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1/103. Bacterial endocarditis in a patient with Marfan's syndrome.

    A patient with Marfan's syndrome and subacute bacterial endocarditis is presented. Echocardiographic studies demonstrated dilatation of the aortic root, prolapse of the posterior leaflet of the mitral valve, and the appearance of shaggy echoes on the anterior miltral leaflet, of the kind previously described as representing bacterial vegetations. ( info)

2/103. White-centred retinal haemorrhages (Roth spots).

    Roth spots (white-centred retinal haemorrhages) were classically described as septic emboli lodged in the retina of patients with subacute bacterial endocarditis. Indeed many have considered Roth spots pathognomonic for this condition. More recent histological evidence suggests, however, that they are not foci of bacterial abscess. Instead, they are nonspecific and may be found in many other diseases. A review of the histology and the pathogenesis of these white-centred haemorrhages will be provided, along with the work-up of the differential diagnosis. ( info)

3/103. Cerebral bacterial aneurysms in subacute bacterial endocarditis.

    Bacterial aneurysms are aneurysms which develop on a vascular wall weakened as a result of a bacterial infection. They can develop anywhere. This paper describes a female patient with subacute bacterial endocarditis and multiple cerebral aneurysms. Conservative treatment followed. ( info)

4/103. Subacute bacterial endocarditis with positive cytoplasmic antineutrophil cytoplasmic antibodies and anti-proteinase 3 antibodies.

    OBJECTIVE: To report a potentially important limitation of antineutrophil cytoplasmic antibody (ANCA) testing: positive results in patients with subacute bacterial endocarditis (SBE). methods: We describe 3 patients with SBE who presented with features mimicking ANCA-associated vasculitis (AAV) and positive findings on tests for cytoplasmic ANCA (cANCA) by indirect immunofluorescence and for anti-proteinase 3 (anti-PR3)antibodies by antigen-specific enzyme-linked immunosorbent assay (ELISA). We also reviewed the published literature describing infectious diseases with (misinterpreted) positive ANCA results through a medline search of English-language articles published between 1966 and January 1999. These previously reported cases were reinterpreted using an ANCA scoring system that combines the findings of immunofluorescence and antigen-specific ELISA testing. RESULTS: We are now aware of a total of 7 cases of SBE with positive cANCA and anti-PR3 antibodies. We are not aware of any cases of SBE associated with antimyeloperoxidase/perinuclear ANCA. Clinical manifestations mimicking AAV included glomerulonephritis, purpura, epistaxis, or sinus symptoms in 6 of the patients. Streptococcal species were identified in 5 patients, and cardiac valvular abnormalities were demonstrated in 6. All patients except 1, who died of a complication of SBE, recovered with antibiotic therapy. CONCLUSION: Findings of tests for anti-PR3/ cANCA antibodies may be positive in patients with SBE. When encountering ANCA positivity in patients suspected of having systemic vasculitis, physicians should take appropriate steps to rule out infectious diseases, including SBE, before committing the patient to long-term, aggressive immunosuppressive therapy. ( info)

5/103. Compiling the identifying features of bacterial endocarditis. Vague clues may point to this dangerous infection.

    Bacterial endocarditis is a life-threatening disease. Before the advent of antibiotics, its mortality rate was nearly 100%, but with today's diagnostic and therapeutic advances, it can be successfully managed in most cases. In this article, Drs Harris and Steimle explain the changes that occur when someone, who usually has an underlying cardiac defect, contracts bacteremia with an organism likely to adhere to heart valve surfaces. They describe risk factors, clinical presentations, identification of causative organisms, and empirical and specific therapy. A case report illustrates the many possible manifestations of the disease. ( info)

6/103. Right ventricular and septal anomalies complicated by subacute bacterial endocarditis.

    We report the case of a 31-year-old woman with no history of heart disease. She came to the hospital with fever, dyspnea, palpitation, and edema of the lower extremities. She was found to have aortic, mitral, and pulmonary valve insufficiency, and the initial diagnosis was subacute bacterial endocarditis. At surgery, we replaced the aortic and mitral valves with mechanical prostheses and the pulmonary valve with a bioprosthesis. The prostheses were soaked intraoperatively with fluconazole and the heart chambers were irrigated with povidone-iodine to prevent infection by bacteria and fungi. We also found 2 previously unsuspected anomalies: 1 was a muscular bundle that divided the right ventricle into 2 chambers, and the other was a ventricular septal defect, 1.0 cm in diameter. We resected the muscular bundle and patched the septal defect. The patient had an uneventful postoperative course and was in new york Heart association functional class I at the 15-month follow-up visit. We speculate that this patient's congenital anomalies made the heart more susceptible to damage from the endocarditis. Therefore, any patient who has infective endocarditis should also be examined closely for congenital defects. ( info)

7/103. Recurrent streptococcal endocarditis.

    A woman is described who suffered from multiple episodes of Streptococcus viridans endocarditis over a decade. The possible mechanisms for recurrence are discussed and the past literature on recurrent endocarditis is reviewed. In addition, the patient developed fever and eosinophilia in response to penicillin V, while tolerating penicillin g without incident. ( info)

8/103. Pneumococcal endocarditis of subacute evolution.

    With the development of penicillin, streptococcus pneumoniae has become an uncommon cause of bacterial endocarditis in adults. Subacute manifestation of pneumococcal endocarditis has been reported a few times in the literature, but most reports define the disease as acute, severe, and having a high mortality rate. We report the case of a 58-year-old male with subacute bacterial endocarditis due to streptococcus pneumoniae. We stress the low frequency of this agent as a cause of endocarditis and the atypical evolution of this case. The pathophysiology, clinical manifestations and evolution, and the therapeutical options for this type of infection are also discussed. ( info)

9/103. Diffuse crescentic glomerulonephritis in bacterial endocarditis.

    Renal involvement is common in patients with bacterial endocarditis. The most common bacteria are staphylococci and streptococci, and the commonest renal histopathological lesion is a diffuse proliferative and exudative type of glomerulonephritis. Very rarely, patients may present with an extensive glomerular epithelial crescent formation with a rapid deterioration in the renal function. This study reviews the published literature on diffuse crescentic glomerulonephritis in bacterial endocarditis and reports a 24-year-old male patient with endocarditis due to Capnocytophagia species, a gramnegative facultative anaerobic bacillus, which normally inhabits the oral cavity. Appropriate antibiotic therapy is essential to eradicate the infection. A brief course of corticosteroid therapy may be helpful in those with deteriorating renal function. plasmapheresis may be useful in those with persistent hypocomplementemia, increased circulating immune complexes, and a progressive deterioration in the renal function. Removal of vegetation or valve replacement may be necessary. prognosis is generally good. ( info)

10/103. Nodular regenerative hyperplasia of the liver.

    Nodular regenerative hyperplasia of the liver, an uncommonly reported and poorly defined clinicopathological entity, obscured clinical diagnosis and was misdiagnosed on hepatic biopsy in a recent case. Approximately 19 cases are recorded in the English literature. Six patients had Felty's syndrome, about 12 patients had congestive heart failure, and the patient under discussion had subacute bacterial endocarditis. light- and electron-microscopic examination was utilized to define nodular regenerative hyperplasia pathologically. Features common to all reported cases are discussed but elucidation of the pathogenesis of nodular regenerative hyperplasia must await further investigation. ( info)
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