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Melioidosis: an unusual cause of infective endocarditis: a case report

Melioidosis: an unusual cause of infective endocarditis: a case report CASE REPORT European Heart Journal - Case Reports (2018) 2, 1–4 doi:10.1093/ehjcr/yty055 Melioidosis: an unusual cause of infective endocarditis: a case report 1 2 3 4,5 Tonnii Sia *, Yuwana Podin , Teik-Beng Chuah , and Jin-Shyan Wong 1 2 Medical Department, Hospital Bintulu, Jalan Nyabau, 97000 Bintulu, Sarawak, Malaysia; Institute of Health and Community Medicine, Universiti Malaysia Sarawak, Sarawak, 3 4 Malaysia; Radiology Department, Hospital Bintulu, Jalan Nyabau, 97000 Bintulu, Sarawak, Malaysia; Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak, Sarawak, Malaysia; and Borneo Medical Centre, Hospital Bintulu, Jalan Nyabau, 97000 Bintulu, Sarawak, Malaysia Received 29 September 2017; accepted 7 April 2018; online publish-ahead-of-print 2 May 2018 Introduction As a causal organism in infective endocarditis, Burkholderia pseudomallei is rare. Burkholderia pseudomallei is intrinsically resistant to aminoglycosides but a gentamicin-susceptible strain was discovered in Sarawak, Malaysian Borneo in 2010. We report the first occurrence of infective endocarditis due to the gentamicin-susceptible strain of B. pseudomallei. ................................................................................................................................................................................................... Case A 29-year-old man presented with pneumonia and melioidosis septicaemia. His condition was complicated with in- presentation fective endocarditis and septic emboli to the brain. Despite difficulties in reaching a diagnosis, the patient was suc- cessfully treated using intravenous gentamicin and ceftazidime and was discharged well. ................................................................................................................................................................................................... Discussion The role of gentamicin in the treatment of the gentamicin-susceptible strain of B. pseudomallei remains unclear. Keywords Melioidosis Infective endocarditis Gentamicin Burkholderia pseudomallei Case report • • • • • Bintulu Sarawak Malaysia Borneo Gentamicin susceptible strain • • • • Learning points Burkholderia pseudomallei is an unusual cause of infective endocarditis. Burkholderia pseudomallei is known to be resistant to many antibiotics, including aminoglycosides. A strain of B. pseudomallei that is gentami- cin-susceptible was found in Sarawak in Malaysian Borneo in 2010. The standard intensive phase therapy using carbapenem or ceftazidime can be instituted together with intravenous gentamicin for its syner- gistic effect in the treatment of infective endocarditis caused by the gentamicin susceptible strain of B. pseudomallei. . 4,5 . Infective endocarditis causes significant morbidity and mortality. Introduction . Complications of infective endocarditis include thromboembolic . events, which could be life-threatening. Treatment of infective endo- Melioidosis is caused by the bacterium Burkholderia pseudomallei.It carditis requires the administration of an effective intravenous (IV) is endemic in many regions in Southeast Asia and Northern antibiotic over a prolonged duration. Common organisms identified Australia. It is also increasingly reported in other tropical coun- for infective endocarditis are Streptococci and Staphylococci, both of tries. It has a high mortality rate due to its systemic involvement which contributed to 80% of cases. and intrinsic resistance to a myriad of antibiotics. A novel strain We report the first occurrence of infective endocarditis due to of gentamicin-susceptible B. pseudomallei was recently reported to the gentamicin-susceptible strain of B. pseudomallei in a tertiary hos- be predominantly found in the central region of Sarawak in pital in central Sarawak of Malaysian Borneo. Malaysian Borneo. * Corresponding author. Tel: þ60 142852382, Email: tonnii_sia@yahoo.com. This case report was reviewed by Monika Arzanauskaite, Magdy Abdelhamid and Ola Jan Magnus Vedin. V The Author(s) 2018. Published by Oxford University Press on behalf of the European Society of Cardiology. