School of Medicine and Health Sciences Poster Presentations
Gemella sanguinis as a Rare Cause of Infective Endocarditis
Poster Number
278
Document Type
Poster
Status
Medical Resident
Abstract Category
Immunology/Infectious Diseases
Keywords
endocarditis, Gemella sanguinis
Publication Date
Spring 2018
Abstract
Introduction: Pathogens responsible for endocarditis among IV drug abusers with prostatic heart valves are not always the most common organisms. Other rare species should always be considered when faced with such a patient. Learning objectives: Recognize the clinical importance of considering alternative organisms as it may help expedite the diagnosis of infectious endocarditis in such patients.
Case: This patient is a 67 years old male with a a complicated past medical history including coronary artery disease (CAD), endocarditis (s/p aortic valve replacement with a 25mm Edwards tissue value) and primary patent foramen ovale repair that was done 04/25/16, hemomediastinum after epicardial pacer wire removal, chronic kidney disease, hepatitis C, severe pulmonary hypertension and poly-substance abuse who came in to the ED complaining of right shoulder pain. The pain initially started the morning of admission when he was trying to tie his shoes. His symptoms were concerning for acute coronary syndrome. On arrival his troponin was elevated to 0.137 without EKG changes and he was admitted for treatment of NSTEMI. His vital signs were stable. His urinary toxicology screen was positive for methadone and opiates. Given his history of endocarditis, blood cultures were sent. He was afebrile on admission, but became febrile the night of admission. He was also tachycardic and had a WBC of 20 with 9% bands. His blood cultures were positive for gram positive cocci (GPC) and he was started on empiric Vancomycin for treatment of presumed S. aureus bacteremia. A TTE was obtained which showed no evidence of vegetation, but given his IV drug use history, personal history of endocarditis, prosthetic valve, and GPC bacteremia a TEE was obtained which showed a 1.8cm aortic valve vegetation. It was not until 4 days into his admission that the blood culture speciation was completed showing Gemella sanguinis. Infectious disease was consulted and his antibiotics were transitioned to rifampin 300mg TID and penicillin 3 million units q4h. His antibiotics were changed again to ceftriaxone 2g BID after final speciation. The patient remained hemodynamically stable and his WBC returned to normal after three days of antibiotics. He was discharged on a 6 week course of ceftriaxone.
Discussion: 1- Gemella sanguinis Catalase negative, facultative anaerobe, gram positive cocci, that is usually part of the oral, upper respiratory track, intestinal track flora, is a rare yet possible cause of acute bacterial endocarditis in patients with prostatic heart valves with the aortic valve being the most common site of infection (1), up to out knowledge there are only 5 cases reported yet. In most cases it has been related to abnormal dentation (1), but in our patient we believe that the cause of his Endocarditis is related intra venous drug abuse given that he had normal dentation, and active drug use. 2- Bacteremia in such patients necessitates the need for a TEE even if initial blood cultures appear consistent with more common pathogens.
References: 1. Ching-Huei Yang, Kuei-Ton Tsai, Gemella sanguinis endocarditis: First case report in Taiwan and review of the literature, In Journal of the Formosan Medical Association, Volume 113, Issue 8, 2014, Pages 562-565, ISSN 0929-6646, https://doi.org/10.1016/j.jfma.2012.02.012.
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Gemella sanguinis as a Rare Cause of Infective Endocarditis
Introduction: Pathogens responsible for endocarditis among IV drug abusers with prostatic heart valves are not always the most common organisms. Other rare species should always be considered when faced with such a patient. Learning objectives: Recognize the clinical importance of considering alternative organisms as it may help expedite the diagnosis of infectious endocarditis in such patients.
Case: This patient is a 67 years old male with a a complicated past medical history including coronary artery disease (CAD), endocarditis (s/p aortic valve replacement with a 25mm Edwards tissue value) and primary patent foramen ovale repair that was done 04/25/16, hemomediastinum after epicardial pacer wire removal, chronic kidney disease, hepatitis C, severe pulmonary hypertension and poly-substance abuse who came in to the ED complaining of right shoulder pain. The pain initially started the morning of admission when he was trying to tie his shoes. His symptoms were concerning for acute coronary syndrome. On arrival his troponin was elevated to 0.137 without EKG changes and he was admitted for treatment of NSTEMI. His vital signs were stable. His urinary toxicology screen was positive for methadone and opiates. Given his history of endocarditis, blood cultures were sent. He was afebrile on admission, but became febrile the night of admission. He was also tachycardic and had a WBC of 20 with 9% bands. His blood cultures were positive for gram positive cocci (GPC) and he was started on empiric Vancomycin for treatment of presumed S. aureus bacteremia. A TTE was obtained which showed no evidence of vegetation, but given his IV drug use history, personal history of endocarditis, prosthetic valve, and GPC bacteremia a TEE was obtained which showed a 1.8cm aortic valve vegetation. It was not until 4 days into his admission that the blood culture speciation was completed showing Gemella sanguinis. Infectious disease was consulted and his antibiotics were transitioned to rifampin 300mg TID and penicillin 3 million units q4h. His antibiotics were changed again to ceftriaxone 2g BID after final speciation. The patient remained hemodynamically stable and his WBC returned to normal after three days of antibiotics. He was discharged on a 6 week course of ceftriaxone.
Discussion: 1- Gemella sanguinis Catalase negative, facultative anaerobe, gram positive cocci, that is usually part of the oral, upper respiratory track, intestinal track flora, is a rare yet possible cause of acute bacterial endocarditis in patients with prostatic heart valves with the aortic valve being the most common site of infection (1), up to out knowledge there are only 5 cases reported yet. In most cases it has been related to abnormal dentation (1), but in our patient we believe that the cause of his Endocarditis is related intra venous drug abuse given that he had normal dentation, and active drug use. 2- Bacteremia in such patients necessitates the need for a TEE even if initial blood cultures appear consistent with more common pathogens.
References: 1. Ching-Huei Yang, Kuei-Ton Tsai, Gemella sanguinis endocarditis: First case report in Taiwan and review of the literature, In Journal of the Formosan Medical Association, Volume 113, Issue 8, 2014, Pages 562-565, ISSN 0929-6646, https://doi.org/10.1016/j.jfma.2012.02.012.