Nosocomial Native Valve Endocarditis Due To Methicillin-Susceptible Staphylococcus Aureus in A Patient With Psoriatic Arthritis

DISCUSSION 

This case report highlights a fatal case due to nosocomial IE caused by MSSA. The most common source of healthcare-associated IE is a vascular catheter (48%), particularly hemodialysis and peripheral vein catheters [4]. Our case had a hemodialysis catheter as a possible entry site of bacteria. Active psoriatic arthritis [6] and long-term corticosteroid therapy [7] have also been documented as risk factors for bacteremia. In addition, staphylococcal infection is common in patients with psoriasis [8,9]. S. aureus could easily colonize the skin of patients with erythroderma [8]. Recently a relationship between psoriasis and IE [10] has also been reported. We were able to locate only five reports of IE cases with psoriasis published in English, and three were due to S. aureus [8,11-14], which agrees with the facts of our case. Some combination of risk factors contributed to the occurrence of staphylococcal bacteremia and IE in our case.

Fig. 1. Echocardiography revealed stringy vegetation (a, b. arrows) attached to the native mitral valve.

Fig. 2. Diffusion-weighted magnetic resonance imaging confirmed shower emboli to the brain (a) followed by a massive infarction (b).

MSSA which was the invading pathogen in our case was not a drug-resistant organism. Nosocomial IE due to MSSA, however, should not be underestimated. The neurologic complication rate (29%) [15] and the rate of in-hospital mortality (22.4%) [16] from IE due to S. aureus is higher than IE that is caused by other pathogens. Moreover, the rate of mortality from nosocomial IE is higher than that from community-acquired IE (39.5% vs 18.6%) [17]. Such a high rate of mortality in nosocomial IE is caused by a patient population that tends to be elderly with comorbidities [4,5], or by patients undergoing chemotherapy for malignancies [5]. Our case also had risk factors, elderly and the pathogen, of the in-hospital stroke and death.

Cistanche Supplement Support Heart Supplement

Recent studies have reported that the differences in anti-staphylococcal drugs could influence the death rate [18,19]. In a retrospective study, empirical treatment by third-generation cephalosporins or beta-lactam/beta-lactamase inhibitors was associated with a higher rate of mortality compared with therapy using oxacillin/cefazolin [18]. On the other hand, vancomycincin as the definitive therapy for MSSA bacteremia has also been related to a higher rate of mortality than when beta-lactams are used [19]. The American Heart Association guidelines were published in 2015 [20] and recommended treatment with nafcillin, oxacillin, or cefazolin for the native valve endocarditis due to drug-susceptible staphylococci. Since we could not rule out meningitis without performing a spinal puncture, cefazolin was not selected. In addition, anti-staphylococcal penicillin was not available as a single agent in Japan. Given the complicated situation described above, we selected dual antibiotics as the definitive therapy in this case. 

In addition to antibiotics, surgical valve replacement is also an important option for the treatment of infective endocarditis. The prevalence of early valve replacement currently is increasing [21], and brain stroke is not a contraindication for surgical treatment [21]. In our case, the operation was considered by the attending team; but was not performed finally due to the patient's severe neurologic damage [21] and shock status. In conclusion, even with proper infectious disease consultation, and the use of the appropriate antibiotics, nosocomial IE is nonetheless a critical disease. Cliniclans must remember that indwelling vascular devices, psoriatic arthritis, and long-term corticosteroid therapies could cause not only uncomplicated bacteriemia but also fatal nosocomial IE.

ETHICS: The publication of this case report was approved by the Chidoribashi General Hospital Ethics Committee. (approved number CH-2019-04) CONFLICT OF INTEREST: There are no conflicts of interest in connection with this article. ACKNOWLEDGEMENTS: None.

Fig. 3. Clinical course. AKI, acute kidney injury; AML, anterior mitral leaflet; MSSA, methicillin-susceptible Staphylococcus aureus; PIP/TAZ, piperacillin/tazobactam; PML, posterior mitral leaflet;

REFERENCES 

1. Fukuchi T, Iwata K, and Ohji G. Failure of Early Diagnosis of Infective Endocarditis in Japan--a Retrospective Descriptive Analysis. Medicine 2014; 93:e237. 

2. Slipczuk L, Codolosa JN, Davila CD, Romero-Corral A, Yun J et al. Infective Endocarditis Epidemiology Over Five Decades: A Systematic Review. PLoS One 2013; 8:e82665. 

3. Martín-Dávila P, Fortún J, Navas E, Cobo J, Jiménez-Mena M et al. Nosocomial Endocarditis in a Tertiary Hospital: An Increasing Trend in Native Valve Cases. Chest. 2005; 128:772-779. 

4. Lomas JM, Martínez-Marcos FJ, Plata A, Ivanova R, Galvez J et al. Healthcare-associated infective endocarditis: an undesirable effect of healthcare universalization. Clin Microbiol Infect. 2010; 16:1683-1690. 

5. Hwang JW, Park SW, Cho EJ, Lee GY, Kim EK et al. Risk factors for poor prognosis in nosocomial infective endocarditis. Korean J Intern Med. 2018; 33:102-112. 

6. Karmacharya P, Crowson CS, Poudel D, Shrestha P, and Wright K. Hospitalizations for Serious Infections in Psoriatic Arthritis Patients: Data from the National Inpatient Sample 2000-2014 [abstract]. Arthritis Rheumatol 2018; 70 (suppl 10). 

7. Smit J, Kaasch AJ, Søgaard M, Thomsen RW, Nielsen H et al. Use of Glucocorticoids and Risk of CommunityAcquired Staphylococcus aureus Bacteremia: A Population-Based Case-Control Study. Mayo Clin Proc 2016; 91:873-880. 

8. Green MS, Prystowsky JH, Cohen SR, Cohen JI, and Lebwohl MG. Infectious complications of erythrodermic psoriasis. J Am Acad Dermatol 1996; 34:911-914. 

9. Hsu DY, Gordon K, and Silverberg JI. Serious infections in hospitalized patients with psoriasis in the United States. J Am Acad Dermatol 2016; 75:287-296. 

10. Lauridsen TK, Bruun LE, Dahl A, Ahlehoff O, TorpPedersen C et al. Risk assessment of infective endocarditis in psoriasis patients, the impact of gender and disease severity: A cohort study from Danish nationwide registries. 25th European Congress of Clinical Microbiology & Infectious Diseases, Copenhagen, 2015.