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/ehjcr/article-abstract/2/2/1/4990877 by Ed 'DeepDyve' Gillespie user on 03 July 2018 2 T. Sia et al. Timeline Week Day Patient’s progress Culture site Culture result .................................................................................................................................................................................................................... 1 1 Septic shock secondary to pneumonia Blood Burkholderia pseudomallei Stared intravenous (IV) ceftazidime and IV C- penicillin 3–4 Developed ventilator associated pneumonia — — 6 Blood culture taken on first day confirmed for B. Blood B. pseudomallei pseudomallei 2 8 Weaned off inotrope Respiratory tract Multidrug-resistant Acinetobacter baumanii 11 — Respiratory tract Multidrug-resistant A. baumanii 12 — Blood B. pseudomallei 14 Started on oral bactrim 24 — Blood No growth 3 25 Left side hemiplegia and pansystolic murmur Echocardiography and computed tomography of the brain done 26 — Blood No growth 27 Weaned from ventilator support Blood No growth 5 Started on IV gentamicin 7 Completed intensive phase of antibiotics and physiotherapy. Patient was discharged from hospital 36 Last follow-up visit isolate appeared to be gentamicin-susceptible by the Kirby–Bauer Case presentation disk diffusion susceptibility test (Table 1). He remained bacteraemic The patient, a regular and heavy consumer of alcohol, was a 29-year- with positive blood cultures on Day 6 and 12 of admission yielding B. old male lumberjack with no known medical illness. He had been hav- pseudomallei with the same antibiogram pattern. Subsequent blood ing fever and cough for 2 weeks. He was brought to the hospital in a cultures on Day 24, 26 and 27 of admission had no growth. confused state after being reported missing from work for a few days. The patient was administered IV noradrenaline upon admission. The patient presented with septic shock, which was consistent . The highest dose used was 0.27 mcg/kg/min on Day 4 of admission, with the definition of Sepsis-3. He was in a very confused state and and he was subsequently weaned off after a week. Upon admission, was talking irrelevantly. His Glasgow Coma Scale (GCS) registered . he was empirically given IV ceftazidime and IV C-penicillin. On Day 4 E4V2M5. His temperature was 38.0 C, blood pressure was 85/ . of admission, antibiotics were escalated to IV imipenem in view of the 42 mmHg, and his pulse rate was 135 b.p.m. He also had neck stiff- patient’s persistent high-grade temperature and leukopenia. He ness, bilateral upper and lower limbs power registered at least three, . required ventilatory support on a high setting for 2 weeks. During while his tone and reflexes were normal. He had normal heart the second week of intensive phase therapy with IV antibiotics, he sounds with no murmur and bilateral lung crepitations. The patient . was started on oral trimethoprim-sulfamethoxazole (co-trimoxa- was given fluid resuscitation and required a vasopresssor for blood zole). His condition was complicated with ventilator-associated pressure support. He was also put on a mechanical ventilator before pneumonia. Culture of endotracheal secretions grew a multidrug re- being admitted into the intensive care unit (ICU). . sistant Acinetobacter baumanii, which was treated successfully with Initial blood investigations showed anaemia and thrombocytopenia . high dose IV ampicilin-sulbactamfor 14 days. He also developed with normal total white cells and renal function. Ultrasonography . sepsis-induced supraventricular tachycardia which resolved examination showed the presence of splenic microabscesses and . spontaneously. chest radiograph showed bilateral lung fields consolidation. . In the third week of admission, there was a new onset of left-sided Computed tomography (CT) of the brain was normal and lumbar . hemiparesis (muscle power 1/5) and pansystolic murmur with thrills puncture examination of the cerebrospinal fluid on admission . at the apex of the heart. A repeat CT of the brain showed a right showed no signs of inflammation or infection. corona radiata infarct with a high parietal