Pişkin Nihal, Akduman Deniz, Aydemir Hande, Celebi Güven, Oztoprak Nefise, Aktaş Elif
Zonguldak Karaelmas Universitesi Tip Fakültesi, infeksiyon Hastaliklari ve Klinik Mikrobiyoloji Anabilim Dali, Zonguldak.
Mikrobiyol Bul. 2008 Jul;42(3):509-14.
Infective endocarditis has variable clinical presentations and may present with rheumatologic manifestations. Infective endocarditis due to high level aminoglycoside resistant enterococci represents a severe therapeutic challenge as none of the currently recommended treatment regimens are bactericidal against these isolates. In this report, a case of infective endocarditis with double aetiology, high level aminoglycoside resistant Enterococcus faecalis together with methicillin-resistant coagulase-negative staphylococci (MR-CNS), presenting with leukocytoclastic vasculitis and rapidly progressive glomerulonephritis, has been presented. A 48-years-old woman was admitted to our hospital with malaise and non-pruritic purpural rush on her lower extremities. On admission she had no fever or leukocytosis. Skin biopsy showed leukocytoclastic vasculitis and steroid therapy was started. On 12th day of admission rapidly progressive glomerulonephritis was diagnosed and she received plasmapheresis and haemodialysis support. Transthoracic echocardiography (TTE) demonstrated 1 x 1.5 cm vegetation on the mitral valve. An initial diagnosis of infective endocarditis was made and empirical treatment with vancomycin and gentamicin was started. All blood cultures yielded high level aminoglycoside resistant E. faecalis and additionally two of them yielded MR-CNS. Vancomycin was administered in combination with high dose ampicillin and repeated blood cultures taken after administration of ampicillin, revealed no growth. The patient remained afebrile, renal functions improved and a repeat TTE done on 20th day of ampicillin therapy showed waning of the vegetation. On 42nd day of treatment repeat TTE showed new vegetation on the mitral valve and severe valve insufficiency, so the patient was scheduled for mitral valve replacement. She was treated for 12 weeks with vancomycin and ampicillin and recovered successfully. In conclusion; infective endocarditis should be considered in the differential diagnosis of leukocytoclastic vasculitis and rapidly progressive glomerulonephritis. Physicians should document their treatment outcomes and experience with high level aminoglycoside resistant enterococcal infective endocarditis, which is a therapeutic challenge, so that the best therapeutic options can be identified.
感染性心内膜炎临床表现多样，可能伴有风湿性表现。由高水平氨基糖苷类耐药肠球菌引起的感染性心内膜炎是一个严峻的治疗挑战，因为目前推荐的治疗方案中没有一种对这些分离株具有杀菌作用。在本报告中，介绍了一例具有双重病因的感染性心内膜炎病例，即高水平氨基糖苷类耐药粪肠球菌与耐甲氧西林凝固酶阴性葡萄球菌（MR-CNS）同时存在，表现为白细胞破碎性血管炎和快速进行性肾小球肾炎。一名48岁女性因全身不适和下肢非瘙痒性紫癜皮疹入院。入院时她无发热或白细胞增多。皮肤活检显示白细胞破碎性血管炎，开始使用类固醇治疗。入院第12天诊断为快速进行性肾小球肾炎，她接受了血浆置换和血液透析支持。经胸超声心动图（TTE）显示二尖瓣上有1×1.5cm的赘生物。初步诊断为感染性心内膜炎，并开始使用万古霉素和庆大霉素进行经验性治疗。所有血培养均培养出高水平氨基糖苷类耐药粪肠球菌，另外两份培养出MR-CNS。万古霉素与高剂量氨苄西林联合使用，氨苄西林给药后重复进行血培养，结果显示无细菌生长。患者持续无发热，肾功能改善，氨苄西林治疗第20天重复进行的TTE显示赘生物缩小。治疗第42天，重复TTE显示二尖瓣出现新的赘生物和严重瓣膜功能不全，因此患者计划进行二尖瓣置换。她接受了12周的万古霉素和氨苄西林治疗并成功康复。总之；在白细胞破碎性血管炎和快速进行性肾小球肾炎的鉴别诊断中应考虑感染性心内膜炎。医生应记录他们对高水平氨基糖苷类耐药肠球菌性感染性心内膜炎的治疗结果和经验，这是一个治疗挑战，以便确定最佳治疗方案。
