323 STREPTOCOCCUS GALLOL YTICUS SPONTANEOUS INFEC TIVE ENDOCARDITIS ON NATI VE VALVES, IN A DIABETI C PATIENT FLORINA CÃRUNTU1,2*, MINODORA ANDOR1,2,… [601680]

323 STREPTOCOCCUS GALLOL YTICUS
SPONTANEOUS INFEC TIVE
ENDOCARDITIS ON NATI VE
VALVES, IN A DIABETI C PATIENT

FLORINA CÃRUNTU1,2*, MINODORA ANDOR1,2, CAIUS
STREIAN1,3, MIRELA TOMESCU1,2, IOSIF MARINCU1, 4

1“Victor Babes ”University of Medicine and Pharmacy, Timisoara, Romania
2Department of Internal Medicine
3Department of Cardiovascular Surgery Clinic,
4Department of Infectious Diseases

ABSTRACT
The immune depressed patients are at increased risk of developing Streptococcus gallolyticus endocarditis.
The infection is easily controlled by antibiotics but a valvular replacement may be needed for gross valvular
dysfunction, embolization or severe heart failure. Some patients may have associated colonic or hepatic lesions
needing surgical intervention that increase morbidity, mortality and cos ts. We describe a 55 -year-old diabetic
patient with spontaneous Streptococcus gallolyticus endocarditis on native valves and discuss some specific aspects
regarding infective endocarditis with Streptococcus gallolyticus.
Key words: diabetes mellitus, endocarditis, Streptococcus gallolyticus

Correspondence to:
Dr. Mirela Tomescu
MD,PhD
Address: Cardiology Clinic, Department of Internal Medicine I, ”V. Babeș”Timisoara University of Medicine and Pharmacy,
Bd Revolutiei din 1989 nr 12, Timisoara, cod 300024, Romania
Phone : +4 [anonimizat]
Fax: +4 [anonimizat]
E-mail address: [anonimizat]

324 INTRODUCTION

Viridans streptococci are the most
important causative agents for native
valve infective endocarditis (IE) in non –
drug -addicted patients [1].
Streptococcus gallolyticus, subspecies
gallolyticus, formerly referred as
Streptococcu s bovis biotype I, is a
member of group D streptococci, and is
estimated to be incriminated in 24% of
streptococcal endocarditis [2]. Based on
genetic, physiologic and phylogenetic
criteria, Schle gel et al. [3] proposed the
reclassification of Streptococc us bovis
biotype I as Streptococcus gallolyticus.
In Southern Europe, the proportion of
endocarditis which is caused by
Streptococcus gallolyticus has
increased duringrecent years [4 .
Hoen5 et al. documented that
Streptococcus gallolyticus is
responsible for an important
proportion of streptococcal IE cases:
58% in France, 9.4% in other European
countries and 16.7% in USA. Immune depressed patients, as well as
nutritional habitssuch as frequ ent
consumption of uncooked meat and
fresh milk products, might have an
impact on S. gallolyticus intestinal
colonization and subsequent
bacteremia, increasing the risk of
developing Streptococcus (S) gallolyticus
endocarditis. This infection is usually
well controlled by antibiotics; however,
in certain cases, valvular replacements
may be needed for gross valvular
dysfunction, embolization or severe
heart failure. Additionally, some
patients may have associated colonic or
hepatic lesions that require surgi cal
interventions, that increase morbidity
and mortali ty.
We report a case of Streptococcus
gallolyticus, subspecies
gallolyticus,spontaneousinfective
endocarditis on native valvs,in a
diabetic patient.

