Enterococcal endocarditis in a patient with a renal oncocytoma.

Enterococci account for 5-20% of cases of native-valve infective endocarditis [1Wilson WR Giulani ER Danielson GK Geraci JE. Symposium on infective endocarditis. II. General considerations in the diagnosis and treatment of infective endocarditis.Mayo Clin Proc. 1982; 57: 81-85PubMed Google Scholar, 2Megran DW. Enterococcal endocarditis.Clin Infect Dis. 1992; 15: 63-71Crossref PubMed Scopus (123) Google Scholar, 3Kaye D. Changing pattern of infective endocarditis.Am J Med. 1985; 78: 157-162Abstract Full Text PDF PubMed Scopus (81) Google Scholar]. This incidence will probably increase as the population ages and more people are placed at risk by degenerative valve disease and by sources of infection such as infections of the genitourinary tract [4Maki DG Agger WA. Enterococcal bacteremia: clinical features, the risk of endocarditis and management.Medicine (Baltimore). 1988; 67: 248-269Crossref PubMed Scopus (261) Google Scholar, 5Herztein J Ryan JL Mangi RJ Greco TPM Andriole VT. Optimal therapy for enterococcal endocarditis.Am J Med. 1984; 76: 186-191Abstract Full Text PDF PubMed Scopus (45) Google Scholar, 6Morrison Jr, AJ Wenzel RP. Nosocomial urinary tract infections due to Enterococcus: ten years experience at a university hospital.Arch Intern Med. 1986; 146: 1549-1551Crossref PubMed Scopus (119) Google Scholar]. Oncocytomas are benign neoplasms which arise in various organs, particularly the pancreas, thyroid and adrenals [7Neisius D Braedel HU Schindler E Hoene E Alloussi Sch. Computed tomographic and angiographic findings in renal oncocytoma.Br J Radiol. 1988; 61: 1019-1025Crossref PubMed Scopus (17) Google Scholar,8Morra MN Das S. Renal oncocytoma: a review of histogenesis, histopathology, diagnosis and treatment.J Urol. 1993; 150: 295-302Abstract Full Text PDF PubMed Scopus (65) Google Scholar]. Their clinical presentation is not characteristic and sometimes they are found on routine ultrasound screening [8Morra MN Das S. Renal oncocytoma: a review of histogenesis, histopathology, diagnosis and treatment.J Urol. 1993; 150: 295-302Abstract Full Text PDF PubMed Scopus (65) Google Scholar]. We present a patient with an enterococcal endocarditis and a kidney oncocytoma. A 72-year-old woman was admitted to the hospital as an emergency with severe pulmonary edema. She had high blood pressure but no history of major illnesses. The patient had complained of intermittent acute burning, right flank pain and gross painless hematuria in the previous 4-5 months. On occasion the patient had fever of 38°C and peripheral edema. She had been diagnosed as having a renal colic, and analgesics had been prescribed. Three weeks prior to admission she had pitting edema in the pretibial region and in the ankles and she complained of nocturia, oliguria and increasing dyspnea. One week before admission the patient felt fatigued and she also complained of loss of appetite. On admission the patient had a temperature of 38°C, the pulse was 120/min and the respirations were 32/min. The blood pressure was 170/50 mmHg. On physical examination the patient appeared ill and was in respiratory distress. No rash or lymphadenopathy was found. The cardiologic examination revealed a systolic grade II murmur in the second right intercostal space and a holosystolic grade III murmur at the cardiac apex as well as a third sound. Pulmonary examination revealed disseminated crepitant rales. The abdomen was normal except that a mass was palpated 6 cm below the right costal margin and the splenic tip was palpated 5.5 cm below the left costal margin. There was pitting edema in the pretibial areas and in the ankles. The complete blood count showed a hematocrit of 26% and a white cell and differential count within normal limits. The erythrocyte sedimentation rate was 97 mm/h. Urinalysis revealed 60-80 red blood cells per high-powered field. Radiographs of the chest disclosed bilateral patchy consolidation with visible air bronchograms and global cardiomegaly. The patient was treated with diuretics, vasodilators and inotropic agents, with a good response. On the second day of hospitalization an echocardiogram showed a mass that was 0.8 cm in diameter involving the right leaflet of the aortic valve and a mass that was 0.9 cm in diameter involving the septal leaflet of the mitral valve. During the same day an Enterococcus faecalis strain was isolated from three blood cultures and the urine culture; this was susceptible to ampicillin, and synergy