Bartonella native valve endocarditis: the first brazilian case alive and well

Abstract

Bartonella is an important cause of blood culture-negative endocarditis in recent studies. Seroprevalence studies in the States of Minas Gerais and Rio de Janeiro have shown Bartonella IgG positivity around 14% in healthy adults and 40% in HIV seropositive adults, respectively. A case report of a 46-year-old white male with moderate aortic regurgitation (AR) due to rheumatic heart disease (RHD), admitted due to worsening heart failure, is presented. Clinical features were apyrexia, anemia, polyclonal hypergammaglobulinemia, hematuria and splenomegaly. He was submitted to surgery due to worsening AR. Histopathology of the excised valve showed active bacterial endocarditis and underlying RHD. Routine blood cultures were negative. Indirect immunofluorescence (IFI) assays for Coxiella burnetii were non-reactive. Bartonella henselae IgG titer was 1:4096 prior to antibiotics and 1:512 14 months after treatment. History of close contact with a young cat during the months preceding his admission was elicited. Key-Words: Bartonella spp., infective endocarditis, blood culture-negative infective endocarditis, rheumatic heart disease, serology, indirect immunofluorescence.Bartonella endocarditis has been recognized since the first reports from the 1990's [1-8] and its importance in blood culture-negative infective endocarditis (IE) has been reinforced in recent studies [9][10][11][12][13][14]. Although there are three national rickettsial diseases reference laboratories in Brazil (FIOCRUZ, Rio de Janeiro, Adolpho Lutz, in São Paulo, and FUNEDE, in Minas Gerais), only two probable fatal cases of Bartonella endocarditis have been reported so far in our country [14]. There are also case reports of Bartonella disease such as bacillary angiomatosis in HIV-positive individuals, disseminated disease in children and cat-scratch disease in Brazil, and there are also groups who work experimentally with Bartonella [15][16][17][18][19][20][21]. Two seroprevalence studies, one in the State of Minas Gerais [22], and the other in the city of Rio de Janeiro [23], show that the Brazilian population is significantly exposed to Bartonella. We present the first case of Bartonella endocarditis from Brazil, whose diagnosis was done ante-mortem and who had an extremely favourable outcome. Case ReportA 46-year-old white male patient was admitted to Instituto Nacional de Cardiologia (INC), Rio de Janeiro, due to worsening heart failure in October 2005. He was born and resided in São Gonçalo, a town situated one hour from Rio de Janeiro. He became ill in 1994, during his job as a security officer. Essential hypertension was diagnosed then, as well as valvular disease. He was followed up in INC outpatient clinic. His first transthoracic echocardiography (TTE) in 1995 showed moderate aortic regurgitation and a calcified aortic valve. He retired a few years later due to heart failure. He was a poor historian, but his present admission was due to progression of fatigue and dyspnea on minimal exertion over the past four months. He denied fever. He was on...

Aproximación clínica y principales rickettsiosis transmitidas por garrapatas presentes en Latinoamérica

“…Se han documentado casos humanos de R. rickettsii en los siguientes países de la región: Brasil, donde es conocida como fiebre manchada brasileña [6][7][8][9][10] Los síntomas suelen iniciarse entre 5 y 10 días después de la picadura de la garrapata, y dado que gran parte de estas picaduras pueden pasar desapercibidas, se debe tener un alto índice de sospecha. El cuadro clínico incluye fiebre elevada de aparición súbita, con escalofríos, malestar general, mialgias, artralgias, cefalea, vómitos, fotofobia y exantema.…”

“…La frecuencia de exantema es variable en las distintas series, habiéndose descrito entre 18 y 100% 8,12,13,20,23,25 . Se han observado manifestaciones gastrointestinales, en especial en los niños, consistentes en náuseas, vómitos y dolor abdominal 9,10,13,15,25,27 . En un paciente se describió Infectología al Día edema periorbitario con corioretinitis 27 .…”

“…De forma muy excepcional, (solamente en dos comunicaciones en Latinoamérica), se ha documentado la presencia de escara en el sitio de la picadura y linfadenopatía regional 11,17 . En aproximadamente 25% de los casos se presentan síntomas de gravedad, como insuficiencia respiratoria, shock, ictericia, insuficiencia renal, efusión pericárdica y pleural, manifestaciones hemorrágicas que incluyen necrosis de dedos, ortejos o del pabellón auricular y compromiso neurológico en forma de convulsiones, disminución de la conciencia, parestesias, rigidez de extremidades y debilidad muscular 8,10,12,13,[15][16][17]21,24,[27][28][29] . En los casos de desenlace fatal, éste se produce por insuficiencia respiratoria o falla multiorgánica 23,27,28 .…”

“…En los exámenes de laboratorio se puede apreciar leucocitosis o leucopenia con desviación izquierda, trombocitopenia, hiponatremia, hipoalbuminemia, aumento de las transaminasas y creatininemia, y ocasionalmente albuminuria 8,[10][11][12][13]16,17,20,21,23,[25][26][27][28] . Las publicaciones que incluyen análisis de líquido cefalorraquídeo han mostrado un resultado alterado en 6 de 9 pacientes, con pleocitosis mononuclear en tres y polimorfonuclear (PMN) en tres 10,12,27 .…”

“…Las publicaciones que incluyen análisis de líquido cefalorraquídeo han mostrado un resultado alterado en 6 de 9 pacientes, con pleocitosis mononuclear en tres y polimorfonuclear (PMN) en tres 10,12,27 . En estos casos, la cuantía de los leucocitos en el LCR no ha superado las 213 células por mm 3 .…”