petechia haemorrhage The patient’s blood culture taken on admission grew B. pseudomal- (Figure 1). An echocardiogram showed a thickened mitral valve with lei. This was confirmed by a real-time polymerase chain reaction assay an oscillating mass at the posterior mitral valve leaflet suggestive of targeting the type III secretion system (TTS1). This B. pseudomallei vegetation (Figure 2) with a moderate eccentric mitral regurgitation. Downloaded from https://academic.oup.com/ehjcr/article-abstract/2/2/1/4990877 by Ed 'DeepDyve' Gillespie user on 03 July 2018 An unusual cause of infective endocarditis 3 The intensive phase therapy for melioidosis was extended to 6 rare. A prospective study on melioidosis in Darwin reported pericar- weeks using IV ceftazidime, and we added IV gentamicin at the dose ditis in only 4 out of 540 cases. As well, melioidosis pericardial effu- of 60 mg, 8-hourly for 14 days. He was also given concurrent oral sion was reported in around 1–3% of the total cases in previous 9,10 co-trimoxazole, which was subsequently continued as monotherapy studies. A defective native heart valve, however, is a predispos- in the eradication phase therapy for melioidosis. ition for infective endocarditis. And B. pseudomallei was recently . 4,5 He was discharged after 12 weeks of admission with minimal residual . found to cause infective endocarditis. left sided weakness (Modified Rankin Score of 2). The patient was able . This case illustrates that of a young man, with no known medical ill- to perform all activities of daily living independently with intact cognitive . ness, who presented with disseminated melioidosis but, which was function. He was subsequently transferred to a cardiac referral centre . complicated with infective endocarditis and cerebral infarct. The diag- for definitive management. He remained well during follow-up in the car- . nosis of infective endocarditis was unexpected because the patient was diac centre at nine months from initial presentation. Echocardiogram initially sedated and ventilated. Infective endocarditis was only discov- showed that the vegetation on mitral valve had resolved with residual ered upon cessation of sedative medications, when he was found to moderate mitral regurgitation and left ventricular ejection fraction of have hemiparesis. A possible septic embolus was suspected. This led to 66.5%. He remained in Modified Rankin Score of 2. the discovery of the prolapsed mitral valve, which had a vegetation. Discussion Majority of the melioidosis cases are presented with bacteraemia and pneumonia is a common presentation. Cardiac involvement is very Table 1 Antibiogram of B. pseudomallei isolate based on disk diffusion test . Antibiotics tested Disk diffusion result . ................................................................................................. Ampicilin Sensitive . Ceftazidime Sensitive . Ciprofloxacin Sensitive . Trimethoprim-sulfamethoxazole Sensitive . Imipenem Sensitive Meropenem Sensitive Figure 2 Echocardiogram of parasternal long-axis view showed Tetracycline Sensitive an oscillating mass of 0.3 cm  0.8 cm attached to posterior mitral . leaflet suggestive of vegetation. Gentamicin Sensitive Figure 1 (A) Axial plain computed tomography brain shows there is a small hyperdense punctate haemorrhage at right high parietal region. (B) Axial plain computed tomography brain shows ill-defined hypodense area at right basal ganglia in keeping with infarction. Downloaded from https://academic.oup.com/ehjcr/article-abstract/2/2/1/4990877 by Ed 'DeepDyve' Gillespie user on 03 July 2018 4 T. Sia et al. Infective endocarditis was complicated with septic emboli to the brain. Scheme [RACE/b(2)/1246/2015(02))] and partly by our own oper- ational funds. This resulted in cerebral infarct and haemorrhages as seen in this case. Gentamicin is not used for treatment of melioidosis because B. pseu- Consent: The author/s confirm that written consent for submission and domallei is intrinsically resistant to penicillin, first and second- . publication of this case report including image(s) and associated text has 3,11 . generation cephalosporin, aminoglycosides, and macrolides. . been obtained from the patient in line with COPE