was obtained with gentamicin. A diagnosis of endocarditis was made. Both antibiotics were started and maintained for 6 weeks. Abdominal ultrasonography showed hepatosplenomegaly and a solid mass with a central hypoechoic scar in the upper pole of the right kidney. Computed tomography (CT) confirmed these findings (Figure 1). A radionuclide bone scan with technetium-99m diphosphonate and a barium enema were normal. Aspiration biopsy of the tumor contained large isolated tumor cells and small loose cellular clusters; cytoplasm was abundant and nuclei were spherical or ovoid, single or multiple. A diagnosis of oncocytoma was made. When ampicillin-gentamicin therapy was discontinued after 6 weeks, the erythrocyte sedimentation rate and the hematocrit were normal. The patient was discharged pending a right nephrectomy. A month later she suffered a mild left hemiparesis. A CT scan of the brain showed the appearances of cerebral infarct. The patient recovered totally after 24 h. Two months later the patient died suddenly at home. An autopsy was not performed. The enterococci provide the third most common cause of infective endocarditis, following streptococci and Staphylococcus aureus [1Wilson WR Giulani ER Danielson GK Geraci JE. Symposium on infective endocarditis. II. General considerations in the diagnosis and treatment of infective endocarditis.Mayo Clin Proc. 1982; 57: 81-85PubMed Google Scholar,2Megran DW. Enterococcal endocarditis.Clin Infect Dis. 1992; 15: 63-71Crossref PubMed Scopus (123) Google Scholar]. The genitourinary tract was considered the portal of entry in 14-70% of cases reviewed in 10 series of patients [4Maki DG Agger WA. Enterococcal bacteremia: clinical features, the risk of endocarditis and management.Medicine (Baltimore). 1988; 67: 248-269Crossref PubMed Scopus (261) Google Scholar, 5Herztein J Ryan JL Mangi RJ Greco TPM Andriole VT. Optimal therapy for enterococcal endocarditis.Am J Med. 1984; 76: 186-191Abstract Full Text PDF PubMed Scopus (45) Google Scholar, 6Morrison Jr, AJ Wenzel RP. Nosocomial urinary tract infections due to Enterococcus: ten years experience at a university hospital.Arch Intern Med. 1986; 146: 1549-1551Crossref PubMed Scopus (119) Google Scholar]. Gastrointestinal sources of infection are found in 3-27% of cases [4Maki DG Agger WA. Enterococcal bacteremia: clinical features, the risk of endocarditis and management.Medicine (Baltimore). 1988; 67: 248-269Crossref PubMed Scopus (261) Google Scholar,6Morrison Jr, AJ Wenzel RP. Nosocomial urinary tract infections due to Enterococcus: ten years experience at a university hospital.Arch Intern Med. 1986; 146: 1549-1551Crossref PubMed Scopus (119) Google Scholar]. Urethral catheters and diagnostic or operative procedures often precipitate enterococcal invasion [4Maki DG Agger WA. Enterococcal bacteremia: clinical features, the risk of endocarditis and management.Medicine (Baltimore). 1988; 67: 248-269Crossref PubMed Scopus (261) Google Scholar, 5Herztein J Ryan JL Mangi RJ Greco TPM Andriole VT. Optimal therapy for enterococcal endocarditis.Am J Med. 1984; 76: 186-191Abstract Full Text PDF PubMed Scopus (45) Google Scholar, 6Morrison Jr, AJ Wenzel RP. Nosocomial urinary tract infections due to Enterococcus: ten years experience at a university hospital.Arch Intern Med. 1986; 146: 1549-1551Crossref PubMed Scopus (119) Google Scholar]. Oncocytomas account for 5-10 % of renal tumors [8Morra MN Das S. Renal oncocytoma: a review of histogenesis, histopathology, diagnosis and treatment.J Urol. 1993; 150: 295-302Abstract Full Text PDF PubMed Scopus (65) Google Scholar, 9Lieber MM. Renal oncocytoma: prognosis and treatment.Eur Urol. 1990; 18: 17-21PubMed Google Scholar, 10Mitchell KM Shilkin KB. Renal oncocytoma.Pathology. 1982; 14: 75-80Crossref PubMed Scopus (23) Google Scholar, 11Romero JA Bielsa O Gil-Vernet JM Alvarez-Vijande R Carretero P. Oncocytome et calcification: une association exceptionnelle.J Urol. 1990; 96: 227-229PubMed Google Scholar]. The vast majority of such tumors have been discovered incidentally during the course of evaluation for some unrelated symptom or at postmortem examination [8Morra MN Das S. Renal oncocytoma: a review of histogenesis, histopathology, diagnosis and treatment.J Urol. 1993; 150: 295-302Abstract Full Text PDF PubMed Scopus (65) Google Scholar]. However, even though oncocytomas might be expected from their slow, well-encapsulated, spherical, expansive growth to be clinically benign, in some series the patients have gross hematuria, abdominal pain, a flank mass or microscopic hematuria [8Morra MN Das S. Renal oncocytoma: a review of histogenesis, histopathology, diagnosis and treatment.J Urol. 1993; 150: 295-302Abstract Full Text PDF PubMed Scopus (65) Google Scholar, 9Lieber MM. Renal oncocytoma: prognosis and treatment.Eur Urol. 1990; 18: 17-21PubMed Google Scholar, 10Mitchell KM Shilkin KB. Renal oncocytoma.Pathology. 