Lactobacillus paracasei endocarditis of bioprosthetic aortic valve presenting with recurrent embolic strokes

Abstract

Introduction. Lactobacillus prosthetic valve endocarditis is a rare infection caused by Lactobacillus bacteria. This bacterium is found in the normal flora of the human mouth, gastrointestinal tract and female genital tract. While there have been isolated cases of Lactobacillus bacteraemia and endocarditis, the infections are associated with comorbidities, immune deficiency, dental manipulation procedures and other medical history. This case of bioprosthetic valve endocarditis caused by Lactobacillus paracasei is unusual, as the patient was immune-competent and treated with pre-procedural antibiotics. Case. We present a case of a 65-year-old male who underwent a dental extraction. He presented after 3 months of fever, chills and fatigue. On initial presentation, blood cultures were positive for alpha-haemolytic streptococcus bacteraemia. He was treated with IV penicillin and underwent aortic valve replacement with a bioprosthetic valve and excision of the mitral vegetation with repair of the mitral valve. Two years later, he had a tooth extraction after being treated properly with antibiotics. Three months later he presented with difficulty speaking, left leg weakness and increased drooling. All testing was normal. Three months later he presented with left side lower extremity weakness and expressive aphasia. He was diagnosed with bioprosthetic aortic valve endocarditis and was treated with IV penicillin and gentamicin for 6 weeks and then switched to oral penicillin. He remained stable. Conclusions. L. paracasei can potentially be a cause of complicated endocarditis in patients with prosthetic heart valves undergoing dental procedures. Timely culture-guided antibiotic therapy is critical and may obviate the need for valve surgery.

Lactobacilli Infection Case Reports in the Last Three Years and Safety Implications

“…Lactobacilli were isolated from blood [ 15 , 16 , 17 , 18 , 20 , 21 , 22 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 49 , 52 , 55 , 56 , 57 ], diseased valve tissue [ 23 ], abscess fluids [ 48 , 51 , 52 , 54 , 57 , 58 ], cerebrospinal fluid (CSF) [ 46 ], marrow [ 30 ], arthrocentesis aspiration fluid [ 53 ] in anaerobiosis and, in some cases, also in aerobiosis [ 15 , 34 ]. Use of automated microbial detection system, i.e., BACT/ALERT 3D or the BACTEC systems (BioMérieux) with incubation at 35 °C were mentioned in some reports [ 23 , 31 , 34 ].…”

“…Most of the cases of endocarditis had a deceitful and slow onset, with or without fever, with symptoms varying among patients and including weight loss, fatigue, dyspnea, cough, chills, sweats, abdominal pain with nausea and vomiting, lumbar pain, syncope, with valvular vegetations becoming detectable after many days or even months from the beginning of symptoms [ 14 , 15 , 16 , 17 , 18 , 20 , 22 , 23 , 27 , 29 , 30 , 31 , 32 , 34 ]. In many cases replacement of the aortic valve [ 15 , 16 , 17 , 18 , 20 , 21 , 26 , 28 , 30 , 35 ], in one case replacement of the mitral valve [ 25 ], and in another case replacement of both aortic and mitral valves [ 23 ] were necessary.…”

Lactobacilli Infection Case Reports in the Last Three Years and Safety Implications

“…Lactobacilli were isolated from blood [15,16,17,18,20,21,22,23,24,25,26,27,29,30,31,32,33,34,35,36,37,38,40,41,42,43,44,45,46,47,49,52,55,56,57], diseased valve tissue [28], abscess fluids [48,51,52,54,57,58], cerebrospinal fluid (CSF) [46], marrow [36], arthrocentesis aspiration fluid [53] in anaerobiosis and, in some cases, also in aerobiosis [40,15]. Use of automated microbial detection system, i.e.…”

“…[42] hypothesized that the origin of the infectious agent was a yogurt made at home by the patient, though isolates from yogurt were not examined. Most of the cases of endocarditis had a deceitful and slow onset, with or without fever, with weight loss, fatigue, dyspnea, cough, chills, sweats, abdominal pain with nausea and vomiting, lumbar pain, syncope, with valvular vegetations becoming detectable after many days or even months from the beginning of symptoms [14,15,16,17,18,25,27,28,32,34,36,37,38,40]. In many cases replacement of the aortic valve [15,16,17,18,25,26,31,33,36,41], in one case replacement of the mitral valve [30] and in another case replacement of both aortic and mitral valves [28] was necessary.…”

“…• recurrent transient ischemic attacks possibly related to a central embolic source causing left side lower extremity weakness and expressive aphasia [15]; • peroneal mycotic pseudoaneurysm supposed to be caused by seeding of blood-borne bacteria to the vasa vasorum of the artery wall or septic emboli from the infected heart valve [41]; • acute respiratory failure and septic shock [17];…”