guidance. However, this patient was infected by the gentamicin-susceptible B. . Conflict of interest: none declared. pseudomallei strain. Therefore, we decided to use the combination of . Authors’ contributions: T.S. was responsible for patient management ceftazidime and gentamicin for the treatment of infective endocarditis . . and this case write-up. T.B. provided radiology support, i.e. selecting in this patient. This was based on the experience of the synergistic ef- . . images and providing related explanations. Y.P. was responsible for la- fect of cephalosporins and aminoglycosides in the treatment of infect- boratory confirmation of the isolates. T.S.,Y.P.and J.W. jointlyprepared ive endocarditis. There are currently no guidelines on the treatment of andcompiledthe factsof thiscase. melioidosis infective endocarditis. The identification of the specific aetiologic organism of infective endocarditis was important for the ap- References . 1. Limmathurotsakul D, Golding N, Dance DA, Messina JP, Pigott DM, Moyes CL, propriate antibiotic therapy. In managing this case, we used 6 weeks of Rolim DB, Bertherat E, Day NP, Peacock SJ, Hay SI. Predicted global distribution intensive phase antibiotics in the treatment of melioidosis, which was of Burkholderia pseudomallei and burden of melioidosis. Nat Microbiol 2016;1:1–5. also consistent with the duration of treatment of infective endocarditis. 2. Currie BJ, Ward L, Cheng AC. The epidemiology and clinical spectrum of meli- . oidosis: 540 cases from the 20 Year Darwin prospective study. PLoS Negl Trop Dis 2010;4:e900. 3. Podin Y, Sarovich DS, Price EP, Kaestli M, Mayo M, Hii K, Ngian H, Wong S, Conclusion Wong I, Wong J, Mohan A, Ooi M, Fam T, Wong J, Tuanyok A, Keim P, Giffard . PM, Currie BJ. Burkholderia pseudomallei isolates from Sarawak, Malaysian Borneo, are predominantly susceptible to aminoglycosides and macrolides. Antimicrob Melioidosis infective endocarditis is rare and reaching a diagnosis can Agents Chemother 2014;58:162–166. be difficult. The intensive phase of melioidosis treatment must coin- . 4. Mansoor CA, Jemshad A. Melioidosis with endocarditis and massive cerebral in- cide with the duration of treatment of infective endocarditis. This . farct. Ital J Med 2015;10:55–57. 5. Piyasiri LB, Wickramasinghe SA, Lekamvasam VC, Corea EM, Gunarathne R, would require clinical judgement, which would be guided by the Priyadarshana U. Endocarditis in melioidosis. Ceylon Med J 2016;61:192–193. patient’s clinical response and blood culture results. The use of genta- . 6. Kandavello G, Adnan A, Chan JKM, Peariasmy KM, Arumugam K, Leong CL et al. micin in the intensive phase of treatment for the gentamicin- Clinical practice guidelines for the prevention, diagnosis and management of in- fective endocarditis. Putrajaya: Ministry of Health Malaysia, 2017. susceptible B. pseudomallei strain requires further study. . 7. Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, Bellomo R, Bernard GR, Chiche JD, Coopersmith CM, Hotchkiss RS, Levy MM, Marshall JC, Martin GS, Opal SM, Rubenfeld GD, van der Poll T, Vincent JL, Angus DC. The third international consensus definitions for sepsis and septic Acknowledgements . . shock (Sepsis-3). JAMA 2016;315: 801–810. We are grateful to Dr Chua Hock Hin and Prof. Bart Currie for their 8. Novak RT, Glass MB, Gee JE, Gal D, Mayo MJ, Currie BJ, Wilkins advice and input in managing this case. We thank Dr Andrew Aeria PP. Development and evaluation of a real-time PCR assay targeting the . type III secretion system of Burkholderia pseudomallei. J Clin Microbiol 2006;44: for language editing. We also acknowledge the contributions of our 85–90. colleagues from the ICU, medical, laboratory, and radiology teams in 9. Schultze D, Muller B, Bruderer T, Dollenmaier G, Riehm JM, Boggian K. A travel- the management of this case. ler presenting with severe melioidosis complicated by a pericardial effusion: a . case report. BMC Infect Dis 2012;12:242. 10. Chetchotisakd P, Anunnatsiri S, Kiatchoosakun S, Kularbkaew C. Melioidosis Funding . pericarditis mimicking tuberculous pericarditis. Clin Infect Dis 2010;51:e46–e49. This work is supported partly by the Ministry of Higher Education . 11. Currie BJ. Melioidosis: evolving concepts in epidemiology, pathogenesis, and under the Research Acculturation Collaborative Effort Grant treatment. Semin Respir Crit Care Med 2015;36: 111–125. Downloaded from https://academic.oup.com/ehjcr/article-abstract/2/2/1/4990877 by Ed 'DeepDyve' Gillespie user on 03 July 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Heart Journal - Case Reports Oxford University Press