1982; 14: 75-80Crossref PubMed Scopus (23) Google Scholar, 11Romero JA Bielsa O Gil-Vernet JM Alvarez-Vijande R Carretero P. Oncocytome et calcification: une association exceptionnelle.J Urol. 1990; 96: 227-229PubMed Google Scholar]. Renal oncocytoma has been described in association with several conditions, including multiple myeloma and tuberous sclerosis [12Litton N Zarabi M. Oncocytoma of kidney involved by multiple myeloma. Report of a case.Oncology. 1988; 45: 322Crossref PubMed Scopus (4) Google Scholar,13Srinivas V Herr HW Hajdu EO. Partial nephrectomy for a renal oncocytoma associated with tuberous sclerosis.J Urol. 1985; 133: 263PubMed Google Scholar]. However, no case has been described in which enterococcal endocarditis has occurred in a patient with a renal oncocytoma. In our patient an alteration of the excretory urinary tract by the oncocytoma of the kidney could have favored urinary infection and subsequently the development of bacteremia. Our patient began to suffer from gross haematuria and flank pain 4 months before admission but the oncocytoma was not diagnosed. She developed enterococcal urinary infection and bacteremia and latterly a native mitral and aortic valve endocarditis. Other sources of enteroccoci, such us colonic carcinoma and polyps, were ruled out. Only a small proportion of patients with significant enterococcal bacteremia have endocarditis [14Graninger W Ragette R. Nosocomial bacteremia due to Enterococcus faecalis without endocarditis.Clin Infect Dis. 1992; 15: 49-57Crossref PubMed Scopus (70) Google Scholar,15Awada A van der Auwera P Meunier F Daneau D Klastersky J. Streptococcal and enterococcal bacteremia in patients with cancer.Clin Infect Dis. 1992; 15: 33-48Crossref PubMed Scopus (119) Google Scholar]. Co-infection of both mitral and aortic valves has been noted in only 4-26% of cases [5Herztein J Ryan JL Mangi RJ Greco TPM Andriole VT. Optimal therapy for enterococcal endocarditis.Am J Med. 1984; 76: 186-191Abstract Full Text PDF PubMed Scopus (45) Google Scholar,16Wilson WR Wilkowske CJ Wright AJ Sande MA Geraci JE. Treatment of streptomycin-susceptible and streptomycin-resistant enterococcal endocarditis.Ann Intern Med. 1984; 100: 816-823Crossref PubMed Scopus (115) Google Scholar]. Although major embolic events have been documented in 2-70% of cases of endocarditis occurring on native valves [2Megran DW. Enterococcal endocarditis.Clin Infect Dis. 1992; 15: 63-71Crossref PubMed Scopus (123) Google Scholar,3Kaye D. Changing pattern of infective endocarditis.Am J Med. 1985; 78: 157-162Abstract Full Text PDF PubMed Scopus (81) Google Scholar], some studies of enterococcal disease have reported a lower frequency of emboli (2-8%) [4Maki DG Agger WA. Enterococcal bacteremia: clinical features, the risk of endocarditis and management.Medicine (Baltimore). 1988; 67: 248-269Crossref PubMed Scopus (261) Google Scholar]. The mortality of enterococcal endocarditis in the antibiotic era has been described as being between 0% and 43% [4Maki DG Agger WA. Enterococcal bacteremia: clinical features, the risk of endocarditis and management.Medicine (Baltimore). 1988; 67: 248-269Crossref PubMed Scopus (261) Google Scholar,5Herztein J Ryan JL Mangi RJ Greco TPM Andriole VT. Optimal therapy for enterococcal endocarditis.Am J Med. 1984; 76: 186-191Abstract Full Text PDF PubMed Scopus (45) Google Scholar] and the relapse rate following standard therapy has been reported to range between 0% and 14% [5Herztein J Ryan JL Mangi RJ Greco TPM Andriole VT. Optimal therapy for enterococcal endocarditis.Am J Med. 1984; 76: 186-191Abstract Full Text PDF PubMed Scopus (45) Google Scholar,16Wilson WR Wilkowske CJ Wright AJ Sande MA Geraci JE. Treatment of streptomycin-susceptible and streptomycin-resistant enterococcal endocarditis.Ann Intern Med. 1984; 100: 816-823Crossref PubMed Scopus (115) Google Scholar]. Our patient developed a transient ischemic attack, presumably due to a cardiac embolus. Although age- related thrombosis could not be ruled out, the patient could have benefited from cardiac surgery, which was not performed because of the presence of the oncocytoma.