Summary: Propionibacterium acnes rarely causes sys- temic disease. Few cases of l? acnes endocarditis have been reported. This report describes a ...
Clin. Cardiol. 15,299-300 (1992)
Case Reports Propionibacterium acnes Prosthetic Valve Endocarditis: A Case of Severe Aortic Insufficiency JASON M. LAZAR, M.D., DOUGLAS s. SCHULMAN, M.D. Division of Cardiology, Department of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
Summary: Propionibacterium acnes rarely causes systemic disease. Few cases of l? acnes endocarditis have
Case Report
been reported. This report describes a 63-year-old man who presented with severe congestive heart failure. He had prosthetic valve endocarditis which resulted in severe acute aortic insufficiency. During surgery he was found to have complete disruption of the aorta and left ventricle with a false aneurysm encompassing the circumferenceof the aortic annulus. Cultures of the valve grew l? acnes. Thus, although l? acnes is a rare cause of endocarditis, it may pursue a very aggressive course, especially in the setting of a prosthetic valve.
A 63-year-old man had a prior aortic valve replacement with a #25 Medtronic tilting disc valve 27 months before admission. He had done well until his current illness. He had discontinued his coumadin 3 weeks prior to admission while on an alcohol binge, and presented to the emergency room with severe congestive heart failure of several days duration. He had no fever, chills, or night sweats. On admission, his blood pressure was 140/80 mmHg, pulse 130 beatdmin, and respiratory rate 32/min. He had jugular venous distention, bilateral rales, a 3/6 diastolic decrescendo murmur, a 2/6 systolic ejection murmur, and a third heart sound. Initial laboratory exam revealed a metabolic acidosis (serum bicarbonate 15 mEq/dl) and a respiratory alkalosis (pH 7.42, Pa02 65 mmHg, Pacoz 21 mmHg on supplemental oxygen). The patient was treated for congestive heart failure and aortic insufficiency with intravenous diuretics, digoxin, and nitroprusside. Heparin therapy was initiated with the presumed diagnosis of thrombosis of the prosthetic aortic valve. Despite therapy, he developed worsening pulmonary edema requiring inotropic support. Diagnostic cardiac catheterization was performed. On fluoroscopy, the prosthetic valve had a normal tilting disc motion. Aortic root angiography revealed a moderately dilated aortic root with 3+ aortic insufficiency. The left ventricle was normal in size and function. Coronary anatomy was normal. Pulmonary artery pressure was 70/38 mmHg, mean 50 mmHg, and the pulmonary artery wedge pressure was 40 mmHg. Left ventricular pressure was 120/40 mmHg, and aortic pressure was 100/48 mmHg. The patient underwent urgent surgery. Intraoperatively, the prosthetic valve was disrupted almost totally from its suture line. Further inspection revealed disruption of the aorta and left ventricle, thereby creating a 1 cm wide false aneurysm which encompassed the circumference of the aortic annulus. The aortic valve was replaced with a #23 St. Jude aortic prosthesis and the aorta and ventricle were reapproximated.No discrete vegetations were found on the excised valve. However, gram stain of fibrinous debris showed gram-positive rods and neutrophils and P. acnes
Key words: endocarditis, aortic insufficiency, false aneurysm
Introduction Propionibacterium acnes is a gram-positive anaerobic diphtheroid found on the skin. This organism rarely is associated with systemic disease. There are several reports of endocarditis secondary to l? acnes.'" We report a case of l? acnes endocarditis which followed a very aggressive course and was associated with unusual pathologic findings.
Address for reprints: Douglas S. Schulman, M.D. Medical College of Pennsylvania Allegheny General Hospital 320 E. North Avenue Pittsburgh, PA 15212, USA Received: November 13, 1991 Accepted: December 10, 1991
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was identified on culture. Peripheral blood cultures were repeatedly negative. The patient was treated with a 6-week course of penicillin and gentamicin. He was discharged after a complicated postoperative course.
Discussion This report describes a case of F! acnes endocarditispresenting as acute insufficiencyof an aortic tilting disc prosthesis. The clinical presentation, specific pathogen, and intraoperative pathological findings are unusual features of this case. F! acnes is a rare cause of bacterial endocarditis. Although described in association with both native' and prosthetic2valves, the true incidence of valvular infection by F! acnes is uncertain. Felner and Dowell identified five isolates of F! acnes in 33 cases of suspected anaerobic endocarditis submitted to the Centers for Disease Control over a 6-year p e r i ~ dAlthough .~ rare, l? acnes endocarditis generally presents as a subacute infection which responds well to medical therapy!.' Johnson et al. reported 2 cases of I! acnes endocarditis after recent aortic valve replacement. Both patients presented with acute aortic insufficiency and 1 patient had an aortic annular abscess? McFadden et al. reported 1 case of prosthetic aortic valve endocarditis
which presented as an arterial embolus but was also associated with an annular abscess? Complete aortoventricular disruption and acute aortic insufficiency late after aortic valve replacement secondary to F! acnes endocarditis has not been reported previously. Although 19 acnes is a rare cause of bacterial endocarditis, it may pursue a very aggressive course, especially in the setting of a prosthetic valve.
References 1. Lewis JF, Abramson JH: Endocarditis due to Propionibacterium acnes. Am J Clin Path 74(5), 690-692 (1980) 2. Johnson WD, Cobbs CG, Arciti I: Diphtheroid endocarditis after insertion of a prosthetic heart valve. JAm Med Assoc 203, 919-926 (1968) 3. Felner JM, Dowell VR: Anaerobic bacterial endocarditis. N EngZJMed 283, 1188-1192(1970) 4. Reid JD, Greenwood L: Corynebacterial endocarditis. Arch Int Med 119,106-110(1967) 5 . Zierdt CH, Wertlake PT:Transitionalforms of corynebucten'um acnes in disease. J Bacterial 97(2), 799-805 (1969) 6. McFadden PM, Gomalez-Lavin L, Remington JS: Limited reliability of the negative two-dimensional echocardiogram in the evaluation of infectious vegetativeendocarditis: Diagnostic and surgical indications. J Cardiovasc Surg 26,59-63 (1985)