Melioidosis: an unusual cause of infective endocarditis: a case report

European Heart Journal - Case Reports , Volume Advance Article (2) – May 2, 2018
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Abstract

CASE REPORT European Heart Journal - Case Reports (2018) 2, 1–4 doi:10.1093/ehjcr/yty055 Melioidosis: an unusual cause of infective endocarditis: a case report 1 2 3 4,5 Tonnii Sia *, Yuwana Podin , Teik-Beng Chuah , and Jin-Shyan Wong 1 2 Medical Department, Hospital Bintulu, Jalan Nyabau, 97000 Bintulu, Sarawak, Malaysia; Institute of Health and Community Medicine, Universiti Malaysia Sarawak, Sarawak, 3 4 Malaysia; Radiology Department, Hospital Bintulu, Jalan Nyabau, 97000 Bintulu, Sarawak, Malaysia; Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak, Sarawak, Malaysia; and Borneo Medical Centre, Hospital Bintulu, Jalan Nyabau, 97000 Bintulu, Sarawak, Malaysia Received 29 September 2017; accepted 7 April 2018; online publish-ahead-of-print 2 May 2018 Introduction As a causal organism in infective endocarditis, Burkholderia pseudomallei is rare. Burkholderia pseudomallei is intrinsically resistant to aminoglycosides but a gentamicin-susceptible strain was discovered in Sarawak, Malaysian Borneo in 2010. We report the first occurrence of infective endocarditis due to the gentamicin-susceptible strain of B. pseudomallei. ................................................................................................................................................................................................... Case A 29-year-old man presented with pneumonia and melioidosis septicaemia. His condition was complicated with in- presentation fective endocarditis and septic emboli to the brain. Despite difficulties in reaching a diagnosis, the patient was suc- cessfully treated using intravenous gentamicin and ceftazidime and was discharged well. ................................................................................................................................................................................................... Discussion The role of gentamicin in the treatment of the gentamicin-susceptible strain of B. pseudomallei remains unclear. Keywords Melioidosis Infective endocarditis Gentamicin Burkholderia pseudomallei Case report • • • • • Bintulu Sarawak Malaysia Borneo Gentamicin susceptible strain • • • • Learning points Burkholderia pseudomallei is an unusual cause of infective endocarditis. Burkholderia pseudomallei is known to be resistant to many antibiotics, including aminoglycosides. A strain of B. pseudomallei that is gentami- cin-susceptible was found in Sarawak in Malaysian Borneo in 2010. The standard intensive phase therapy using carbapenem or ceftazidime can be instituted together with intravenous gentamicin for its syner- gistic effect in the treatment of infective endocarditis caused by the gentamicin susceptible strain of B. pseudomallei. . 4,5 . Infective endocarditis causes significant morbidity and mortality. Introduction . Complications of infective endocarditis include thromboembolic . events, which could be life-threatening. Treatment of infective endo- Melioidosis is caused by the bacterium Burkholderia pseudomallei.It carditis requires the administration of an effective intravenous (IV) is endemic in many regions in Southeast Asia and Northern antibiotic over a prolonged duration. Common organisms identified Australia. It is also increasingly reported in other tropical coun- for infective endocarditis are Streptococci and Staphylococci, both of tries. It has a high mortality rate due to its systemic involvement which contributed to 80% of cases. and intrinsic resistance to a myriad of antibiotics. A novel strain We report the first occurrence of infective endocarditis due to of gentamicin-susceptible B. pseudomallei was recently reported to the gentamicin-susceptible strain of B. pseudomallei in a tertiary hos- be predominantly found in the central region of Sarawak in pital in central Sarawak of Malaysian Borneo. Malaysian Borneo. * Corresponding author. Tel: þ60 142852382, Email: tonnii_sia@yahoo.com. This case report was reviewed by Monika Arzanauskaite, Magdy Abdelhamid and Ola Jan Magnus Vedin. V The Author(s) 2018. Published by Oxford University Press on behalf of the European Society of Cardiology. