Case Report of Infectious endocarditis complicated by lumbar purulent spondylitis diagnosed by acute radial artery occlusion

doi:10.21203/rs.3.rs-2454866/v1

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Case Report of Infectious endocarditis complicated by lumbar purulent spondylitis diagnosed by acute radial artery occlusion

https://doi.org/10.21203/rs.3.rs-2454866/v1

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published 05 Apr, 2023

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Introduction; Infective endocarditis (IE) is a rare but serious disease with a wide range of phenotypes and clinical courses. The diagnosis of IE is often difficult and must be comprehensively judged.

Case Presentation; We report the case of a 78-year-old woman with back pain and fever of unknown origin, who was transferred to our hospital due to acute radial artery occlusion. We diagnosed purulent spondylitis and IE. The mobile vegetation remained in the anterior mitral valve leaflet after embolism, and the embolism to the central nervous system was relatively mild, so we decided to perform early surgery. Mitral valve replacement was performed because of embolic symptoms without further complications.

Conclusions; Early evaluation by echocardiography is required for the prompt diagnosis of IE and its associated high-risk features may benefit from surgical intervention. Early diagnosis of infective endocarditis and surgical intervention are associated with better outcome in patients with large vegetations, recurrent embolisms, and heart failure. While purulent spondylitis is not commonly associated with infective endocarditis, it is important to actively suspect the existence of IE in patients who complain of back pain along with fever. Both physicians and orthopedic surgeons need to recognize IE as a common disease, especially in the elderly society.

infectious endocarditis

arterial embolism

Streptococcus species

mitral valve

purulent spondylitis

Infective endocarditis (IE) is a rare but serious disease characterized by bacteremia and vegetation adhering to the endocardium. Some of the most common complications of IE are heart failure caused by valve regurgitation due to valve destruction, and thromboembolic events caused by the fragmentation of vegetation. Since IE presents with a wide range of phenotypes and has diverse clinical courses, it is often difficult to diagnose. We encountered a patient with back pain and fever of unknown origin who was transferred to our hospital due to acute radial artery occlusion. We diagnosed purulent spondylitis and IE. Early surgery was performed because of the embolic symptoms and no further complications occurred.

A 78-year-old woman with a history of hypertension and dyslipidemia was having back pain for six months prior to admission, and her pain gradually worsened. She also had a tooth extraction due to the diagnosis of root cysts around the time of exacerbation of the back pain; however, antibiotics were not administered to her before or after tooth extraction. She consulted a doctor 11 days before she was transferred to our hospital and was admitted to the previous hospital with a diagnosis of lumbar purulent spondylitis. She was treated with antibiotics (cefazolin 1 g every 8 h). Ten days after the start of antibiotic treatment, she developed a pain from her right thumb to the third finger, which was accompanied by loss of sensation, and occlusion of the right radial artery was suspected. Therefore, the patient was transferred to our hospital for additional treatment.

Her blood pressure was 166/95 mmHg, pulse rate was 78 beats/min, oxygen saturation under atmospheric pressure was 100%, and body temperature was 37.0 °C. Several Osler nodes were present on the second and fourth fingers in both hands. The color of the right fingertips changed to purple (Fig. 1a), and there was swelling with redness, tenderness, and loss of sensation beyond the right thumb interphalangeal joint.

A blood examination revealed the following data: white blood cell (WBC) 11,000/μL; hemoglobin 8.6 g/dL; platelet (PLT) 380,000/μL; C-reactive protein 15.49 mg/dL; creatinine 0.56 mg/dL; albumin 2.2g/dL; and D-dimer 2.6 μg/mL. Blood cultures taken at both the sites revealed growth of Streptococcus species.

An electrocardiogram showed sinus rhythm (Fig. 1c), and chest radiography showed cardiomegaly (cardiothoracic ratio [CTR] 62%) and mild ground glass opacity in the lung field (Fig. 1d). The 3D constructed image of the upper right limb by contrast enhanced computed tomography (CT) showed occlusion of the right radial artery (Fig. 1e), which was consistent with the physical findings of acute radial artery occlusion. In addition, CT showed bone destruction from the third to the fifth lumbar vertebra with fat stranding and low-density area around the vertebral body, suggesting purulent spondylitis (Fig. 2a), and multiple low-density areas in the spleen, suggesting infarction (Fig. 2b). Brain magnetic resonance imaging (MRI) revealed a new cerebral infarction in the left parietal lobe (Fig. 2c). Fortunately, the neurological findings were silent. Transthoracic echocardiography revealed a left ventricular ejection fraction of 50%, with no asynergy and trivial mitral valve regurgitation (MR). Mobile areas of vegetation attached to the anterior mitral valve leaflet (AML) and thickening in the posterior mitral valve leaflet (PML) were also observed (Fig. 3).

