We report what is believed to be the first case of late-onset prosthetic valve endocarditis caused by Mycoplasma hominis in a case of blood culture-negative endocarditis. The objective of this report is to emphasize the use of a broad-range PCR technique for bacterial 16S rRNA genes in identifying the causative pathogen, thus enabling targeted antimicrobial treatment.
Case reportA 40-year-old male had undergone aortic (19 mm Sorin Bicarbon) and mitral (25 mm Sorin Bicarbon) valve replacement surgery for rheumatic valvular disease 9 years previously. He was slow to recover from his initial surgery, suffering from fever and lethargy post operation. Blood cultures were negative but echocardiography showed a mitral valve vegetation. The patient was treated for culture-negative endocarditis with intravenous antibiotics (gentamicin 3 mg kg 21 once daily for 2 weeks and vancomycin 1 g daily for 6 weeks), with resolution of his symptoms and the vegetation at follow-up examination.Nine years later, the patient presented with abdominal pain, dark urine, melaena, jaundice, epistaxis and intermittent pyrexia. Examination revealed a murmur of mitral regurgitation but no peripheral stigmata of endocarditis. Blood tests confirmed haemolytic anaemia. Trans-oesophageal echocardiography revealed partial mitral prosthesis dehiscence with severe paraprosthetic regurgitation, but no vegetations were seen. The aortic prosthesis was functioning normally, but there was significant tricuspid regurgitation. The patient underwent urgent mitral valve re-replacement and tricuspid valve repair. During surgery, vegetations were noted to be present on the mitral prosthesis. Microscopy and Gram staining of the explanted valve tissue showed no microorganisms, and valve bacterial culture was initially negative.DNA was extracted from the resected valve using the tissue protocol of the QIAamp DNA mini extraction kit (Qiagen). Amplification of the 16S rRNA gene was performed using the primers FD1, 59-AGAGTTTGATCCTG-GCTCAG-39 (Weisburg et al., 1991), and UR, 59-CTAC-GCATTTCACCGCTACAC-39 (Hendolin et al., 2000), with Brilliant SYBR QPCR MasterMix (Stratagene). The PCR was performed using the MX3000P QPCR platform (Stratagene) using the following programme: activation at 95 u C for 10 min followed by 40 cycles of 95 u C for 30 s, 62 u C for 1 min and 72 u C for 1 min 30 s and a final extension step at 72 u C for 10 min. The amplicons were purified using a MinElute PCR purification kit (Qiagen) and the nucleic acid sequence was determined at Lark Technologies, Essex, UK. PCR amplification and nucleotide sequencing of the bacterial 16S rRNA gene identified the organism as M. hominis from the excised tissue. The nucleotide sequences were compared with those available through the NCBI database using BLAST (http://blast.ncbi. nlm.nih.gov/Blast.cgi). The nucleotide sequence showed 99.8 % (669/670 bp) 16S rRNA gene sequence similarity to that of M. hominis.An active infection was subsequently confirmed when M. hominis was cultured from valve tissue and detect...