Pasteurella multocida Endocarditis with Septic Arthritis: Case Report and Review of the Literature

Abstract

Background: There is a paucity of evidence regarding optimal management of Pasteurella spp. endocarditis. The authors report the first case of Pasteurella spp. endocarditis with septic arthritis and review the literature. Case Description: A 79-year-old patient with significant comorbidities, including prosthetic aortic valve, was admitted with left knee swelling, fever, and confusion, having been scratched by a cat 2-weeks prior. At presentation, there was a metallic click, a Grade 3 pan-systolic murmur and Grade 1 flow murmur audible on auscultation. Blood and synovial fluid cultures both isolated Pasteurella multocida, identified by matrix-assisted laser desorption ionisation–time of flight, which was sensitive to penicillin according to the European Committee on Antimicrobial Susceptibility Testing (EUCAST); minimum inhibitory concentration: 0.094). The patient underwent joint washout and received intravenous piperacillin/tazobactam for 3 days before switching to benzylpenicillin once sensitivities were known. Due to continued pyrexia, a transthoracic echocardiogram was obtained, which revealed a small mobile mass on a thickened mitral valve suspicious for a vegetation. On review by the Infective Endocarditis team, conservative management was deemed best, given the presence of comorbidities. Despite requiring further joint washout due to persistent knee pain, the patient was successfully treated with 8 weeks of antibiotic therapy (24 days of benzylpenicillin monotherapy, 2 weeks of benzylpenicillin and ciprofloxacin, and 15 days ciprofloxacin monotherapy). Discussion: Previous literature reviews report a higher mortality of Pasteurella spp. endocarditis when managed without cardiac surgery, thus recommending surgery in all cases. The authors found these to have confounding factors, including inadequate duration of antimicrobials, aortic root abscess, and rapid progression to death. The authors’ case of Pasteurella spp. endocarditis, complicated by septic arthritis, showed successful therapy without cardiac surgery.

Rare but Fatal Pasteurella multocida Infective Endocarditis: A Case Report and Literature Review

“…Complications are not uncommon and related to bacteremia and valve vegetation. Reported complications included sepsis, septic emboli [8][9], congestive heart failure [2,[10][11], septic shock [2,10,[12][13]31], mycotic aneurysm [9,14], intracranial hemorrhage [14][15], septic arthritis [12,16], and osteomyelitis [15]. One case reported rhabdomyolysis and hearing loss [41].…”

“…Duration of treatment was variable among reported cases, and it depended on the severity, course of the disease, co-existing conditions, and antibiotic susceptibility. Carter et al recommended initial six weeks of antibiotics therapy based on the clinical response and the average duration in previously reported patients who were successfully treated with antibiotics only [ 16 ]. Of all 29 cases (69%) who survived, 12 (41 %) received antibiotics only without surgery.…”

“…Seventeen out of 18 (94%) cases who underwent surgery were cured while only one patient died four months after discharge due to septic shock secondary to Pseudomonas endocarditis of the native mitral and prosthetic aortic valves four weeks after a dental procedure [ 20 ]. Porter et al suggested that surgery should be offered to all patients who have no absolute contraindications given the cure rate of 100% after surgical valve replacement [ 2 ]; however, their analysis did not consider the severity of illness, medical comorbidities, and indications for surgical intervention [ 16 ]. Moreover, they did not include the patient who died four months after surgery from Pseudomonas endocarditis [ 20 ].…”

“…Moreover, they did not include the patient who died four months after surgery from Pseudomonas endocarditis [ 20 ]. Carter et al suggested surgical intervention only if there is any indication, as with any case of other bacterial endocarditis [ 16 ]. The same study reported a patient with P. multocida endocarditis and septic arthritis successfully treated with antibiotics only despite his comorbidities.…”