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/ehjcr/article-abstract/2/2/1/4990877 by Ed 'DeepDyve' Gillespie user on 03 July 2018 2 T. Sia et al. Timeline Week Day Patient’s progress Culture site Culture result .................................................................................................................................................................................................................... 1 1 Septic shock secondary to pneumonia Blood Burkholderia pseudomallei Stared intravenous (IV) ceftazidime and IV C- penicillin 3–4 Developed ventilator associated pneumonia — — 6 Blood culture taken on first day confirmed for B. Blood B. pseudomallei pseudomallei 2 8 Weaned off inotrope Respiratory tract Multidrug-resistant Acinetobacter baumanii 11 — Respiratory tract Multidrug-resistant A. baumanii 12 — Blood B. pseudomallei 14 Started on oral bactrim 24 — Blood No growth 3 25 Left side hemiplegia and pansystolic murmur Echocardiography and computed tomography of the brain done 26 — Blood No growth 27 Weaned from ventilator support Blood No growth 5 Started on IV gentamicin 7 Completed intensive phase of antibiotics and physiotherapy. Patient was discharged from hospital 36 Last follow-up visit isolate appeared to be gentamicin-susceptible by the Kirby–Bauer Case presentation disk diffusion susceptibility test (Table 1). He remained bacteraemic The patient, a regular and heavy consumer of alcohol, was a 29-year- with positive blood cultures on Day 6 and 12 of admission yielding B. old male lumberjack with no known medical illness. He had been hav- pseudomallei with the same antibiogram pattern. Subsequent blood ing fever and cough for 2 weeks. He was brought to the hospital in a cultures on Day 24, 26 and 27 of admission had no growth. confused state after being reported missing from work for a few days. The patient was administered IV noradrenaline upon admission. The patient presented with septic shock, which was consistent . The highest dose used was 0.27 mcg/kg/min on Day 4 of admission, with the definition of Sepsis-3. He was in a very confused state and and he was subsequently weaned off after a week. Upon admission, was talking irrelevantly. His Glasgow Coma Scale (GCS) registered . he was empirically given IV ceftazidime and IV C-penicillin. On Day 4 E4V2M5. His temperature was 38.0 C, blood pressure was 85/ . of admission, antibiotics were escalated to IV imipenem in view of the 42 mmHg, and his pulse rate was 135 b.p.m. He also had neck stiff- patient’s persistent high-grade temperature and leukopenia. He ness, bilateral upper and lower limbs power registered at least three, . required ventilatory support on a high setting for 2 weeks. During while his tone and reflexes were normal. He had normal heart the second week of intensive phase therapy with IV antibiotics, he sounds with no murmur and bilateral lung crepitations. The patient . was started on oral trimethoprim-sulfamethoxazole (co-trimoxa- was given fluid resuscitation and required a vasopresssor for blood zole). His condition was complicated with ventilator-associated pressure support. He was also put on a mechanical ventilator before pneumonia. Culture of endotracheal secretions grew a multidrug re- being admitted into the intensive care unit (ICU). . sistant Acinetobacter baumanii, which was treated successfully with Initial blood investigations showed anaemia and thrombocytopenia . high dose IV ampicilin-sulbactamfor 14 days. He also developed with normal total white cells and renal function. Ultrasonography . sepsis-induced supraventricular tachycardia which resolved examination showed the presence of splenic microabscesses and . spontaneously. chest radiograph showed bilateral lung fields consolidation. . In