INTRODUCTION: Infective endocarditis in patients with prosthetic valves is a serious life threatening infection, that in many cases need surgical removal of the valve and prolonged antibiotics. Gemella species are normal commensals of the oral mucosa, but can cause soft tissue infections, endocarditis and meningitis. We report the first case of prosthetic valve endocarditis associated with perivalvular abscess and aorto atrial fistula caused by Gemella sanguinis.
CASE PRESENTATION: A 28 year old female with a history of rheumatic heart disease manifested by mitral stenosis and aortic regurgitation underwent bivalvular replacement with a St.Jude's valve. Eight months later she developed fever and chills for 2 weeks that did not subside with 1 week of outpatient antibiotics. She also had intermittent irregular palpitations for 1 week. There were no sick contacts, recent travel, pets at home or recent dental procedures. On initial examination, body temperature was 101.4 F, pulse 110/min, and blood pressure 110/60 mm Hg. Oral exam showed severe dental caries. Electrocardiogram on admission showed first degree A-V block. Cardiovascular exam was significant for an early diastolic murmur best heard in the aortic region. Blood cultures were drawn and empiric antibiotics were started. Trans esophageal echocardiogram showed 1cm mobile echo density on the left ventricular side of the aortic valve ring, suggestive of a vegetation and increased thickness of the aortic wall on the posterior aspect with a soft tissue echo density suggestive of a perivalvular abscess. Blood cultures grew Gemella Sanguinis. The antibiotics were adjusted to Ceftriaxone and Gentamicin based on sensitivities. On day 12 of hospitalization she underwent sternotomy with removal of mechanical aortic valve with debridement of aortic root with pericardial patch repair. Introoperatively an aorto atrial fistula was diagnosed and was closed with an aortic homograft and re implantation of the coronary artery. Patient had an uneventful post operative hospital course and was discharged home for 6 weeks of antibiotics.
DISCUSSIONS: Gemella is a catalase negative, facultative anaerobic gram positive coccus which is a commensal of oral mucosa. Gemella species are rare causes of infective endocarditis with approximately 45 cases being reported in the literature. Among these, only three cases were caused by Gemella sanguinis. Gemella sanguinis was first identified in 1998 in a descriptive study of six specimen isolates from bacteremic patients, one among who had sub acute bacterial endocarditis. Since then two more cases of infective endocarditis with Gemella sanguinis have been reported in the literature. All the three cases were infection of native valves. This case is unique in that, it is the first reported case of Gemella sanguinis mechanical valve endocarditis associated with severe anatomical destruction manifested by both peri valvular abscess and aorto atrial fistula. Risk factors for infection with Gemella spp include dental disease and underlying heart disease. Few cases of infection associated with intravenous drug use and gastrointestinal procedures were also reported. Our patient had multiple dental caries and had underlying heart disease.
CONCLUSION: Gemella sanguinis infective endocarditis is a rare cause of endocarditis. Risk factors include poor dental hygiene and structural heart disease. Treatment is crucial to prevent serious complications.
DISCLOSURE: Prashant Gundre, No Financial Disclosure Information; No Product/Research Disclosure Information