Review Article

Streptococcus Pyogenes Infective Endocarditis: Case Report and Literature Review

by Atef Akoum1*, Soha Fakhreddine2

1American University of Beirut, Internal Medicine, Lebanon

2Saint George Hospital-Hadath, Department of Infectious Disease, Lebanon

*Corresponding author: Atef Akoum, American University of Beirut, Internal Medicine, Lebanon

Received Date: 17 March, 2024

Accepted Date: 22March, 2024

Published Date: 25 March, 2024

Citation: Akoum A and Fakhreddine S (2024) Streptococcus Pyogenes Infective Endocarditis: Case Report and Literature Review. Cardiol Res Cardio vasc Med 9:238. https://doi.org/10.29011/2575-7083.100238

Abstract

Infective endocarditis (IE) is defined as an infection caused by microorganisms (bacteria or fungi) involving either the heart structures or the great vessels. The progression of IE can become complex due to heart dysfunction and bacterial particles spreading to almost any part of the body through embolization. Staphylococcus aureus and Viridians group streptococci are the predominant causative pathogens. Cases of IE caused by group A β-haemolytic streptococcus (Streptococcus pyogenes) are infrequently reported. Here, we present a case of native mitral valve endocarditis caused by Streptococcus pyogenes in a patient who is an intravenous drug user (IVDU), accompanied by a literature review. The patient had a native mitral valve endocarditis, complicated by brain, lung, spleen, and kidney septic emboli with septic arthritis and abscesses collections, improving after receiving a combination therapy (high dose penicillin with gentamicin). Unfortunately, the patient passed away after two weeks of antibiotic therapy due to a drug overdose.

Introduction

The term infective endocarditis (IE) refers to an infection affecting the inner surface of the heart, suggesting the actual presence of microorganisms within the lesion [1]. The progression of IE may lead to embolization affecting almost any organ, determined by whether the condition affects the right or left side of the heart [2]. IE is a rare entity, with a yearly incidence of about 3–10 per 100,000 people. The Gram-positive cocci of the Staphylococcus, Streptococcus, and Enterococcus species account for 80–90% of IE [3]. Infective endocarditis due to group A, B, C, G streptococci, and Streptococcus angriness group (S. constellates, S. angriness, and S. intermedia’s) is relatively rare [4]. Cases of IE caused by group A β-hemolytic streptococcus (Streptococcus pyogenes) are infrequently reported. Here, we report a Streptococcus pyogenes native mitral valve endocarditis in an adult patient along with a review of the literature.

Case Presentation

A 48-year-old IVDU Lebanese male patient, known to have hepatitis C, working as a car mechanic, was admitted with a fivedays history of fever, chills, abdominal pain, and right elbow and right knee pain. History goes back 15 days prior to presentation when the patient suffered from thermal burns with bilateral hand skin lesions while manipulating a car battery. He did not report any recent dental procedure or surgery. His past cardiac history was unremarkable. Initial vital signs were temperature 38.6°C, heart rate 80 beats/minute, blood pressure 120/80 mmHg, and respiratory rate18 breaths/min. On admission the patient was dyspneic and his cardiovascular examination revealed an apical systolic heart murmur 3/6. He also presented with multiple necrotic skin lesions on his thumb, index, and middle fingers on both hands, surrounded by minimal erythema. The initial laboratory assessment indicated evidence of disseminated intravascular coagulation (DIC) along with an elevated white blood cell count and an elevated C-reactive protein. He also had anemia and thrombocytopenia. Urine analysis was negative for infection. The electrocardiography (ECG) demonstrated sinus rhythm and the chest x-ray was normal. After taking 3 sets of blood cultures, he was empirically started on cefepime and vancomycin. CT scan of

the chest and abdomen showed findings suggesting pulmonary septic emboli, subtotal splenic infarctions, and bilateral renal infarctions. Blood cultures yielded positive results for gram-positive cocci arranged in chains, subsequently identified as Streptococcus pyogenes. Cefepime and vancomycin were stopped on the second day, and the patient was started on high-dose penicillin IV (18 million IU daily). The transthoracic echocardiogram (TTE) documented severe posterior mitral regurgitation with small hypoechoic mobile masses attached to the anterior valve highly suggestive of vegetations. On the second day, he developed an alteration of mental status, and magnetic resonance imaging of the brain showed findings suggesting recent subacute infarction that could be due to septic emboli. On the third day, the patient developed right elbow and knee swelling, erythema, hotness, and increasing tenderness. Magnetic resonance imaging of the left elbow and left knee showed subcutaneous abscess collections with no signs of osteomyelitis. He underwent incision and drainage. Blood cultures were repeated after 48 hours and showed persistent bacteremia with streptococcus pyogenes. Gentamicin IV (3m/kg daily) was added to penicillin on the third day. The trans-esophageal echocardiogram (TEE) documented severe eccentric mitral regurgitation with tiny hypoechoic mobile masse, highly suggestive of vegetations attached to anterior and posterior mitral leaflets (Figures 1 and 2).