CONCEALED DIAGNOSIS: A CASE OF BARTONELLA ENDOCARDITIS Jose Freire1, M.D., Fernando Dominguez1, M.D, Eduardo Peixoto1, M.D, Thomas Treadwell2, M.D, Harvey Goldfine3, M.D 1 Metrowest

Medical Center, Department of Internal Medicine, Medical Center, Department of Infectious Diseases, 3Metrowest Medical Center, Department of Cardiology 2 Metrowest

INTRODUCTION • • •

Rare disease and a very difficult diagnosis Risk factors: homelessness, alcoholism, infestation with body lice, contact with cats and previous valvular disease Subacute illness with nonspecific findings Mimics many other diseases

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Delay in diagnosis and proper treatment leads to complications Valve destruction Heart failure

PATIENT PRESENTATION •

47 yo M presented to the ER w/ a two year hx of symptoms: Chest pain Palpitations 60lbs weight loss Dysphagia Diarrhea Night sweats

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No EtOH, tobacco or intravenous drug use Lived in Florida working as fishmonger Had a negative workup for hyperthyroidism with his PCP

PHYSICAL EXAMINATION • • • • • •

BP 134/94 HR 104 RR 16 O2Sat 98% in room air Cachectic with poor dentition Jugular venous distention and a soft diastolic murmur heard best at the left sternal border No crackles Abdomen soft and nontender; splenomegaly was present No peripheral edema, all pulses palpable

LABORATORY AND OTHER STUDIES • • • • • • •

Anemia (Hb 7.8 g/dL) w/ no hemolysis and normal WBC CRP of 39.6 mg/L Total protein 9.0mg/dl and Albumin 2.9mg/dl Three sets of blood cultures were negative for >5 days EKG normal Chest X-ray mild cardiomegaly Transthoracic echocardiogram: No vegetations Mildly dilated left ventricle Aortic insufficiency on bicuspid aortic valve

CONTINUATION •

Patient wanted to be discharged home DDx: Amyloidosis, Multiple Myeloma, Sarcoidosis

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One month later returned with persistent chills and weight loss PCR for Bartonella, Coxiella burnetti and Tropheryma whipplei Transesophageal echocardiogram showed multiple lesions in the aortic valve and severe aortic insufficiency Empirical Rx w/ Gentamycin, Unasyn and a fluoroquinolone + serum Bartonella PCR : Gentamycin IV was given for two weeks and oral doxycycline for one year Aortic valve replacement soon after

TRANSESOPHAGEAL ECHOCARDIOGRAM

Figure 1. Aortic valve markedly thickened and with multiple vegetations (arrows). The image in the right also shows the patient bicuspid aortic valve

Figure 2. Aortic valve severely damaged by vegetations showing severe regurgitation in echocardiogram with doppler

DISCUSSION •

Culture-negative endocarditis (CNE): Three independent blood samples Negative cultures Five days of incubation and subculturing

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7% or more of blood cultures remain negative Previous administration of antimicrobial agents Inadequate microbiological techniques

Infection with highly fastidious bacteria or nonbacterial pathogens (eg, fungi)

DISCUSSION •

Common pathogens: Streptococcus spp.*, Coxiella burnetii, Bartonella spp., Brucella spp., Fungi Others: Tropheryma whipplei; Mycobacteria spp.,; Legionella spp.

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What about the HACEK group? Initial workup: Blood cultures x3 and echocardiogram Detailed history, repeated echocardiogram and serology/polymerase chain reaction (blood samples or removed valves) based on presentation, epidemiology and clinical findings DDx includes Nonbacterial Thrombotic Endocarditis

Fig 3. Petechiae (nonblanching, pinpoint reddish brown macules)

Fig 4. Splinter hemorrhages, linear reddish-brown lesions, are seen in the nail bed

Fig 6. Osler nodes are tender papulopustules located on the pulp of the finger

Fig 5. Janeway lesion (arrow) occurred on the palm

Fig 7. Oval shaped, Roth spots, white centered hemorrhages present on the retina of a patient

DISCUSSION • •

Identification of the organism guides the antibiotic therapy Empirical treatment (American Heart Association): HACEK: Ceftriaxone + Ciprofloxacin CNE (subacute): Vancomycin + Ampicillin-sulbactam

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Bartonella endocarditis: Gentamycin for 2wks + Doxycycline for 6wks or more

REFERENCES [1] Fournier PE et al. Comprehensive diagnostic strategy for blood culture-negative endocarditis: a prospective study of 819 new cases. Clin Infect Dis 2010; Jul;51(2):131-40. [2] Brouqui P, Raoult D. Endocarditis due to rare and fastidious bacteria. Clin Microbiol Rev. 2001;14(1):177. [3] Mylonakis E, Calderwood SB. Infective endocarditis in adults. N Engl J Med 2001; 345:1318. [4] Sumatani, I. et al. Infective endocarditis with negative blood culture and negative echocardiographic findings. J Echocardiogr (2015) 13: 66. [5] Zeaiter Z et al. Diagnosis of Bartonella endocarditis by a real-time nested PCR assay using serum. J Clin Microbiol. 2003;41(3):919. [6] Raoult D et al. Outcome and treatment of Bartonella endocarditis. Arch Intern Med. 2003;163(2):226. [7] Foucault C et al. Randomized open trial of gentamicin and doxycycline for eradication of Bartonella quintana from blood in patients with chronic bacteremia. Antimicrob Agents Chemother. 2003;47(7):2204. [8] Baron EJ et al. Prolonged incubation and extensive subculturing do not increase recovery of clinically significant microorganisms from standard automated blood cultures. Clin Infect Dis 2005; 41:1677. [9] Petti CA et al. Utility of extended blood culture incubation for isolation of Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, and Kingella organisms: a retrospective multicenter evaluation. J Clin Microbiol 2006; 44:257.

ACKNOWLEDGMENT Dr. Thomas Treadwell, our P.D. and brilliant Infectious Disease physician Dr. Harvey Goldfine, Cardiologist who helped with the diagnosis Dr. Eduardo Peixoto and Dr. Fernando Dominguez, PGY-3, for the guidance to write the case Metrowest Medical Center residents and staff

QUESTIONS?

THANK YOU!