Based on these findings, the patient was diagnosed with infectious endocarditis complicated by purulent spondylitis and acute radial artery occlusion. Although Streptococcus species were detected in blood culture tests and appropriate antibacterial treatment was administered, arterial embolisms occurred. Therefore, we decided to proceed with an operation, and performed a mitral valve replacement surgery (MITRIS RESILIA mitral valve) the day after hospitalization. In the transesophageal echocardiography findings during the surgery, mitral regurgitation got worse severely, and AML to which vegetation was attached was partially perforated. Mild pericardial and pleural effusion was observed duringthe operation, and it was thought that heart failure was present due to valve destruction by IE just before the start of surgery. Postoperative pathological examination revealed inflammatory granulation tissue formation along with destruction of valve structure. The postoperative course was good, and bacterial development was not observed in the culture from intraoperative specimen. Antibacterial drug treatment (penicillin at a dose of 4 million U every 4 h) was continued for six weeks after surgery, and the general condition remained good. The cold feeling in the right thumb and poor color tone of the right fingers improved with antibacterial drug treatment, and necrosis of the right thumb due to radial artery embolism was minimized (Fig. 1b). Posterior lumbar interbody fusion was performed on the 14^th day of hospitalization and the patient remained afebrile after stopping antibiotic therapy. Blood examination revealed an improvement in the inflammation and the patient was discharged from the hospital one month later.

IE sometimes presents with nonspecific symptoms and it takes several days from onset to reach the diagnosis. IE is often complicated by embolism and early treatment intervention is desirable. Systemic embolism occurs in 22–50% of patients with IE [1, 2], and 60–70% of the left heart system IE cases have central nervous system embolisms, followed by the spleen, kidneys, limb arteries, liver, intestine, and coronary arteries [3]. Embolism of the central nervous system is associated with poor prognosis [4]. These embolisms most often occur before antimicrobials are administered, and their risk decreases with appropriate antibiotic treatment [5]. Therefore, to prevent embolism, it is important to start antibacterial drugs as soon as possible. Patients with embolism have a high mortality rate, and systemic embolism is often noted two–four weeks after the start of antibiotic treatment. In this patient, radial artery embolism occurred during the period of frequent embolisms.

Various evidence has been reported regarding the indications for surgical treatment for IE [1, 6]. Although surgery is recommended for IE associated with congestive heart failure, the timing of surgery to prevent systemic embolism is currently under discussion [7]. According to the Scientific statement of 2015 American College of Cardiology/American Heart Association (ACC-AHA), early surgery for large mobile sites of vegetation is recommended as a class Iib therapy and should be limited to cases that have recurrent embolisms and prolonged vegetation [1]. In general, early surgical treatment is considered for cases with advanced heart failure, disruption of cardiac construction, refractory infections, and possible embolisms. As the timing of surgery and postoperative results are affected by the type of pathogen and complications, each case should be considered within heart teams. The size of embolism (greater than 10 mm increase after antibiotic administration), mobility of the vegetation, part where adhesion occurs (mitral valve, especially AML), and pathogen (Staphylococcus, Fungus) have all been reported as risk factors for embolisms, and hence it is important to evaluate the vegetation using echocardiography [1, 2]. Importantly, a study reported that early surgery in patients with IE and large areas of vegetation significantly reduces death from all causes as well as the embolic events by effectively decreasing the risk of systemic embolism compared with conventional treatment [8]. In this case, the mobile vegetation remained on the AML after embolism, and embolism to the central nervous system was relatively mild. Therefore, we decided to perform an early surgery [9]. The intraoperative findings showed heart failure from severe MR due to perforation of the AML, supporting our decision to perform an early surgery.

While the details of Streptococcus species were not identified in this case since they are said to have a low frequency of embolism, there are reports that vegetations of the Group B streptococcal IE are fragile and can easily cause embolisms [10].

Purulent spondylitis causes epidural and iliopsoas muscle abscesses. The rate of complications of spondylitis in IE is approximately 5%, and the rate of IE in purulent spondylitis is approximately 30%. Thus, the combination of IE and purulent spondylitis is not very rare. In patients who complain of back pain, in addition to fever, it is necessary to consider that IE can be a complication along with purulent spondylitis. It has been reported that patients with vertebral osteomyelitis, in whom infectious endocarditis has not been excluded, are at an increased risk for adverse neurologic events and mortality. Early evaluation by echocardiography is required for the prompt diagnosis of infectious endocarditis, and its associated high-risk features that may benefit from surgical intervention [11]. In this case, the patient was treated with antibiotics by a previous doctor for the back pain and fever that occurred after a dental procedure. While the diagnosis of IE was reached due to the acute radial artery embolism by echocardiography, it was also assumed to be present during the course of purulent spondylitis. In the elderly society, both physicians and orthopedic surgeons need to recognize IE as a common disease, and it is important to actively suspect the existence of IE.

Funding: None

Conflicts of interest/Competing interests: All authors declare that they have no conflict of interest.

Ethics Approval and Consent to Participate: Written informed consent was obtained from the patient.

Written Consent for publication: Written informed consent was obtained from the patient for publication of this case report and any accompanying images.

Contributions: Substantial contributions to conception and design, acquisition of data, analysis, and interpretation data: all authors. Drafting and revising the article: K.H. and R. A.. Final approval of the version to be published: all authors.

Data Availability: The data used to support the findings of this study are available from the corresponding author upon request. We will disclose all information except personally identifiable information.

Code Availability: Not applicable.

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Journal Publication

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Reviewers agreed at journal
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You are reading this latest preprint version

Case Report of Infectious endocarditis complicated by lumbar purulent spondylitis diagnosed by acute radial artery occlusion

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