Dlewati Mohammad M, Harrisingh Kamahl, Dabiri Rannah
Internal Medicine, Memorial Healthcare System, Hollywood, USA.
Internal Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA.
Cureus. 2022 Oct 1;14(10):e29810. doi: 10.7759/cureus.29810. eCollection 2022 Oct.
The modified Duke criterion "predisposing heart condition" is poorly defined, and is based on outdated studies of the epidemiology of infective endocarditis (IE). Hypertrophic obstructive cardiomyopathy (HOCM) is not classified as a modified Duke criterion for the diagnosis of IE but is associated with a higher incidence of IE nonetheless. The presence of a cardiovascular implantable electronic device (CIED) is independently associated with an increased risk of IE. Patients with HOCM may be candidates for the implantation of an automated internal cardiac defibrillator (AICD) for the prevention of sudden cardiac death. Previous studies of the risk of IE in patients with HOCM did not make a distinction for patients with CIEDs. We present a case of a 25-year-old female with HOCM and an AICD for primary prevention, who presented with sudden right-sided hemiplegia, aphasia, dysarthria, and a low-grade fever. CT angiography demonstrated large vessel occlusion of the terminal left internal carotid artery and proximal middle cerebral artery (MCA), prompting emergent treatment with mechanical thrombectomy, which achieved full recanalization and full reperfusion. Cardioembolic stroke was suspected. She had no arrhythmias, a transthoracic echocardiogram showed new mitral valve vegetation. The etiology of the stroke was determined to be septic emboli from mitral valve subacute bacterial endocarditis and two blood cultures grew staph epidermidis. Ten days prior to presentation, she had undergone removal of an etonogestrel implant in her arm, and this was the suspected source of initial bacteremia and valvular seeding. She was treated with a six-week course of vancomycin with improvement and maintained on daily minocycline as long as the AICD were to remain in place. Our patient started developing symptoms of endocarditis after the removal of her etonogestrel implant, had no other recent procedures, and had good dentition. Hence, we maintain that this was the likely source of her initial bacteremia that led to valvular seeding and resultant IE. This is the first reported case of etonogestrel implant removal-related endocarditis. Further studies of the association between etonogestrel implant removal, transient bacteremia, and valvular seeding leading to IE are warranted. Clinicians should be reminded of the increased risk of IE in patients with HOCM. Identifying HOCM patients at higher risk for IE, i.e. dilated left atrium and/or CIEDs is easier to accomplish with current cardiac imaging techniques.
改良的杜克标准中“易患心脏病情况”定义不明确，且基于感染性心内膜炎（IE）流行病学的过时研究。肥厚型梗阻性心肌病（HOCM）未被归类为IE诊断的改良杜克标准，但仍与IE的较高发病率相关。心血管植入式电子设备（CIED）的存在与IE风险增加独立相关。HOCM患者可能是植入自动体内心脏除颤器（AICD）以预防心脏性猝死的候选人。先前关于HOCM患者IE风险的研究未对有CIED的患者进行区分。我们报告一例25岁患有HOCM且植入AICD进行一级预防的女性患者，她出现突发右侧偏瘫、失语、构音障碍和低热。CT血管造影显示左侧颈内动脉末端和大脑中动脉近端（MCA）的大血管闭塞，促使紧急进行机械取栓治疗，实现了完全再通和完全再灌注。怀疑是心源性栓塞性卒中。她没有心律失常，经胸超声心动图显示二尖瓣有新的赘生物。卒中的病因确定为二尖瓣亚急性细菌性心内膜炎的脓毒性栓子，两次血培养培养出表皮葡萄球菌。在出现症状前十天，她接受了手臂上依托孕烯植入剂的取出，这被怀疑是初始菌血症和瓣膜定植的来源。她接受了为期六周的万古霉素治疗，病情好转，只要AICD仍在位，就每日服用米诺环素维持治疗。我们的患者在取出依托孕烯植入剂后开始出现心内膜炎症状，近期没有其他手术操作，且牙齿状况良好。因此，我们认为这很可能是她初始菌血症的来源，导致瓣膜定植和由此引发的IE。这是首例报道的与依托孕烯植入剂取出相关的心内膜炎病例。有必要进一步研究依托孕烯植入剂取出、短暂菌血症和导致IE的瓣膜定植之间的关联。应提醒临床医生HOCM患者IE风险增加。利用当前的心脏成像技术更容易识别IE风险较高的HOCM患者，即左心房扩大和/或有CIED的患者。
