatment protocol may be applied in the treatment of IE cases that are caused by A. defectiva. Gentamicin may be added to ampicillin or penicillin G treatment protocol, for usually four-six weeks. Alternatively, a combination of vancomycin and gentamicin is recommended.[13] However, despite the treatment with in vitro effective antibiotics in IE due to A. defectiva, in the majority of cases, affected valves have serious disruption and surgical treatment is indicated in the future due to relapses. This causes doubts about the reliability of antibiotic susceptibility testing results.[4,9,10,12,14] Studies suggest that early surgical intervention provides more favorable outcomes in patients with severe valve disease and widespread vegetations.[15] In the literature review, we determined three case reports from Turkey, listed with other cases from other countries in Table 1.[2,10,15-19] In the case of Yemişen et al.,[2] there was a history of mitral valve replacement, while in other cases, there was no history of underlying heart disease, as was in our case.[10,15] The aortic and mitral valves are affected with similar frequencies.[2,10,15-19]

Table 1: Infective endocarditis cases due to Abiotrophia defectiva in the literature

In conclusion, the prognosis of endocarditis due to A. defectiva is worse than that of other viridans streptococci. However, rapid identification of the causative agent and early implantation of antimicrobial treatment together with surgical intervention in early phase of the disease are important factors in the prognosis.

Declaration of conflicting interests
The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding
The authors received no financial support for the research and/or authorship of this article.

References

1) Frenkel A, Hirsch W. Spontaneous development of L forms of streptococci requiring secretions of other bacteria or sulphydryl compounds for normal growth. Nature 1961;191:728-30.

2) Yemisen M, Koksal F, Mete B, Yarimcam F, Okcun B, Kucukoglu S, et al. Abiotrophia defectiva: a rare cause of infective endocarditis. Scand J Infect Dis 2006;38:939-41.

3) Park S, Ann HW, Ahn JY, Ku NS, Han SH, Hong GR, et al. A Case of Infective Endocarditis caused by Abiotrophia defectiva in Korea. Infect Chemother 2016;48:229-233.

4) Ramos JN, dos Santos LS, Vidal LM, Pereira PM, Salgado AA, Fortes CQ, et al. A case report and literature overview: Abiotrophia defectiva aortic valve endocarditis in developing countries. Infection 2014;42:579-84.

5) Hase R, Otsuka Y, Yoshida K, Hosokawa N. Profile of infective endocarditis at a tertiary-care hospital in Japan over a 14-year period: characteristics, outcome and predictors for in-hospital mortality. Int J Infect Dis 2015;33:62-6.

6) Alberti MO, Hindler JA, Humphries RM. Antimicrobial Susceptibilities of Abiotrophia defectiva, Granulicatella adiacens, and Granulicatella elegans. Antimicrob Agents Chemother 2015;60:1411-20.

7) Yang YS, Shang ST, Lin JC, Chiu CH, Chang FY. A ruptured cerebral mycotic aneurysm caused by Abiotrophia defectiva endocarditis. Am J Med Sci 2010;339:190-1.

8) Li JS, Sexton DJ, Mick N, Nettles R, Fowler VG Jr, Ryan T, et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis 2000;30:633-8.

9) Carleo MA, Del Giudice A, Viglietti R, Rosario P, Esposito V. Aortic Valve Endocarditis Caused by Abiotrophia defectiva: Case Report and Literature Overview. In Vivo 2015;29:515-8.

10) Akkoyunlu Y, Iraz M, Kocaman G, Ceylan B, Aydin C, Aslan T. Abiotrophia defectiva endocarditis presenting with hemiplegia. Jundishapur J Microbiol 2013;6:8907.

11) Kiernan TJ, O'Flaherty N, Gilmore R, Ho E, Hickey M, Tolan M, et al. Abiotrophia defectiva endocarditis and associated hemophagocytic syndrome--a first case report and review of the literature. Int J Infect Dis 2008;12:478-82.

12) Giannakopoulos K, Zompolou C, Behnes M, Elmas E, Borggrefe M, Akin I. Infective endocarditis - A word of caution on non-typical bacteria. Eur Rev Med Pharmacol Sci 2016;20:4782-4785.

13) Baddour LM, Wilson WR, Bayer AS, Fowler VG Jr, Bolger AF, Levison ME, et al. Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America. Circulation 2005;111:394-434.

14) Pinkney JA, Nagassar RP, Roye-Green KJ, Ferguson T. Abiotrophia defectiva endocarditis. BMJ Case Rep 2014;2014.

15) Bozkurt I, Coksevim M, Cerik IB, Gulel O, Tanyel E, Leblebicioglu H. Infective endocarditis with atypical clinical feature and relapse by Abiotrophia defectiva. J Saudi Heart Assoc 2017;29:136-8.

16) Kang DH, Kim YJ, Kim SH, Sun BJ, Kim DH, Yun SC, et al. Early surgery versus conventional treatment for infective endocarditis. N Engl J Med 2012;366:2466-73.

17) Kalogeropoulos AS, Siva A, Anderson L. Abiotrophia defectivus infectious endocarditis: think beyond the heart. Lancet 2015;385:1044.

18) Botta L, Merati R, Vignati G, Orcese CA, De Chiara B, Cannata A, et al. Mitral valve endocarditis due to Abiotrophia defectiva in a 14th week pregnant woman. Interact Cardiovasc Thorac Surg 2016;22:112-4.

19) Bajaj A, Rathor P, Sethi A, Sehgal V, Ramos JA. Aortic valve endocarditis by a rare organism: Abiotrophia defectiva. J Clin Exp Cardiolog 2013;4:11.

Keywords : Abiotrophia defectiva; infective endocarditis; variant streptococci

Viewed : 1238
Downloaded : 403