Native valve Escherichia coli endocarditis following urosepsis
A 54-year-old Indian male with diabetes mellitus and hypertension presented with right loin pain, fever, and tiredness since 1 week. He had undergone meatotomy and circumcision 3 years ago. A year later, there was recurrence of poor urinary stream.\nOn examination, he was febrile, blood pressure was 140/70 mmHg, chest was clear and there were no murmurs over heart on auscultation. Abdomen was soft on palpation and there was significant tenderness over the right loin. Urethral meatus was pin hole and there were changes of lichen sclerosis in the skin over glans.\nInvestigations showed 1+ proteinuria, 18-20 white blood cells, and 10-15 red blood cells on urine analysis; hemoglobin, 13 g/dL; total leukocyte count, 17.1 × 103/mm3; differential count polymorphs, 89%; lymphocytes, 9%; eosinophils, 1% and monocytes, 1%; platelet count, 108 × 103/mm3; serum creatinine, 3.5 mg/dL; metabolic acidosis; and serum albumin, 2.2 g/dL. Electrocardiography revealed sinus tachycardia, leftward QRS axis, and poor R wave progression over chest leads. There was right turbid hydro-ureteronephrosis on ultrasonogram abdomen. Transthoracic echocardiogram (TTE) revealed regional wall motion abnormalities, normal valves, and mild left ventricle (LV) systolic dysfunction (ejection fraction 45%).\nHe was started on cefoperazone-sulbactam and amikacin (with dose adjusted for renal function pending cultures). Insulin infusion was required for control of severe hyperglycemia. Planning ureteric stenting, he underwent cystoscopy on day 0; there was penile urethral stricture and visual internal urethrotomy was performed followed by right ureteric stenting. There was purulent hydronephrotic drip following the stent insertion.\nBlood and urine grew E. coli. Levofloxacin was substituted for amikacin based on anti-biogram 5 days after admission to minimize the risk of nephrotoxicity. He was continued on two antibiotics as he was still sick and febrile with persisting leukocytosis (22.0 × 103/mm3; 22.0 × 109/L). Evaluation for focal renal and prostatic abscesses with abdominal and transrectal ultrasound was negative. There was some improvement in renal function following these measures and serum creatinine was 2.4 mg/dL on day 6.\nHe developed a new grade 3 systolic murmur over the apex of the heart along with clinical and radiological signs of congestive cardiac failure on day 6; repeat TTE revealed flail mitral valve, severe mitral regurgitation, a small echogenic mass on the tip of anterior mitral leaflet suggestive of vegetations on the mitral valve, and dilated left atrium and left ventricle []. Amikacin was restarted with dose modified for renal function and levofloxacin was stopped. Cardiac failure was managed with intravenous frusemide. He had an episode of transient weakness of right upper limb that lasted for less than 12 h on day 7, suggesting a possible embolic transient ischemic attack (TIA) in middle cerebral artery territory. With worsening cardiac failure and respiratory distress, he was intubated and started on dobutamine infusion and ventilator support the same day. There was progressive decline in renal function from day 6. Serum creatinine was 3.2 mg/dL (282.8 μmol/L) on day 9. Repeat cultures were sterile.\nIn view of persistent fever, IE and congestive cardiac failure, valve replacement was carried out on day 9. Mitral valve had vegetations over the anterior leaflet; chordae were necrotic and there were abscesses over the papillary muscles []. Mitral valve excision and replacement with 27 mm St. Jude Medical Biocor™ was carried out along with two vessel coronary artery bypass grafting as there was 100% occlusion of left anterior descending artery and long segment stenosis of proximal left coronary artery on angiogram. Transesophageal echocardiography (TEE) at the end of the procedure showed no residual mitral incompetence.\nHis overall clinical status gradually and steadily improved; he could be successfully weaned off ventilator. Smear from the resected valve showed numerous pus cells on gram-stain and scanty growth of E. coli on culture. Repeat cultures on day 16 were sterile. He was continued on cefoperazone sulbactam for 6 weeks and alternate day amikacin for 4 weeks (with periodic monitoring of serum creatinine). Acitrom was added for anticoagulation. Serum creatinine declined to 1.9 mg/dL on day 19 and 1.7 mg/dL on day 50. Cultures continued to be sterile more than 2 weeks after discontinuation of all antibiotics. At last visit (22 months since first presentation), he was clinically comfortable and serum creatinine was 1.6 mg/dL; there was no further episode of urinary infection and there was no valve regurgitation.