Infective Endocarditis From Escherichia Coli Sepsis in the Setting of Mitral Valve Clipping: An Uncommon and Complex Presentation

Document Type

Conference Proceeding

Publication Date

5-1-2025

Publication Title

Am J Respir Crit Care Med

Keywords

antihypertensive agent, apixaban, ceftriaxone, creatinine, lactic acid, noradrenalin, troponin, Actinobacillus, adult, artificial heart pacemaker, atrial fibrillation, bacteremia, bacterial infection, Cardiobacterium, case report, clinical article, complication, conference abstract, diagnosis, drug therapy, echocardiograph, echocardiography, Eikenella, Escherichia coli, fatigue, female, heart disease, heart ejection fraction, heart rate, hemodynamics, human, hypotension, implantable cardioverter defibrillator, infective endocarditis, intensive care unit, leukocyte count, mitral valve, mitral valve clip, mortality rate, nonhuman, nonischemic cardiomyopathy, reflux esophagitis, sepsis, surgery, urinalysis, urinary tract infection, urine culture, valvular heart disease, weakness

Abstract

Background: Mitral valve endocarditis is a rare but serious complication, particularly in patients with pre-existing cardiac pathology, including valvular disease or prior interventions such as mitral valve clipping. Escherichia coli (E. coli), a non-HACEK (Haemophilus species, Actinobacillus, Cardiobacterium, Eikenella, or Kingella) Gram-negative bacillus, is an uncommon cause of infective endocarditis (IE), accounting for 2.5-3% of cases, but carries a significantly higher mortality rate (20-30%) than HACEK-related IE. This case report highlights E. coli-induced mitral valve endocarditis and sepsis in a 76-year-old female with a history of mitral valve clipping. Case Presentation: A 76-year-old female with a history of atrial fibrillation on Eliquis, non-ischemic cardiomyopathy with an implantable cardioverter-defibrillator (ICD) and permanent pacemaker, and mitral valve clipping 5 years ago, presented with weakness and a fall. She reported a gradual onset of weakness and fatigue over 3 days. On arrival, the patient was hypotensive (70/31 mmHg), febrile (102°F), and had a heart rate of 100 beats per minute, suggestive of sepsis. Initial labs showed elevated white blood cell count (24.9 Thous/mcL), lactic acid (2.6 mmol/L), troponin (0.38 ng/mL), and creatinine (2.67 mg/dL). Urinalysis was positive for urinary tract infection (UTI). The patient received a 30 cc/kg fluid bolus, blood and urine cultures were obtained, and Intravenous (IV) ceftriaxone was started. Despite this, her hypotension persisted, requiring Intensive Care Unit transfer and IV norepinephrine for hemodynamic support. Due to elevated troponin levels, a transthoracic echocardiogram (TTE) revealed a reduced ejection fraction (45-50%), severe mitral valve thickening, and moderate regurgitation, without vegetation. Suspecting endocarditis, a transesophageal echocardiogram (TEE) showed a clip on the mitral valve, moderate regurgitation, and an echogenic density on the ventral aspect of the mitral valve suggestive of vegetation. Positive blood cultures for E. coli confirmed mitral valve endocarditis likely secondary to E. coli bacteremia from the UTI, progressing to sepsis. The patient received 6 weeks of IV ceftriaxone. Discussion: Endocarditis due to E. coli, a non-HACEK GNB, is uncommon and often linked to urological infections. Prompt diagnosis through echocardiography, cultures, and appropriate combination therapy is essential for improving outcomes, though surgical intervention may be warranted in severe cases. In this case, the patient's mitral valve clip likely predisposed her to endocarditis and subsequent sepsis. This case highlights the importance of considering endocarditis and sepsis in bacteremia cases, especially involving non-HACEK GNB pathogens, and the need for expert collaborative management. (Figure Presented).

Volume

211

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