Streptococcus agalactiae endocarditis of the native valve in the patient with end-stage renal disease

SESSION TITLE: Infections In and Around the Heart Case PostersSESSION TYPE: Case Report PostersPRESENTED ON: 10/17/2022 12:15 pm - 01:15 pmINTRODUCTION: Streptococcus agalactiae (S. agalactiae) is a known cause of invasive infections in pregnant patients, and neonates. However little is known that it can affect elderly men too. S. agalactiae infectious endocarditis (IE) is a rare manifestation associated with high mortality risk. We report the case of a patient with end-stage renal disease who developed S.agalactiae endocarditis.CASE PRESENTATION: A 73-year-old male with end-stage renal disease on hemodialysis presented to the hospital with fever, chills, and altered mental status for 2 days. According to the family, the patient missed a session of hemodialysis resulting in increased confusion, nausea, and vomiting. Vitals signs included regular tachycardia of 108 beats/minute, blood pressure of 140/60 mmHg, respiratory rate of 18 breaths/minute, oxygen saturation of 97% on room air, and febrile 104 F. Physical exam revealed a 3/6 systolic murmur in the left 4th intercostal space radiating towards the axilla. Blood urea nitrogen and creatinine were 120 and 7. The blood cultures were positive for S. agalactiae. This prompted a Transthoracic Echocardiogram that demonstrated a large, mobile mass on the mitral valve affecting anterior and posterior leaflets with moderate mitral regurgitation. Due to high concern for infectious endocarditis, a transesophageal echocardiogram was performed, demonstrating sessile vegetation on the mitral valve. At this stage, the patient was managed with penicillin G and gentamicin. He was discharged with antibiotic therapy and referred to a medical center for cardiothoracic surgery evaluation.DISCUSSION: S. agalactiae bacteremia may result in endocarditis, typically affecting the mitral valve, and is associated with a high risk of embolization. Traditionally, pregnant and post-partum women were affected by group B streptococcal (GBS) endocarditis. However, the epidemiology of GBS changed since the 1960s, and its occurrence can now be seen in non-pregnant women and men. The predisposing risk factors are liver cirrhosis, cancer, diabetes, and immunosuppression. Chronic kidney disease also makes the patient susceptible to the development of invasive S. agalactiae. However, IE is remaining the unusual complication of GBS. In comparison to other types of endocarditis, it has an aggressive clinical picture with local and systemic complications due to extensive valve destruction. Management with only antibiotics is not sufficient and surgery is frequently required. Despite this, mortality remains high, especially in the case of the bioprosthetic valve. Furthermore, S. agalactiae IE in the context of underlying diseases can be even more challenging to manage.CONCLUSIONS: S. agalactiae IE is a rare clinical entity, and not typically expected in non-pregnant individuals. The underlying end-stage kidney disease can be one of the predisposing risk factors for the development of fatal S. agalactiae infectious endocarditis.Reference #1: Farley MM. Group B streptococcal disease in nonpregnant adults. Clin Infect Dis. 2001 Aug 15;33(4):556-61. doi: 10.1086/322696. Epub 2001 Jul 20. PMID: 11462195.Reference #2: Raabe VN, Shane AL. Group B Streptococcus (Streptococcus agalactiae). Microbiol Spectr. 