Ann Thorac Surg 2007;84:1008-1010
© 2007 The Society of Thoracic Surgeons
Case Reports
Aortic Valve Endocarditis by Capnocytophaga Haemolytica
Maria A. Gutierrez-Martin, MD*,
Omar A. Araji, MD, PhD,
Jose M. Barquero, MD,
Carlos Velázquez, MD,
Mariano García-Borbolla, MD,
Pastora Gallego, MD,
Carlos A. Infantes, MD, PhD
Department of Cardiovascular Surgery, Virgen Macarena University Hospital, Seville, Spain
Accepted for publication March 23, 2007.
* Address correspondence to Dr Gutierrez-Martin, Virgen Macarena University Hospital, C/Muro de los Navarros 24, Bajo E4, Seville, 41003, Spain (Email: ma_gutierrez4{at}yahoo.es).
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Abstract
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We report a case of a 51-year-old patient with suspected prosthetic valve endocarditis. Capnocytophaga haemolytica was isolated in blood cultures and the repeated echocardiograms showed growth of vegetations and disruption of the proximal prosthetic valve suture line with progressive aortic regurgitation. The patient underwent a root debridement and replacement with a stentless bioprosthesis.
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Introduction
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Capnocytophaga haemolytica is a gram-negative bacterium present in the oral cavity that has been related exclusively to periodontal disease. Other Capnocytophaga species are protagonists of described serious diseases in the literature, such as sudden sepsis, meningitis, or endocarditis (ie, C canimorsus [transmitted by dog bites]) and some present species in the human oral cavity (ie, C ochracea, C sputigena, or C gingivalis), which act like opportunistic pathogens in immunosuppressed patients. In this article we believe that we describe the first known case of endocarditis produced by C haemolytica.
We describe the case of a 51-year-old patient who had undergone two previous aortic valve replacements; the first one because of an aortic stenosis in 2003 and the second procedure because of a mismatch in 2006 when we implanted a stentless bioprosthesis (Sorin Freedom, 19 mm [Sorin Medical, Milan, Italy]). Eight months after the last surgery the patient began having a fever, migratory arthritis, and microemboli in the four extremities.
According to the initial suspicion of a prosthetic valve infective endocarditis, we initiated an empiric antibiotic treatment with ceftriaxone, cloxacillin, and gentamicin. The in-hospital echocardiography revealed a central aortic regurgitation and an anechoic image at the noncoronary and right coronary cusps.
Ten days after his admission into the hospital, C haemolytica was isolated in blood cultures, and specific antibiotic treatment with ceftriaxone was begun.
The repeated echocardiographic studies revealed the growth of vegetations, the disruption of the proximal suture line of the prosthesis, and progression of the aortic regurgitation (Fig 1).
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Fig 1. Last echocardiographic study before surgery: disruption of the proximal suture line, an anechoic image in noncoronary and right coronary cusps that could be a pseudoaneurysm and an image of a vegetation in the right coronary cusp.
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The patient was operated on after 2 weeks with antibiotic treatment, including the first empiric one because of his unfavorable evolution. We found vegetations in the noncoronary cusp, disruption of the proximal suture line at this noncoronary cusp, and an abscess in the right coronary cusp. The patient underwent debridement of the abscess and reimplantation of a stentless bioprosthesis (Sorin Freedom, 19 mm [Sorin Medical]).
The postoperative period was characterized by hemodynamic instability, the insertion of an intraaortic balloon pump, and high doses of amines. He died 18 hours after surgery because of an intractable ventricular fibrillation. The results of intraoperative blood cultures were negative. No autopsy was performed.
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Comment
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Capnocytophaga spp are fastidious, slow growing, gram-negative rods that inhabit the oral cavity. This microorganism grows best in an anaerobic or microaerophilic environment with increased concentration of carbon dioxide [1]. Thus it was given its name from the Greek word capnos (smoke) meaning like carbon dioxide.
There are many Capnocytophaga species, five of them have been recovered from the human oral cavity (ie, C gingivalis, C ochracea, C sputigena, C granulosa, and C haemolytica; the last two species listed are the most recent Capnocytophaga ones isolated from supragingival dental plaque of adults; the first report recounts the presence of these two species dated from 1994 [2]. Apart from this group of microorganisms, which are common inhabitants of the human being, there is another significant Capnocytophaga species named C canimorsus, which is known as dysgenic fermenter 2 that forms part of the normal oral flora of dogs and cats.
