CASE REPORT

 

Chlamydia psittaci as a cause of mitral valve endocarditis: presentation of a rare case

 

 

Rinaldo Luiz Wolker^I; Cristiano Gustavo Hahn^I; Jorge Rafael Ruiz Rita^II; Paulo Roberto Giublin^I

^ICardiovascular surgeon
^IIIntensivist physician

Correspondence address

 

 

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ABSTRACT

The authors report a clinical case of bird breeder who evolved with fever, myalgia, weight lost and negative blood cultures. On three occasions he was treated with different antibiotics, without improvement. He became progressively worse and after four months a diagnosis of endocarditis was made. An echocardiogram showed mitral valve dysfunction with vegetation that had not been seen previously. A blood test proved positive for Chlamydia psittaci (indirect immunofluorescence). In surgery the mitral valve was seen to have severe lesions with anterior cuspid rupture and large areas with vegetation. After surgery, he presented with a clinical improvement and was discharged on the thirteenth post-operative day on specific antibiotic therapy. Although rare, Chlamydia psittaci must be considered in cases of endocarditis with negative blood cultures, when there is a possibility of contact with birds.

Descriptors: Endocarditis. Mitral valve, surgery. Chlamydia. Ornithosis.

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INTRODUCTION

Infection endocarditis refers to bacterial or fungalinfections inside the heart and diagnosis is suspected by theclinical signs and symptoms of the patient (fever, feeling bad,weight loss, fatigue, anorexia, nocturnal sudoresis, anemia,cutaneous or conjunctival petechiae, splenomegaly, among others).Diagnosis is confirmed by isolating the infecting microorganismin blood, an embolus or vegetation. Laboratorial confirmation ofthe infecting microorganism is particularly difficult andcultures can be negative in infections with fastidiousmicroorganisms [1].

A review of publications identified few reports ofendocarditis caused by Chlamydia psittaci [2,3]. We do not knowif this number reflects the real incidence of endocarditisassociated with Chlamydia psittaci or if many cases are notdiagnosed due to the difficulty to identify the agent causing theinfection.

Chlamydias are gram-negative parasitic bacteria that aredescribed as three species: Chlamydia pneumoniae, Chlamydiatrachomatis and Chlamydia psittaci [4]. Chlamydia psittaciproduces a variety of infections in birds and lower mammals; inhumans it usually causes pneumonia acquired by the inhalation ofparticles infected by secretions of birds [1]. The associationbetween contact with birds and the development of acquiredvalvulopathies has already been described in the literature [5].Generally, the infection affects previously abnormal valves,however, there are reports of the involvement of normal valves[4] with the aortic valve being the most commonly involved [1,4].The clinical course of the infection can be acute orsubacute-chronic based on the time of evolution, severity of theclinical presentation and on the progression of the non-treateddisease [4,6].

In this report, we describe the case of a bird-breeder withprolapse of the mitral valve, who presented with mitral valveendocarditis and negative blood cultures. The serum and indirectimmunofluorescence tests were positive for Chlamydiapsittaci.

 

CASE REPORT

A 62-year-old lean Caucasian male patient, who was a birdsalesman, in September 2002 presented with generalized musclepain, fever (39 ºC) and indisposition. A blood test did notidentify signs of infection; the partial urine test and chest andface sinus radiograms were normal. The HSV was 8 mm in the firsthour. An investigation of salmonella was also negative. Theadministration of oral cephalexin was initiated. Ten days later,the patient was hospitalized for two days when he presented withanemia (hemoglobin = 11.60 g/dL) and a leukocyte count of 13,800/mm³. A test for toxoplasmosis was negative. He wasreleased from hospital taking 250 mg ciprofloxacin every 12hours. Fifteen days later he was again hospitalized with fever,joint pain and weight loss. The anemia had worsened (hemoglobin =11.40 g/dL) and the leukocyte count was 11,000 /mm³.An echocardiogram demonstrated a dense mitral valve with prolapseof the posterior cuspid and slight to moderate insufficiencywithout the presence of vegetation. Investigations of hematozoa,lsteriosis, anti-HIV antibodies and three blood cultures were allnegative. BAAR was negative in sputum. Testing withtuberculostatic therapy was initiated.

