Streptococcus oralis MitraClip endocarditis following a dental procedure: a case report

Abstract

Background Transcatheter edge-to-edge mitral valve repair using the MitraClip device is increasingly used for high surgical risk patients with severe mitral regurgitation (MR). Previous guidelines for infective endocarditis prophylaxis prior to dental procedures focused on high-risk patients, but without explicit recommendation for MitraClip recipients. We believe this could be the first reported case to identify Streptococcus oralis as the causative organism. Case presentation An 87-year-old male with severe MR treated with two MitraClip devices three months prior to index admission, presented with worsening malaise and intermittent chills on a background of multiple comorbid conditions. The patient had dental work a month prior to presentation, including a root canal procedure, without antibiotic prophylaxis. Vitals were significant for fever and hypotension. On physical examination, there was a holosystolic murmur at the apex radiating to the axilla, bilateral pitting edema in the lower extremities, and elevated jugular venous pulsation. A transthoracic echocardiogram showed severe MR with a possible echodensity on the mitral valve, prompting a transesophageal echocardiogram, which demonstrated a pedunculated, mobile mass on the posterior leaflet of the mitral valve. Five blood cultures grew gram positive cocci in pairs and chains, later identified as Streptococcus oralis, with minimum inhibitory concentration to penicillin 0.06 mg/L. Initial empiric antibiotics were switched to ceftriaxone 2 gr daily and subsequent blood cultures remained negative. However, the patient developed pulmonary edema and worsening hemodynamic instability requiring vasopressors. As surgical risk for re-operation was considered prohibitive, the decision was made to continue medical management and comfort-directed care. The patient died a week later. Conclusions Despite low incidence, infective endocarditis should be included in the differential among MitraClip recipients. The explicit inclusion of this growing patient population in the group requiring prophylaxis prior to dental procedures in the 2020 ACC/AHA valvular heart disease guidelines is an important step forward.

A case of adult patent ductus arteriosus‐associated infective endarteritis who was successfully treated with only antibiotics

“…5 Streptococcus oralis, an alpha-hemolytic streptococcus, is a member of the normal human oral microbiota, feasible of opportunistic pathogenicity. 6 Oral streptococcal infective endocarditis, can also result from not only invasive dental procedure but also daily dental activities. Therefore, oral hygiene, particularly in adult individuals with unclosed PDA, is extremely important and prophylactic antibiotics is needed when performing invasive dental procedure.…”

“…Previous study revealed that Streptococcus mutans are most frequent (47.9%) and Streptococcus oralis , detected in the present case, are found in 19.4% in patients with streptococcal infective endocarditis 5 . Streptococcus oralis , an alpha‐hemolytic streptococcus, is a member of the normal human oral microbiota, feasible of opportunistic pathogenicity 6 . Oral streptococcal infective endocarditis, can also result from not only invasive dental procedure but also daily dental activities.…”

Infective endocarditis after transcatheter edge‐to‐edge repair for severe mitral regurgitation; a case report and a systematic review

“…Our search strategy included the use of the terms “infective endocarditis or infectious endocarditis” and “transcatheter mitral valve repair, percutaneous mitral valve repair, MitraClip, or PASCAL.” A manual search for these topics within case reports at major cardiology meetings was also performed until February 2023. A total of 23 publications describing 26 cases of IE following TEER treatment for severe MR were identified, 7–29 in addition to our one case. Our local ethics committee approved this case report and systematic review.…”

Emerging Concepts on Infection of Novel Cardiac Implantable Devices

“…S. aureus is the major causative microorganism (11/25 pts; 44%). However, infections of MitraClip caused by Enterococci (3/25 pts, 12%), Streptococci (2/25 pts, 8%) [ 6 , 32 ], Pseudomonas aeruginosa [ 33 ] or atypical microorganisms such as Bartonella haenselae [ 34 ] are also reported.…”