the third week of admission, there was a new onset of left-sided Computed tomography (CT) of the brain was normal and lumbar . hemiparesis (muscle power 1/5) and pansystolic murmur with thrills puncture examination of the cerebrospinal fluid on admission . at the apex of the heart. A repeat CT of the brain showed a right showed no signs of inflammation or infection. corona radiata infarct with a high parietal petechia haemorrhage The patient’s blood culture taken on admission grew B. pseudomal- (Figure 1). An echocardiogram showed a thickened mitral valve with lei. This was confirmed by a real-time polymerase chain reaction assay an oscillating mass at the posterior mitral valve leaflet suggestive of targeting the type III secretion system (TTS1). This B. pseudomallei vegetation (Figure 2) with a moderate eccentric mitral regurgitation. Downloaded from https://academic.oup.com/ehjcr/article-abstract/2/2/1/4990877 by Ed 'DeepDyve' Gillespie user on 03 July 2018 An unusual cause of infective endocarditis 3 The intensive phase therapy for melioidosis was extended to 6 rare. A prospective study on melioidosis in Darwin reported pericar- weeks using IV ceftazidime, and we added IV gentamicin at the dose ditis in only 4 out of 540 cases. As well, melioidosis pericardial effu- of 60 mg, 8-hourly for 14 days. He was also given concurrent oral sion was reported in around 1–3% of the total cases in previous 9,10 co-trimoxazole, which was subsequently continued as monotherapy studies. A defective native heart valve, however, is a predispos- in the eradication phase therapy for melioidosis. ition for infective endocarditis. And B. pseudomallei was recently . 4,5 He was discharged after 12 weeks of admission with minimal residual . found to cause infective endocarditis. left sided weakness (Modified Rankin Score of 2). The patient was able . This case illustrates that of a young man, with no known medical ill- to perform all activities of daily living independently with intact cognitive . ness, who presented with disseminated melioidosis but, which was function. He was subsequently transferred to a cardiac referral centre . complicated with infective endocarditis and cerebral infarct. The diag- for definitive management. He remained well during follow-up in the car- . nosis of infective endocarditis was unexpected because the patient was diac centre at nine months from initial presentation. Echocardiogram initially sedated and ventilated. Infective endocarditis was only discov- showed that the vegetation on mitral valve had resolved with residual ered upon cessation of sedative medications, when he was found to moderate mitral regurgitation and left ventricular ejection fraction of have hemiparesis. A possible septic embolus was suspected. This led to 66.5%. He remained in Modified Rankin Score of 2. the discovery of the prolapsed mitral valve, which had a vegetation. Discussion Majority of the melioidosis cases are presented with bacteraemia and pneumonia is a common presentation. Cardiac involvement is very Table 1 Antibiogram of B. pseudomallei isolate based on disk diffusion test . Antibiotics tested Disk diffusion result . ................................................................................................. Ampicilin Sensitive . Ceftazidime Sensitive . Ciprofloxacin Sensitive . Trimethoprim-sulfamethoxazole Sensitive . Imipenem Sensitive Meropenem Sensitive Figure 2 Echocardiogram of parasternal long-axis view showed Tetracycline Sensitive an oscillating mass of 0.3 cm  0.8 cm attached to posterior mitral . leaflet suggestive of vegetation. Gentamicin Sensitive Figure 1 (A) Axial plain computed tomography brain shows there is a small hyperdense punctate haemorrhage at right high parietal region. (B) Axial plain computed tomography brain shows ill-defined hypodense area at right basal ganglia in keeping with infarction. Downloaded from https://academic.oup.com/ehjcr/article-abstract/2/2/1/4990877 by Ed 'DeepDyve' Gillespie user on 03 July 2018 4 T. Sia et al. Infective endocarditis was complicated with septic emboli to the brain. Scheme [RACE/b(2)/1246/2015(02))] and partly by our own oper- ational funds. This resulted in cerebral infarct and haemorrhages as seen in this