In January 2003, the patient was again hospitalized withmyalgia, artralgia, irritating cough, deterioration of thegeneral health, weight loss and anorexia. Lung auscultationdemonstrated crackles at the right base and heart auscultationevidenced systolic murmur at a mitral focus +/6. The hemoglobinwas 10.6 g/dL, leukocytes 12,400/mm³ and HSV = 35 mmin the first hour. A test for Chlamydia psittaci antibodies wasrequested. A control echocardiogram demonstrated the right atriumslightly enlarged, the left ventricle dilated with normalfunction, the mitral valve dense, prolapse of the posteriorcuspid, the anterior cuspid with a mass of 2.2 x 1.7 cm withmoving echo on the ventricular face and another pedicled on theatrial face with moderate mitral insufficiency. Administration ofcrystalline penicillin was initiated at 18,000,000 U/dayassociated with 240 mg gentamicin endovenously/day, 200 mg oraldoxicyclin per day and 500 mg levofloxacin endovenously/day.

After ten days the patient continued with fever with new bloodcultures negative. Another echocardiogram demonstrated anincrease in the mitral valve reflux and so surgical treatment wasindicated.

On January 17 2003 surgery was performed using median sternotomy, cardiopulmonary bypass, and moderate hypothermia. The ascending aorta and both vena cavae were cannulated and myocardial protection was achieved with normothermic anterograde sanguineous cardioplegia repeated at twenty-minute intervals. After left atriotomy, the insufficient mitral valve was exposed with the anterior cuspid ruptured and with vegetation of 2 x 2 cm (Figure 1).

 

 

The mitral valve was resected and a porcine prosthesis wasimplanted. After normalization of the body temperature, removalof the air from the left chambers, aortic declamping and returnof the normal heartbeats the cardiopulmonary bypass wasdiscontinued and the arterial and venous cannulae removed.

The patient evolved well postoperatively and was released fromthe ICU on the 2^nd postoperative day. He remainedafebrile on endovenous antibiotics for another 13 days when hewas released from hospital on 200 mg doxicycline and 400 mgmoxifloxacin daily.

Indirect immunofluorescence was reactive for psittacosis (tit. 1/80) and the anatomopathologic examination demonstrated histiocytary cells with multiple vacuolized cytoplasms and intravacuolar corpuscles (Figure 2), a finding consistent with morphologic characteristics identified in cases of infection by Chlamydia sp., which was confirmed by a specific immunohistochemical examination and by ultra-structural evaluation by electronic microscope.

 

 

DISCUSSION

This report describes the case of a patient with mitral valveendocarditis caused by Chlamydia psittaci. The diagnosis, in thiscase was based on the clinical presentation, by the contact withbirds, by serum positivity (reactive indirectimmunofluorescence), by anatomopathologic examination, specificimmunohistochemical examination and by ultra-structuralevaluation using electronic microscopy of the mitral vegetation.The blood cultures were all negative.

As a predisposing factor, the patient presented with mitralvalve prolapse, which is today, in industrialized countries, themost common cardiovascular lesion associated with mitral valveendocarditis, a greater indication of the high incidence of thislesion in the general population than the hemodynamic disordercaused by the valvar lesion [6], which is the highest risk inover 45-year-old men [7]. In developing countries injury causedby rheumatic fever is still the main predisposing factor ofendocarditis.

Chlamydias are common human pathogens responsible for a widerange of infections including infections of the genitals,intestines, conjunctivitis and atypical pneumonias. In the heart,although infrequent, Chlamydia psittaci can cause endocarditis,myocarditis or pericarditis with negative blood cultures [4].

Endocarditis with negative blood cultures are responsible for5% of the cases of endocarditis in native valves in this agerange of patients (over 60-year-olds), and the commonly involvedgerms include, species of Bartonella, Coxiella burnetti, bacteriaof the HACEK group (haemophilus, actinobacillus, cardiobacterium,eikella, kingella), Tropheryma whipplei, species of Legionella,species of Brucella and fungi [6] in addition to Chlamydiapsittaci.

