Abstracts
We report the case of a 66 year-old female patient with infectious endocarditis due to Streptococcus bovis and adenocarcinoma of the colon that developed acute aortic insufficiency. She was submitted to aortic valve replacement surgery and later to tumor resection (right hemicolectomy). It is important to emphasize the need for complementing the study of the colon, even in asymptomatic individuals, when infectious endocarditis due to S. bovis is diagnosed.
Bacterial endocarditis; adenocarcinoma; Streptococcus bovis; aortic valve insufficiency
Descrevemos o caso de uma paciente de 66 anos de idade, com endocardite infecciosa por Streptococcus bovis e adenocarcinoma colônico, que desenvolveu insuficiência aórtica grave aguda. Foi submetida à cirurgia de troca valvar aórtica e posteriormente à ressecção tumoral (hemicolectomia direita). É importante ressaltar a necessidade de complementação do estudo do cólon, mesmo em indivíduos assintomáticos, quando diagnosticamos endocardite infecciosa por S. bovis.
Endocardite bacteriana; adenocarcinoma; Streptococcus bovis; insuficiência da valva aórtica
Describimos el caso de una paciente de 66 años de edad, con endocarditis infecciosa por streptococcus bovis y adenocarcinoma colónico, que desarrolló insuficiencia aórtica grave aguda. Fue sometida a cirugía de reemplazo valvular aórtico y posteriormente a resección tumoral (hemicolectomía derecha). Es importante destacar la necesidad de complementación del estudio del colon, aun en individuos asintomáticos, cuando diagnosticamos endocarditis infecciosa por S. bovis.
Endocarditis bacteriana; adenocarcinoma; streptococcus bovis; insuficiencia de la válvula aórtica
CASE REPORT
Hospital São José do Avaí, Itaperuna, RJ - Brazil
Mailing address
ABSTRACT
We report the case of a 66 year-old female patient with infectious endocarditis due to Streptococcus bovis and adenocarcinoma of the colon that developed acute aortic insufficiency. She was submitted to aortic valve replacement surgery and later to tumor resection (right hemicolectomy). It is important to emphasize the need for complementing the study of the colon, even in asymptomatic individuals, when infectious endocarditis due to S. bovis is diagnosed.
Key words: Bacterial endocarditis; adenocarcinoma; Streptococcus bovis; aortic valve insufficiency.
Introduction
Streptococcus bovis is a microorganism that colonizes the human gastrointestinal (GI) tract and is present in 2.5% to 15% of individuals. It is a Group D Streptococcus bacterium that can cause bacteremia and endocarditis, as well as urinary tract infection and septic arthritis, among others. It accounts for approximately 14% of infection causes and 13% of all cases of infectious endocarditis (IE)1,2.
Sometimes the IE caused by S. bovis is associated with colorectal cancer. This association was first described in 1951 by McCoy and Mason, but it was only in 1977 that it was recognized in clinical practice and its pathogenesis remains to be elucidated1,2.
The objective of the present study is to report a case of IE due to S. bovis associated with colorectal cancer, discussing the epidemiological, clinical, diagnostic and therapeutic aspects.
Case report
A 66-year-old female diabetic and hypertensive patient, from the town of Italva, state of Rio de Janeiro, Brazil, was admitted at the Intensive Care Unit of HSJA/Itaperuna, in March 2008, with acute respiratory failure type I. After being stabilized, she was referred to the Cardiology Infirmary for investigation.
At the time, she reported a picture of fatigue at exertion for the previous three years and a worsening of the situation for a month prior to hospitalization, associated with febrile episodes (no predilection for the time of the day), nausea and generalized arthralgia. At the physical examination, the patient was febrile, pale (+/4+), presented diastolic murmur with aortic focus and aortic accessory (+++/4+), as well as pulmonary crackles. The remainder of the physical examination was normal. Laboratory assessment: hemoglobin = 11g/dl, hematocrit = 32%, hemosedimentation velocity (HSV) = 120 mm. The chest x-ray showed enlargement of the cardiac area. The echocardiogram showed slightly increased left atrium and ventricle. The pulmonary arterial pressure was 42 mmHg. The aortic valve was thickened, with a cusp fragment projecting to the LVOT (left ventricular outflow tract) in diastole. She presented a slight MI and significant AI. The left ventricular (LV) systolic function was preserved. The transesophageal echocardiogram (Figure 1) disclosed the LA (3.2 cm), LV (3.4 cm), LV indexed mass = F191.63 g (normal up to 276 g), LV ejection fraction (LVEF) = 69.13%. The LV presented hyperdynamic walls compatible with a probably acute volume overload. The tricuspid aortic valve presented vegetation adhered to the left coronary cusp, moving towards the LVOT, with around 12.3 mm in extension. The blood culture confirmed the hypothesis of infectious endocarditis caused by group D Streptococcus bovis.
Therapy with crystalline penicillin and amikacin was initiated even before the result of the blood cultures was available. On the subsequent days, the patient presented a good clinical picture evolution and symptom improvement without fever. She received amikacin for 14 days and penicillin for 28 days.
A colonoscopy was carried out, which disclosed the presence of a sessile polyp in the transversal colon and a plane tumor at the hepatic angle (Figure 2). The histopathological analysis showed it was a well-differentiated and infiltrating adenocarcinoma.
