Journal of Clinical and Preventive Cardiology

CASE REPORT
Year
: 2019  |  Volume : 8  |  Issue : 3  |  Page : 136--138

A case report of Mycobacterium abscessus infective endocarditis in rheumatic heart disease


Rakesh Sharma, Saurabh Mehrotra 
 Department of Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Correspondence Address:
Dr. Saurabh Mehrotra
Department of Cardiology, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh - 160 012
India

Abstract

Infective endocarditis owing to Mycobacterium abscessus infection is extremely rare and is usually seen as prosthetic valve endocarditis. A 34-year-old male with rheumatic heart disease presented to us with undiagnosed pyrexia. He had vegetation on anterior mitral leaflet, and his blood cultures grew M. abscessus. The patient responded transiently to amikacin, clarithromycin, and minocycline. His course was complicated by recurrent cardioembolic strokes. The patient was not willing for surgery and had downhill course with persistent fever and heart failure leading to death. Native valve M. abscessus endocarditis is extremely rare. Early surgical intervention is recommended along with intravenous antibiotics, but the course is usually fatal.



How to cite this article:
Sharma R, Mehrotra S. A case report of Mycobacterium abscessus infective endocarditis in rheumatic heart disease.J Clin Prev Cardiol 2019;8:136-138


How to cite this URL:
Sharma R, Mehrotra S. A case report of Mycobacterium abscessus infective endocarditis in rheumatic heart disease. J Clin Prev Cardiol [serial online] 2019 [cited 2019 Sep 20 ];8:136-138
Available from: http://www.jcpconline.org/text.asp?2019/8/3/136/263832


Full Text



 Introduction



Mycobacterium abscessus is highly pathogenic and chemotherapy-resistant organism.[1]M. abscessus endocarditis is rare and usually reported as prosthetic valves endocarditis. Native valve endocarditis by M.abscessus is extremely rare. Infections caused by M.abscessus complex are more difficult to treat because of antimicrobial drug resistance.[2]

 Case Report



A 34-year-old male having rheumatic heart disease with severe aortic regurgitation, moderate mitral stenosis, moderate mitral regurgitation having no other comorbidities, and addictions presented to us with fever of 3 months' duration. Fever was high grade, associated with chills and rigors with two to three spikes daily and no localizing symptoms. The patient was admitted outside on three occasions, was diagnosed as pyrexia of unknown origin, and received intravenous antibiotics but continued to have fever; therefore he came to our institute. Blood cultures (Bectec) were sent, and the patient was started on injection ceftriaxone and gentamycin empirically for infective endocarditis. Transthoracic echocardiography showed vegetation on anterior mitral leaflet (AML), which was confirmed on transesophageal echocardiography as 8 mm × 8 mm vegetation on AML on the ventricular side [Figure 1]. The patient had anemia (Hb 9.7 g/dl) with a total leukocyte count of 10,800 cells/mm3. Blood cultures were sterile after overnight incubation. Serum procalcitonin was elevated (0.853 ng/mL), WIDAL and HIV serology were negative, and urine culture was sterile. After 5 days of incubation, blood culture was reported to have growth of Diphtheroid species. The patient had an acute onset of the left upper motor neuron type of facial nerve palsy and weakness of the left upper limb. Computed tomography (CT) angiography of the brain revealed short segmental thrombus in the superior division of the right middle cerebral artery. Conservative management was advised by neurology physician. On echocardiography, vegetation was still present on AML, but the size was 7 mm × 6 mm. Contrast-enhanced magnetic resonance imaging brain was suggestive of multiple cardioembolic septic acute infracts in the right parieto-temporal lobe and insular cortex with gyriform enhancement [Figure 2]. The patient continued to have fever spikes; therefore, antibiotics were hiked up to meropenem and teicoplanin, whereas gentamycin was continued alongside. Later, blood cultures growth was identified as M. abscessus, so antibiotics were changed to injection amikacin, injection minocycline, and tablet clarithromycin [Figure 3]. After 3–4 days, fever spikes decreased, and the patient became transiently afebrile for 2–3 days. During this period, his blood cultures were sterile, but after 3 days, he again had high-grade fever spikes. The patient had sudden-onset slurring of speech associated with impaired comprehension, but CT angiography had no new major vascular occlusion. The patient continued to have high-grade fever spikes with persistent growth of M.abscessus in all his blood cultures over a period of nearly 6 weeks. Patient and family members were not willing for surgery and left the hospital against medical advice. Later, the patient died at home after 3 days.{Figure 1}{Figure 2}{Figure 3}

 Discussion



Infective endocarditis caused by M.abscessus is very rare and unique. Infection with M.abscessus may lead to localized infections such as subcutaneous abscesses, pneumonia, prosthetic valve endocarditis, and disseminated infection.[3] On Gram staining, M.abscessus can be confounded with diphtheroids or other Gram-positive rods and can grow within 7 days of incubation in routine bacterial culture medium, as occurred in our patient. As per literature review, only 12 cases of endocarditis due to M.abscessus have been reported. Four cases of endocarditis due to M.chelonae were reported before the recognition of M.abscessus as a separate mycobacterial species, and therefore, these could also represent M.abscessus cases. Among these 16 cases, seven (43%) involved prosthetic valve infection. The associated mortality was very high (11 cases; 69%), despite surgery and prolonged antimicrobial therapy.[4] To the best of our knowledge, this is the first reported case of M.abscessus infective endocarditis in rheumatic heart disease. Rapid-growth nontuberculous mycobacteria (NTM) have been reported to be resistant to many antimicrobial agents, including most primary and secondary line antitubercular agents in vitro. However, some strains of M.abscessus were found to be sensitive to amikacin, clarithromycin, cefoxitin, erythromycin, and quinolones. Due to the development of resistance with monotherapy, combination therapy with different classes of antimicrobial agents is usually recommended.[3] Previous reports have suggested that the antimicrobial treatment should last for at least 6 months or 3 months after aggressive surgical intervention.[3] Owing to the frequent failure of medical treatment, early surgical intervention in combination with antimicrobial treatment has been recommended for patients with NTM-related endocarditis.[3] Our case was treated with amikacin, clarithromycin, and minocycline, but the patient continued to have fever and had stroke also; therefore, surgical consultation was taken. After multiple discussions with the surgical team, family members declined for the valve replacement. Since treatment outcome in all previous studies has remained dismal, it remains uncertain if early institution of appropriate therapy or valve replacement would have altered the fatal outcome in our case.

In summary, infective endocarditis caused by M.abscessus is not readily diagnosed and is associated with very high mortality because of multiple drug resistance.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Mahajan S, Mishra V, Sorabjee J. Mycobacterium abscessus: Causing fatal endocarditis after cardiac catheterization. J Postgrad Med 2015;61:131-3.
2Lee MR, Sheng WH, Hung CC, Yu CJ, Lee LN, Hsueh PR, et al.Mycobacterium abscessus complex infections in humans. Emerg Infect Dis 2015;21:1638-46.
3Tsai WC, Hsieh HC, Su HM, Lu PL, Lin TH, Sheu SH, et al.Mycobacterium abscessus endocarditis: A case report and literature review. Kaohsiung J Med Sci 2008;24:481-6.
4Tennant SJ, Forster DW, Burgess DR, Huaman MA. Mycobacterium abscessus prosthetic valve endocarditis in a patient with Marfan syndrome. JMM Case Rep 2015;2. [doi: 10.1099/jmmcr. 0.000084]. [Last accessed on 2019 Apr 20].