In spite of being difficult, diagnosis has importanttherapeutic implications in choosing the antibiotic therapy.Penicillin and other beta-lactamic antibiotics present littleactivity against Chlamydia and the aminoglycosides do not exertany therapeutic effect whatsoever. On the other hand, otherantibiotics, such as tetracycline, doxicycline, fluoroquinolone,chloramphenicol, erythromycin and rifampin are efficacious[1,4,8].

Thus, it is necessary with patients with endocarditis andnegative blood cultures, to identify the microorganismresponsible and utilize an antibiotic therapeutic regimen at aneffective dose. In cases of contact with birds or domesticanimals such as cats [9], it is important to remember Chlamydiapsittaci and perform serologic and immunofluorescence tests foranti-Chlamydia antibodies.

Surgical indication should be considered early specifically ifthere are signs of progressive heart failure, embolicphenomenons, failure in etiologic treatment, the presence ofperivalvar destruction (abscesses) or involvement of valvarprostheses [6,10]. This infection is highly destructive, themortality rate is high and, in many cases, valve replacement isnecessary [1,4,11]. The use of antibiotics should be prolongedfor at least thirty days after the surgical treatment, althoughthe ideal time is still not known [4,8].

 

ACKNOWLEDGMENT

To professor assistant-PHD of Unifesp/EPM, Doctor Luiz A. R.Moura, responsible by the area os Renal Pathology ofFundação Oswaldo Ramos - Hospital do Rim eHipertensão, by microscopic optical image.

 

REFERENCES

1. Jones RB, Priest JB, Kuo C. Subacute chlamydial endocarditis. JAMA.1982;247(5):655-8.         [ Links ]

2. Shapiro DS, Kenney SC, Johnson M, Davis CH, Knight ST, Wyrick PB. Brief report: Chlamydia psittaci endocarditis diagnosed by blood culture. N Engl J Med. 1992;326(18):1192-5.         [ Links ]

3. Etienne J, Ory D, Thouvenot D, Eb F, Raoult D, Loire R et al. Chlamydial endocarditis: a report on ten cases. Eur Heart J. 1992,13(10):1422-6.         [ Links ]

4. Odeh M, Oliven A. Chlamydial infections of the heart. Eur J Clin Microbiol Infect Dis. 1992;11(10):885-93.         [ Links ]

5. Ward C, Ward AM. Acquired valvular heart-disease in patients who keep pet birds. Lancet. 1974;2(7883):734-6.         [ Links ]

6. Mylonakis E, Calderwood SB. Infective endocarditis in adults. N Engl J Med. 2001;345(18):1318-30.         [ Links ]

7. Zuppiroli A, Rinaldi M, Kramer-Fox R, Favilli S, Roman MJ, Devereux RB. Natural history of mitral valve prolapse. Am J Cardiol. 1995;75(15):1028-32.         [ Links ]

8. Walker LJ, Adgey AA. Successful treatment by doxycycline of endocarditis caused by ornithosis. Br Heart J. 1987;57(1):58-60.         [ Links ]

9. Regan RJ, Dathan JR, Treharne JD. Infective endocarditis with glomerulonephritis associated with cat chlamydia (Chlamydia psittaci) infection. Br Heart J. 1979;42(3):349-52.         [ Links ]

10. Dias AR, Pomerantzeff PM, Brandão CMA, Dias RR, Grinberg M, Lahoz EV et al. Tratamento cirúrgico da endocardite infecciosa ativa: análise de 361 doentes operados. Rev Bras Cir Cardiovasc. 2003;18(2):172-7.         [ Links ]

11. Lamaury I, Sotto A, Le Quellec A, Perez C, Boussagol B, Ciurana AJ. Chlamydia psittaci as a cause of lethal bacterial endocarditis. Clin Infect Dis. 1993;17(4):821-2.         [ Links ]

 

 

Correspondence address:
Rinaldo Luiz Wolker
Av. Brasil, 530 - 4ª andar - Centro
Pato Branco, PR. CEP 85501-080

Article received in January, 2006
Article accepted in May, 2006

 

 

Work performed in the Center of Cardiovascular Surgery of the Sudoeste Hospital Policlínica Pato Branco, Pato Branco, Brazil.