case. Gentamicin is not used for treatment of melioidosis because B. pseu- Consent: The author/s confirm that written consent for submission and domallei is intrinsically resistant to penicillin, first and second- . publication of this case report including image(s) and associated text has 3,11 . generation cephalosporin, aminoglycosides, and macrolides. . been obtained from the patient in line with COPE guidance. However, this patient was infected by the gentamicin-susceptible B. . Conflict of interest: none declared. pseudomallei strain. Therefore, we decided to use the combination of . Authors’ contributions: T.S. was responsible for patient management ceftazidime and gentamicin for the treatment of infective endocarditis . . and this case write-up. T.B. provided radiology support, i.e. selecting in this patient. This was based on the experience of the synergistic ef- . . images and providing related explanations. Y.P. was responsible for la- fect of cephalosporins and aminoglycosides in the treatment of infect- boratory confirmation of the isolates. T.S.,Y.P.and J.W. jointlyprepared ive endocarditis. There are currently no guidelines on the treatment of andcompiledthe factsof thiscase. melioidosis infective endocarditis. The identification of the specific aetiologic organism of infective endocarditis was important for the ap- References . 1. Limmathurotsakul D, Golding N, Dance DA, Messina JP, Pigott DM, Moyes CL, propriate antibiotic therapy. In managing this case, we used 6 weeks of Rolim DB, Bertherat E, Day NP, Peacock SJ, Hay SI. Predicted global distribution intensive phase antibiotics in the treatment of melioidosis, which was of Burkholderia pseudomallei and burden of melioidosis. Nat Microbiol 2016;1:1–5. also consistent with the duration of treatment of infective endocarditis. 2. Currie BJ, Ward L, Cheng AC. The epidemiology and clinical spectrum of meli- . oidosis: 540 cases from the 20 Year Darwin prospective study. PLoS Negl Trop Dis 2010;4:e900. 3. Podin Y, Sarovich DS, Price EP, Kaestli M, Mayo M, Hii K, Ngian H, Wong S, Conclusion Wong I, Wong J, Mohan A, Ooi M, Fam T, Wong J, Tuanyok A, Keim P, Giffard . PM, Currie BJ. Burkholderia pseudomallei isolates from Sarawak, Malaysian Borneo, are predominantly susceptible to aminoglycosides and macrolides. Antimicrob Melioidosis infective endocarditis is rare and reaching a diagnosis can Agents Chemother 2014;58:162–166. be difficult. The intensive phase of melioidosis treatment must coin- . 4. Mansoor CA, Jemshad A. Melioidosis with endocarditis and massive cerebral in- cide with the duration of treatment of infective endocarditis. This . farct. Ital J Med 2015;10:55–57. 5. Piyasiri LB, Wickramasinghe SA, Lekamvasam VC, Corea EM, Gunarathne R, would require clinical judgement, which would be guided by the Priyadarshana U. 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Novak RT, Glass MB, Gee JE, Gal D, Mayo MJ, Currie BJ, Wilkins advice and input in managing this case. We thank Dr Andrew Aeria PP. Development and evaluation of a real-time PCR assay targeting the . type III secretion system of Burkholderia pseudomallei. J Clin Microbiol 2006;44: for language editing. We also acknowledge the contributions of our 85–90. colleagues from the ICU, medical, laboratory, and radiology teams in 9. Schultze D, Muller B, Bruderer T, Dollenmaier G, Riehm JM, Boggian K. A travel- the management of this case. ler presenting with severe melioidosis complicated by a pericardial effusion: a . case report. BMC Infect Dis 2012;12:242. 10. Chetchotisakd P, Anunnatsiri S, Kiatchoosakun S, Kularbkaew C. Melioidosis Funding . pericarditis mimicking tuberculous pericarditis. Clin Infect Dis 2010;51:e46–e49. This work is supported partly by the Ministry of Higher Education . 11. Currie BJ. Melioidosis: evolving concepts in epidemiology, pathogenesis, and under the Research Acculturation Collaborative Effort Grant treatment. Semin Respir Crit Care Med 2015;36: 111–125. Downloaded from https://academic.oup.com/ehjcr/article-abstract/2/2/1/4990877 by Ed 'DeepDyve' Gillespie user on 03 July 2018

Journal

European Heart Journal - Case Reports – Oxford University Press

Published: May 2, 2018

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