Non-toxigenic Corynebacterium diphtheriae infective endocarditis with embolic events: a case report
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CASE REPORT
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Non-toxigenic Corynebacterium diphtheriae infective endocarditis with embolic events: a case report Antonio de Santis1,2* , Rinaldo Focaccia Siciliano3, Roney Orismar Sampaio1, Masahiko Akamine4, Elinthon T. Veronese5, Francisco Monteiro de Almeida Magalhaes1, Maria Rita Elmor Araújo6, Flavia Rossi6, Marcelo M. C. Magri7, Ana Catharina Nastri7, Tarso A. D. Accorsi1, Vitor E. E. Rosa1, David Provenzale Titinger1, Guilherme S. Spina1 and Flavio Tarasoutchi1
Abstract Background: Corynebacterium diphtheriae (C. diphtheriae) infections, usually related to upper airways involvement, could be highly invasive. Especially in developing countries, non-toxigenic C. diphtheriae strains are now emerging as cause of invasive disease like endocarditis. The present case stands out for reinforcing the high virulence of this pathogen, demonstrated by the multiple systemic embolism and severe valve deterioration. It also emphasizes the importance of a coordinated interdisciplinary work to address all these challenges related to infectious endocarditis. Case presentation: A 21-year-old male cocaine drug abuser presented to the emergency department with a 1week history of fever, asthenia and dyspnea. His physical examination revealed a mitral systolic murmur, signs of acute arterial occlusion of the left lower limb, severe arterial hypotension and acute respiratory failure, with need of vasoactive drugs, orotracheal intubation/mechanical ventilation, empiric antimicrobial therapy and emergent endovascular treatment. The clinical suspicion of acute infective endocarditis was confirmed by transesophageal echocardiography, demonstrating a large vegetation on the mitral valve associated with severe valvular regurgitation. Abdominal ultrasound was normal with no hepatic, renal, or spleen abscess. Serial blood cultures and thrombus culture, obtained in the vascular procedure, identified non-toxigenic C. diphtheriae, with antibiotic therapy adjustment to monotherapy with ampicillin. Since the patient had a severe septic shock with sustained fever, despite antimicrobial therapy, urgent cardiac surgical intervention was planned. Anatomical findings were compatible with an aggressive endocarditis, requiring mitral valve replacement for a biological prosthesis. During the postoperative period, despite an initial clinical recovery and successfully weaning from mechanical ventilation, the patient presented with a recrudescent daily fever. Computed tomography of the abdomen revealed a hypoattenuating and extensive splenic lesion suggestive of abscess. After sonographically guided bridging percutaneous catheter drainage, surgical splenectomy was performed. Despite left limb revascularization, a forefoot amputation was required due to gangrene. The patient had a good clinical recovery, fulfilling 4-weeks of (Continued on next page)
* Correspondence: [email protected] 1 Heart Valve Unit, Heart Institute (InCor), University of São Paulo Medical School, Av. Dr. Eneas de Carvalho Aguiar, 44, São Paulo, SP 05403-000, Br
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