Neurological Complications of Infective Endocarditis

Abstract

We reviewed the files of 80 successive patients with native and prosthetic valve endocarditis admitted to Riyadh Armed Forces Hospital. Neurological complications (NC) occurred in 28 (35%) patients. The valves involved were mitral in 12 (43%), aortic in eight (29%), combined mitral and aortic lesions in six (21%), and others in two (7%). The common causative organisms were Streptococci in 12 (43%), Staphylococcus aureus and Staphylococcus epidermides, both occurring in four (14%). Compared to the 52 infective endocarditis patients with no neurological complications (NNC), the NC occurred more frequently in male patients, those with aortic valve lesion, those with atrial fibrillation, those with delayed therapy and those with causative organisms being Streptococci or Staphylococci. Eleven patients died (39%), 12 (43%) recovered with motor sequelae, six (21%) had seizure disorder, and five (18%) had full recovery. The frequency of neurological complications and mortality is comparable to those reported in the literature; however, the frequency of strokes was higher in our patients. The incidence of neurological complications in infective endocarditis is 20%-40%. 4 Stroke is the most common neurological complication occurring in patients with infective endocarditis (IE).2 Intracranial hemorrhage is identified in 5% of cases 6 and cerebral infarctions in 14%-19% 3,5,7 other complications include acute meningitis, brain abscess, encephalopathy, seizures and headache. 1,3,5 Rarely, back pain with root lesion due to intervertebral disc infection or acute mononeuropathy may occur.1,3 Despite the introduction of potent antimicrobial agents and new diagnostic and therapeutic procedures, the neurological complications remain high.1,3 We retrospectively reviewed 80 successive patients with IE who were admitted to Riyadh Armed Forces Hospital between 1981-1993, in order to evaluate the frequency, pattern, etiology and prognosis of neurological complications in patients with IE. Material and MethodsWe reviewed the files of all patients with a first attack of native or prosthetic valve endocarditis admitted to Riyadh Armed Forces Hospital between 1980 and 1993, The patients we included fulfilled two or more of the following criteria: 1) clinical picture suggestive of IE, such as persistent fever with heart murmurs; peripheral stigmata of IE, such as Roth's spots, conjunctival petechiae, Janeway's lesions, Osier's node and splenomegaly; and immunologic abnormalities such as rheumatoid factors, cryoglobulins, hyperglobulinemia or active urinary sediment; 2) two or more blood cultures growing organisms or positive serology in blood culture-negative IE; 3) direct evidence of IE by positive vegetations on echocardiogram or vegetations at surgery; and 4) exclusion of other causes of septicemia.Out of 150 charts reviewed, only 80 patients (54%) satisfied the inclusion criteria. We excluded patients with an obvious extracardiac source of septicemia and those with bacteremia who were treated presumptively as IE. Patients who were suspe...

Peculiar clinical and diagnostic features of infective endocarditis in Yemen: Comparative analysis with a Western University Hospital

“…Only 6% of Al-Thawra Hospital Cardiac Center patients had positive blood cultures, unlike the patients seen in Western hospitals, as shown by the comparative analysis of patients reported in our study. This is similar to data reported in other developing countries 5,7 that have a similar situation such as Yemen in terms of prehospital fever management by the pharmacist or general practitioner who usually treat fever as a simple infection without paying attention to the underlying heart condition or the suspicion of IE in these high-risk patients. This makes the diagnosis of IE very difficult based on blood cultures and doctors in Yemen rely only on clinical suspicion and echocardiographic evidence of IE.…”

“…Failure to culture the organism in IE may result from inadequate antimicrobial therapy, infection with nonbacterial organisms, or administration of antimicrobial agents before blood cultures are obtained. 5,6 Fastidious (demanding growth requirements) or yet uncultured microorganisms that are regularly missed by routine culture methods may be involved in culturenegative IE cases. 7 Identification of the pathogen in culture-negative disease depends on special procedures, which comprise inactivating antibiotics in the culture media, prolonging incubation, serology, agglutination, indirect fluorescence, ELISA, complement fixation, and PCR amplification of the 16S ribosomal RNA gene.…”

“…7 Identification of the pathogen in culture-negative disease depends on special procedures, which comprise inactivating antibiotics in the culture media, prolonging incubation, serology, agglutination, indirect fluorescence, ELISA, complement fixation, and PCR amplification of the 16S ribosomal RNA gene. 5 The role of echocardiography to diagnose IE has increased, although a thorough assessment of clinical features remains important in the evaluation of patients with IE. 1,2,22 In this study, in addition to the careful clinical assessment of all cases with IE, TTE was performed in all patients admitted to the cardiac center with suspicion of IE as an important tool for the diagnosis of IE.…”

“…3 The epidemiology, clinical, and microbiologic spectra of IE are significantly different in the developing countries compared to the western world. [4][5][6][7] These differences may be attributable to multiple factors found in poorer countries, including significantly higher incidences of RHD, excessive and improper use of antibiotics, late clinical presentation, and worse outcomes. In addition, developing countries may have a higher incidence of ''culture-negative endocarditis'' than in the west, largely secondary to prior doctor-prescribed or self-administered antibiotic use.…”

Neurological complications in children with infective endocarditis

“…In a published local study, 28 out of 80 (35%) adult patients with IE developed neurological manifestations, with a high incidence of stroke that reached up to 49% [ 9 ]. A study conducted by Asaki and colleagues included 76 pediatric patients with radiology-confirmed ischemic stroke; they reported IE as the source of CNS embolization in 3% of cases [ 10 ]. In our study, the incidence of neurological complications in IE patients is 23% (7/31 patients) with 57% of them developed as a result of vascular events.…”