After the end of the antibiotic therapy, a new control echocardiogram showed the persistence of the significant aortic failure and the patient was referred to aortic valve replacement surgery. The surgical procedure was uneventful and the patient presented a favorable postoperative evolution, which allowed her hospital discharge on the 6th postoperative day. The valve culture was negative.
Two months later a right hemicolectomy was performed and she was discharged on the 4th postoperative day.
Discussion
Infectious endocarditis is a disease in which microorganisms invade the endocardial surface, causing inflammation and injury. Its incidence is stable at around 1.7 to 6.2 cases per 100,000 individuals. Men tend to be more affected than women (1.7:1); however, the age of the affected individuals increased from 30-40 years in the pre-antibiotic era to 47-69 in the recent years. In developed countries, the degenerative valvular alterations and prostheses, and no longer rheumatic disease, are the most important predisposing factors for the occurrence of endocarditis1,3,4.
S. Bovis is an important cause of bacteremia and infectious endocarditis in adults5. It represents from 7% to 14% of the cases of subacute endocarditis and is often associated with colonic neoplasia. The incidence of this association is around 18% to 62%4. The colonic neoplasia can appear years after the infectious event.
The endocarditis by S. bovis usually affects patients older than 60 years and has a predilection for the aortic valve. Its main complication is congestive heart failure. Moreover, it is frequently accompanied by a valvular abscess and systemic thromboembolism2,5.
Clinically, there is no characteristic that differentiates the endocarditis by S. bovis from other etiologies; fever is observed in practically all patients.
The diagnosis of infectious endocarditis is based on Duke's criteria, which were subsequently modified6,7. The transthoracic echocardiogram (TTE) is fast and noninvasive and has an excellent specificity for the diagnosis of endocarditis (98%); however, it has a general sensitivity of only 40-60%. The transesophageal echocardiogram (TEE) is a less available and more expensive method, but it presents high sensitivity (between 75% and 95%) and specificity (between 85% and 98%)5. It is particularly useful in patients that have valvular prostheses and in the assessment of endocarditis complications. The 2005 Guidelines of the ACC and AHA suggested that the TTE should be used in the assessment of native valves in patients with good images, whereas the presence of prosthesis or any other circumstances that impair the echocardiographic window usually requires the use of TEE4.
The concomitant occurrence of bacterial endocarditis and colonic carcinoma was first described in 1951, by McCoy and Mason7. However, only in 1977 S. bovis was recognized by Klein et al8, as the pathogenic agent of this neoplasia2. Although many authors have reported, throughout the years, the association between several types of infectious agents and tumors, the best and strongest association described to date is between the colorectal adenocarcinoma and infection by S. bovis2. Moreover, this pathogen is associated with several other pathologies in the GI tract, such as adenomatous colonic polyp, hyperplastic polyp and diverticular disease. According to Gold et al9, the most commonly found alteration was the adenomatous polyp (53%)9.
Based on these data, we conclude that it is important to perform a colonoscopy in all patients with a diagnosis of infection by S. bovis, even in the asymptomatic ones2,9. A more stringent follow-up is required for these patients, as infectious endocarditis can precede the onset of colonic neoplasia.
Potential Conflict of Interest
No potential conflict of interest relevant to this article was reported.
Sources of Funding
There were no external funding sources for this study.
Study Association
This study is not associated with any post-graduation program.
References
- 1. Waisberg J, Matheus CO, Pimenta J. Infectious endocarditis from streptococcus bovis associated with colonic carcinoma: case report and literature review. Arq Gastroenterol. 2002; 39: 177-80.
- 2. Ferrari A, Botrugno I, Bombelli E, Dominioni T, Cavazzi E, Dionigi P. Colonoscopy is mandatory after Streptococcus bovis endocarditis: a lesson still not learned: case report. World J Surg Oncol. 2008; 6: 49.
- 3. McCoy WC, Mason JM 3rd. Enterococcal endocarditis associated with carcinoma of the sigmoid: report a case. J Med Assoc State Ala. 1951; 21 (6): 162-6.
- 4. Ellmerich S, Scholler M, Duranton B, Gossé F, Galluser M, Klein JP, et al. Promotion of intestinal carcinogenesis by Streptococcus bovis. Carcinogenesis. 2000; 21: 753-6.
- 5. Barbosa MM. Endocardite infecciosa: perfil clínico em evolução. Arq Bras Cardiol. 2004; 83: 189-90.
- 6. Neto LS, Gangoni C, Pereira V, Lima RC. Cerebral ischemia caused by Streptococcus bovis aortic endocarditis. Arq Neuropsiquiatria. 2005; 63: 673-5.
- 7. Bisno AL. Streptococcal infection. In: Harrison´s principles of internal medicine. 12nd ed. New York: McGraw-Hill; 1991. p. 563-9.
- 8. Klein RS, Catalano MT, Edberg SC, Casey JI, Steingbigel NH. Streptococcus bovis septicemia and carcinoma of the colon. Ann Intern Med. 1979; 91: 560-2.
- 9. Gold JS, Bayar S, Salem RR. Association of Streptococcus bovis bacteremia with colonic neoplasia and extracolonic malignancy. Arch Surg. 2004; 139: 760-5.
Infectious endocarditis due to Streptococcus bovis in a patient with colon carcinoma
Publication Dates
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Publication in this collection
13 Oct 2010 -
Date of issue
Sept 2010
History
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Reviewed
11 Aug 2009 -
Received
18 May 2009 -
Accepted
20 Aug 2009