2019;7(2):10.1128/microbiolspec.GPP3-0007-2018. doi:10.1128/microbiolspec.GPP3-0007-2018Reference #3: Sambola A, Miro JM, Tornos MP, Almirante B, Moreno-Torrico A, Gurgui M, Martinez E, Del Rio A, Azqueta M, Marco F, Gatell JM. Streptococcus agalactiae infective endocarditis: analysis of 30 cases and review of the literature, 1962-1998. Clin Infect Dis. 2002 Jun 15;34(12):1576-84. doi: 10.1086/340538. Epub 2002 May 24. PMID: 12032892.DISCLOSURES: No relevant relationships by Nemanja DraguljevicNo relevant relationships by Katherine HodginNo relevant relationships by Kristina MenchacaNo relevant relationships by Catherine Ostos Perez SESSION TITLE: Infections In and Around the Heart Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Streptococcus agalactiae (S. agalactiae) is a known cause of invasive infections in pregnant patients, and neonates. However little is known that it can affect elderly men too. S. agalactiae infectious endocarditis (IE) is a rare manifestation associated with high mortality risk. We report the case of a patient with end-stage renal disease who developed S.agalactiae endocarditis. CASE PRESENTATION: A 73-year-old male with end-stage renal disease on hemodialysis presented to the hospital with fever, chills, and altered mental status for 2 days. According to the family, the patient missed a session of hemodialysis resulting in increased confusion, nausea, and vomiting. Vitals signs included regular tachycardia of 108 beats/minute, blood pressure of 140/60 mmHg, respiratory rate of 18 breaths/minute, oxygen saturation of 97% on room air, and febrile 104 F. Physical exam revealed a 3/6 systolic murmur in the left 4th intercostal space radiating towards the axilla. Blood urea nitrogen and creatinine were 120 and 7. The blood cultures were positive for S. agalactiae. This prompted a Transthoracic Echocardiogram that demonstrated a large, mobile mass on the mitral valve affecting anterior and posterior leaflets with moderate mitral regurgitation. Due to high concern for infectious endocarditis, a transesophageal echocardiogram was performed, demonstrating sessile vegetation on the mitral valve. At this stage, the patient was managed with penicillin G and gentamicin. He was discharged with antibiotic therapy and referred to a medical center for cardiothoracic surgery evaluation. DISCUSSION: S. agalactiae bacteremia may result in endocarditis, typically affecting the mitral valve, and is associated with a high risk of embolization. Traditionally, pregnant and post-partum women were affected by group B streptococcal (GBS) endocarditis. However, the epidemiology of GBS changed since the 1960s, and its occurrence can now be seen in non-pregnant women and men. The predisposing risk factors are liver cirrhosis, cancer, diabetes, and immunosuppression. Chronic kidney disease also makes the patient susceptible to the development of invasive S. agalactiae. However, IE is remaining the unusual complication of GBS. In comparison to other types of endocarditis, it has an aggressive clinical picture with local and systemic complications due to extensive valve destruction. Management with only antibiotics is not sufficient and surgery is frequently required. Despite this, mortality remains high, especially in the case of the bioprosthetic valve. Furthermore, S. agalactiae IE in the context of underlying diseases can be even more challenging to manage. CONCLUSIONS: S. agalactiae IE is a rare clinical entity, and not typically expected in non-pregnant individuals. The underlying end-stage kidney disease can be one of the predisposing risk factors for the development of fatal S. agalactiae infectious endocarditis. Reference #1: Farley MM. Group B streptococcal disease in nonpregnant adults. Clin Infect Dis. 2001 Aug 15;33(4):556-61. doi: 10.1086/322696. Epub 2001 Jul 20. PMID: 11462195. Reference #2: Raabe VN, Shane AL. Group B Streptococcus (Streptococcus agalactiae). Microbiol Spectr. 2019;7(2):10.1128/microbiolspec.GPP3-0007-2018. doi:10.1128/microbiolspec.GPP3-0007-2018 Reference #3: Sambola A, Miro JM, Tornos MP, Almirante B, Moreno-Torrico A, Gurgui M, Martinez E, Del Rio A, Azqueta M, Marco F, Gatell JM. Streptococcus agalactiae infective endocarditis: analysis of 30 cases and review of the literature, 1962-1998. Clin Infect Dis. 2002 Jun 15;34(12):1576-84. doi: 10.1086/340538. Epub 2002 May 24. PMID: 12032892. DISCLOSURES: No relevant relationships by Nemanja Draguljevic No relevant relationships by Katherine Hodgin No relevant relationships by Kristina Menchaca No relevant relationships by Catherine Ostos Perez