This group of organisms are considered among the Hemophilus spp, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella spp (HACEK) group of fastidious, gram-negative organisms that are capable of causing endocarditis and are characterized for slow growth in blood cultures.
Invasive Capnocytophaga infections have been reported in immunocompromised patients and in the normal host after animal bites. Neutropenia and oral mucositis are the most important risk factors predisposing to bloodstream infection with the genus [3]. Patients with other conditions associated with immunosuppression, such as short bowel syndrome and end-stage liver disease, also seem to be prone to Capnocytophaga infection. More recently, Capnocytophaga infections in immunocompetent patients have been reported. Capnocytophaga spp septicemia has rarely been complicated by serious deep-seated infections, such as meningitis, endocarditis, arthritis, pleuritis, endophthalmitis [4], pneumonia [5], and osteomyelitis.
Concretely, C gingivalis, C ochracea, and C sputigena have been implicated as focal infection agents in systemic disease, especially in immunocompromised patients with autologous stem cell transplantation or patients with neutropenia because of myelodysplastic syndromes, aplastic anemia, lymphomas, and acute leukemias [6]. There is a case report of the isolation of C granulosa from an abscess in the lumbosacral area [7], and C canimorsus has been associated with a variety of conditions including meningitis, fulminant septicemia, cellulites, and endocarditis. However, we believe there has not been any previous report of a systemic infection due to C haemolytica to date.
Most reported cases of Capnocytophaga spp infections have been susceptible to antibiotics including cephalosporin, ureidopenicillin, and fluoroquinolone; however, there are case reports of isolates resistance to quinolones or beta-lactams [8]. This occasional existence of resistant strains makes susceptibility testing useful for administration of the proper antibiotic therapy.
We believe that this is the first reported case of endocarditis related to C haemolytica. After the correct diagnosis of this disease, we tried a treatment with intravenous ceftriaxone (2 g) every 24 hours. Although many of the cases reported in the literature were susceptible and responded to the antibiotic therapy, in our case the patient needed a surgical excision of the infected material and a new aortic prosthesis.
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References
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- Fung JC, Berman M, Fiorentino T. Capnocytophaga: a review of the literature Am J Med Technol 1983;49:589-591.[Medline]
- Yamamoto T, Kajiura S, Hirai Y, Watanabe T. Capnocytophaga haemolytica sp. nov. and Capnocytophaga granulosa sp. nov., from human dental plaque Int J Syst Bacteriol 1994;44:324-329.[Abstract/Free Full Text]
- Bonatti H, Rossboth DW, Nachbaur D, Fille M, et al. A series of infections due to Capnocytophaga spp in inmunosuppressed and inmunocompetent patients Clin Microbiol Infect 2003;9:380-387.[Medline]
- Phipps SE, Tamblyn DM, Badenoch PR. Capnocytophaga canimorsus endophtalmitis following cataract surgery Clin Experiment Ophthalmol 2002;30:375-377.[Medline]
- Geisler WM, Malhotra U, Stamm WE. Pneumonia and sepsis due to fluoroquinolone-resistant Capnocytophaga gingivalis after autologous stem cell transplantation Bone Marrow Transplant 2001;28:1171-1173.[Medline]
- Ciantar M, Spratt DA, Newman HN, Wilson M. Capnocytophaga granulosa and Capnocytophaga haemolytica: novel species in subgingival plaque J Clin Periodontol 2001;28:701-705.[Medline]
- Ebinger M, Nichterlein T, Schumacher UK, Mannake B, Schmidt D, Bohn I. Isolation of Capnocytophaga granulosa from an abscess in an inmunocompetent patient Clin Infect Dis 2000;30:606-607.[Medline]
- Mantadakis E, Danilatou V, Christidou A, Stiakaki E, Kalmanti M. Capnocytophaga gingivalis bacteremia detected only on quantitative blood cultures in a child with leukemia Pediatr Infect Dis J 2003;22:202-204.[Medline]
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Abstract
Introduction
