Meagan Mayo, DO,
Resident
Florida Atlantic University, Charles E Schmidt College of Medicine
Boca Raton, Florida
Disclosure information not submitted.
Anneka Hutton, MD
Pulmonary Critical Care Fellow
University of Alabama at Birmingham (UAB)
Birmingham, Alabama
Disclosure information not submitted.
Enoemem Okpokpo, DO
Resident
Florida Atlantic University Charles E Schmidt College of Medicine, United States
Disclosure information not submitted.
Title: Staphylococcus Epidermidis Native Valve Endocarditis
Case Report Body:
Introduction: Staphylococcus epidermidis is the most frequently isolated bacteria from human skin and is therefore also frequently isolated in blood cultures. However, native valve S. epidermidis endocarditis is rare, only 5-11% of all native valve endocarditis is caused by coagulase negative staph (CoNS). Unfortunately, the frequency seems to be increasing and the infection carries a high mortality rate of 19-36%. We report a case of native valve S. epidermidis endocarditis with abscess and flail leaflet.
Description: A 68-year-old female with a history of systemic lupus erythematosus and recurrent lower extremity cellulitis presented with three days of progressive dyspnea and generalized fatigue. On initial examination, she was hypotensive and hypoxemic with a benign physical exam. Blood cultures resulted positive for S. epidermidis in 3 of 4 vials. She was started on Vancomycin and diuresis with clinical improvement over the next several days. A transthoracic echocardiogram was performed and did not reveal evidence of infective endocarditis (IE). However, surveillance blood cultures remained positive. On hospital day 7, she was emergently intubated for acute respiratory decompensation. CXR revealed increased interstitial edema and a transesophageal echocardiogram revealed multiple abscesses of the aortic valve with a 2cm communication between the annulus and the left atrium. She was diagnosed with complicated IE with aortic flail leaflet and severe regurgitation and underwent emergent surgical intervention.
Discussion: Determining whether growth of CoNS in blood cultures represents contamination or true infection can be clinically challenging. If cultures are positive in a fraction of the vials and there is low suspicion of true bacteremia or IE, culture contamination may be presumed. However, CoNS endocarditis often initially follows an indolent course and literature suggests that it is increasingly affecting native valves. When CoNS causes IE, there is a high rate of intracardiac abscess (15-38%) and mortality (19-36%). Therefore, clinicians should maintain a high index of suspicion for IE even in patients without typical signs and symptoms of endocarditis or who lack a history of valvular pathology. Notably, gram positive bacteremia is an indication for both repeat culturing and echocardiography.