Background Infective endocarditis (IE) is the most feared complication of Staphylococcus aureus bacteremia (SAB). Transesophageal echocardiogram (TEE) is generally recommended for all patients with SAB, however, supporting data for this are limited. We previously developed a scoring system, “PREDICT”, that quantifies the risk of IE and identifies patients who would benefit the most from undergoing TEE. The current prospective investigation aims to validate this score. Methods We prospectively screened all consecutive adults (≥18 years) hospitalized with SAB at three Mayo Clinic sites between January 2015 and March 2017. Results Of 220 patients screened, 199 with SAB met study criteria and were included in the investigation. Of them, 23 (11.6%) patients were diagnosed with definite IE within 12 weeks of initial presentation based on modified Duke’s criteria. Using the previously derived PREDICT model, the day 1 score of ≥4 had a sensitivity of 30.4% and a specificity of 93.8%, whereas day 5 score of ≤2 had a sensitivity and negative predictive value of 100%. Additional factors including surgery or invasive procedure in the past 30 days, prosthetic heart valve, and higher number of positive blood culture bottles in the first set of cultures were associated with increased risk of IE independent of the day 5 risk score. Conclusion We validated the previously developed PREDICT scoring tools for stratifying risk of IE, and the need for undergoing a TEE, among cases of SAB. We also identified other factors with predictive potential, although larger prospective studies are needed to further evaluate possible enhancements to the current scoring system.
A 52-year-old Caucasian American male without any significant past medical history presented from an outside hospital for evaluation and treatment of recurrent hemophagocytic lymphohistiocytosis (HLH) of unclear etiology. The patient reported feeling well until 2 months prior to initial evaluation at an outside institution, when he developed fever, night sweats, knee arthralgias, and an unintentional 7-kg weight loss. A complete blood count revealed pancytopenia with severe neutropenia and thrombocytopenia. He was admitted to a local hospital, where a bone marrow biopsy specimen was obtained and a diagnosis of HLH was made. A workup for the underlying cause of HLH was unrevealing; genetic testing for inheritable forms of HLH was negative. He received nine doses of etoposide along with dexamethasone. He was then discharged but presented again to the same hospital with recurrent fever after 2 days. Once again, a complete blood count was notable for pancytopenia. The patient was readmitted and transferred to our hospital for further evaluation of recurrent HLH and the potential need for bone marrow transplantation. Upon admission to our hospital, the patient was pale, diaphoretic, and febrile (temperature, 39.3°C) but otherwise appeared well. He had a widespread truncal and extremity rash with nonpalpable erythema and desquamation. The rest of the physical examination was normal. Pertinent laboratory results are listed in Table 1. A fourth-generation HIV-1/2 antigen/antibody test was negative. Abdominal ultrasound revealed an echogenic liver and mild splenomegaly (14.3 cm at its maximum dimension). A repeat bone marrow biopsy specimen was obtained; the patient continued 2 mg oral dexamethasone while awaiting the results. Histologic examination of a bone marrow biopsy specimen (hematoxylin and eosin stain) and aspirate (Wright-Giemsa stain) subsequently demonstrated hypercellular (60 to 70%) bone marrow with increased hemophagocytic macrophages. Also noted within the macrophages were abundant round-to-oval objects that were morphologically consistent with Leishmania species amastigotes (Fig. 1 and 2). These objects were negative by Gomori methenamine silver staining, thus excluding similar-appearing small yeasts from the differential diagnosis. Leishmania antibodies were also detected in his serum. The bone marrow was sent to the Centers for Disease Control and Prevention (CDC), where DNA amplification and sequencing identified the causative agent of his visceral leishmaniasis (VL) as Leishmania infantum. Upon further questioning, the patient reported a 10-day vacation with his family in Rome, Venice, and Florence, Italy, 3 months prior to the onset of his symptoms. They stayed in hotels in Rome and Venice, but in Florence, they vacationed in a restored stone farmhouse on a hill overlooking the city. There were dogs on the property
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