Endocarditis as a manifestation of Chlamydia B infection (psittacosis).

Abstract

A case of Chlamydia B (psittacosis) endocarditis is described in a patient with no known previous valve disease. After mitral valve replacement a fall in Chlamydia B antibody titre occurred. At repeat mitral valve replacement five months later for a paravalve leak no evidence of continuing endocarditis was present. Direct confirmation of infection in the patient's apparently healthy budgerigar was obtained. Aspects of the pathogenesis, diagnosis, and treatment are discussed.Endocarditis caused by Chlamydia B is rare. We are aware of only two previous well-authenticated reports in which the patient was diagnosed and treated by valve replacement (Birkhead and Apostolov, 1974;Ward et al., 1975). We report a further case in which the diagnosis was established by histology and serology and in which mitral valve replacement was performed. Case reportA 43-year-old housewife was admitted with a history of tiredness, vague left-sided chest discomfort, and weight loss.There was no history of previous rheumatic fever or other major illness. A soft apical systolic murmur had been noted one year previously but not subsequently confirmed.Examination revealed left basal atelectasis, a soft apical systolic murmur as previously noted, and a short diastolic murmur at the left sternal edge. Mild pyrexia was subsequently noted on two occasions during this admission.Chest x-ray film showed a normal cardiac contour, with left lower lobe atelectasis. Haemoglobin was 8-3 g/dl; white count 5-4 x 109/1; blood film normochromic and normocytic; and erythrocyte sedimentation rate (ESR) 112 mm in the first hour. Repeated blood cultures (six) were negative.Haemophilus influenzae was isolated in the sputum. She was treated with ampicillin and improved, being discharged after 13 days. Three months later she was readmitted because of exertional dyspnoea and orthopnoea. She also complained of retrosternal chest pain and a 'loud' heart beat.She was apyrexial, but now had an apical systolic thrill with a grade 5/6 pansystolic murmur conducted to the axilla. Fine crepitations were heard at the lung bases. The spleen was palpable.Haemoglobin was 11-5 g/dl and ESR 24 mm in the first hour. Chest x-ray film showed gross cardiac enlargement with pulmonary venous congestion.The electrocardiagram was normal on admission but T wave inversion in leads III aVF, V2-V3 and ST segment depression in leads V4-V6 developed over the ensuing weeks.Blood cultures (six) were again repeatedly negative but Chlamydia B complement-fixing antibody titre was 1:128. A presumptive diagnosis of Chlamydia B endocarditis was, therefore, made.Further inquiry revealed that the patient had kept an apparently healthy budgerigar for five years and she had been the only member of the household to clean the cage.Subsequently serology on the other members of the family proved negative. The budgerigar was sacrificed and necropsy showed Chlamydia B in stained smears of the liver.The patient was treated with tetracycline for six weeks but mitral regurgitation was clinically so severe that m...

Serological cross-reactions between Bartonella and Chlamydia species: implications for diagnosis

“…was probably the etiologic agent. Of the 15 remaining patients previously reported as suffering from Chlamydia endocarditis, C. psittaci was considered the etiologic agent in 11 patients (3,7,8,18,19,21,25,30,38,39), C. trachomatis was considered the etiologic agent in 2 patients (6, 37), C. pneumoniae was considered the etiologic agent in 2 patients (10,26), and identification to the species level was not available for the etiologic agent in 1 patient (15). Chlamydia endocarditis and Bartonella endocarditis share clinical and epidemiological features, including a predominant involvement of males, no previous cardiac valve damage, more frequent involvement of aortic valves, diagnostic delay due to the difficulty in culturing the microorganisms, frequent relapses despite adequate antibiotic therapy, extensive valve damage, and the necessity of valve replacement for cure.…”

Infective Endocarditis and Other Intravascular Infections

“…(239)(240)(241)(242)(243) The diagnosis is usually established postmortem or at operation to replace a perforated valve, but very rarely a positive serology leads to the correct diagnosis earlier in the evolution of the disease. (240) The disease can attack normal heart valves, and it is doubtful whether tetracycline alone (even for several months) is sufficient to eliminate the microorganism from an endocardial vegetation. Current thoughts are that the patient should remain on tetracycline(?…”

Endocarditis Due to Rare and Fastidious Bacteria

“…Chlamydia spp. have often been suggested to be causative agents of endocarditis (18,24,60,61,89,132,136,156,201,231,253,285,291,295 19:1054, 1990). However, in a recent review of 10 patients reported to have chlamydial endocarditis, 8 were finally diagnosed with Bartonella endocarditis after their sera were tested by antibody cross-absorption and Western immunobloting (176,225).…”