CASE REPORT

A 55 –year -old men was admitted
to our clinic for one month after the
onset of persistent fever. He had been
hospitalized in another department,
where pneumonia had been suspected
and ceftriaxone therapy had been
administered. U nder this treatment, the
fever persisted, associated with fatigue,
profuse sweating, decreased appetite
and 8 kg weight loss. The patient was
referred to a clinic for infectious
diseases, where echocardiography was
recommended, which set the current
diagno sis.The patient was a non -drug
abuser and had no previous history of
rheumatic or degenerative valvular
heart disease. He had no recent dental
or other invasive bleeding procedures.
He was known with diabetes mellitus
complicated with grade III sensitive
and motor polyneuropathy, non –
proliferative diabetic retinopathy,
requiring insulin therapy. Physical examination on admission revealed:
temperature 38.8 C, mild pallor of the
conjunctiva. Irregular heart rhythmus,
130 beats/minute; blood pressure
120/60 mm Hg, respiratory rate 18 per
minute. No pulmonary rales were
heard. The jugular venous pressure
was normal, no legs edema were
found. The apex beat was not
displaced. A 3/6 decrescendo diastolic
murmur was heard along the left
sternal border and cardiac ape x.
Abdominal examination revealed mild
hepatosplenomegaly. Laboratory tests
demonstrated an inflammatory
syndrome (erythrocyte sedimentation
rate of 88 mm after an hour, fibrinogen
of 7,8g/L, white cell count of 15,500 per
mL with 75% neutrophils) and a mi ld
normochromic, normocytic anemia
(hemoglobin of 10.8 g/dL).
Electrocardiogram showed atrial
fibrillation with a ventricular rate of

325 130 bpm. A chest -X ray demonstrated
moderate pulmonary venous
congestion. Echocardiography showed
aortic valve vegetation, a moderate
(grade 2) aortic regurgitation, normal
diameters of the left ventricle and
normal (>50%) left ventricular ejection
fraction ( Figure 1 ).
Blood cultures were positive for
Streptococcus gallolyticus and the
antibiogram showed sensibility of the
infective agent to Ampicillin and
Linezolid. Antibiotic therapy was
started with intravenous Ampicillin
12g daily. The treatment for atrial
fibrillation consisted in Digoxin and
anticoagulation with Enoxaparin. The
response to Ampicillin was good, as
the fe ver ceased, the laboratory values
returned to normal and the general
health status of the patient improved.
Two weeks following the
institution of therapy, the patient
developed acute ischemia in the left
leg, by embolization with a fragment of
the aortic valve vegetation.
Embolectomy was performed with a
Fogarty arterial catheter introduced in
the left popliteal artery. The
echocardiographic control showed the
persistence of the vegetation, but
having a smaller sizeand an increase in
the severity of the a ortic regurgitation
(grade 3). The patient was referred to Cardiovascular Surgery, where he
suffered an embolic cerebrovascular
accident, with syncope followed by
obnubilation and complete recovery.
Because of these embolic events,
emergency open heart surg ery was
performed, revealing extensive
vegetation of the right aortic cusp, with
necrosis of the valve ( Figure 2 ).
Debridement and replacement of the
aortic valve with a Sorin Carbomedics
prosthesis was performed ( Figure 3 ).
The antibiotic therapy was cont inued
for 4 weeks following the surgery. The
post -operative evolution was marked
by a toxic hepatitis following general
anesthesia and severe variations of the
glycaemia, requiring an attentive
dosing of insulin therapy. The recovery
was successful and the patient was
discharged after completing the
antibiotic therapy and postoperative
care. Colonoscopy was performed and
revealed no abnormalities. We believe
that decreased immunity and diabetic
neuropathy with reduced intestinal
motility favored bacteremia and
infective endocarditis in this patient
with no previously known valvular
lesion.Another possible explanation
could be the diabetic
microangiopathywhich leads to lesions
of the colonic mucosa, followed by the
bacterial entry into the blood stream.

Figure 1. 2-D echocardiography of the heart showing large vegetation on the aortic valve

326
Figure 2. Extensive vegetation of the right aortic cusp, with necrosis of the valve

Figure 3. Replacement of the aortic valve with a Sorin Carbomedics prosthesis

DISCUSSION

Streptococcus gallolyticus is a
normal inhabitant of the human
gastrointest inal tract. There is a
demonstrated association between
Streptococcus gallolyticus,IE, gastroin –
testinal neoplasia [6 -7] and liver
disease [8, 9]. One explanation could be
that the underlying colonic disease or
the altered hepa tic function may favor
the bacterial migration [10]. The exact
reason why the streptococcus suddenly
becomes invasive is not known, but it
is thought that intestinal or liver
pathology might decrease the intestinal
motility thereby and thus allowing its
overgrowth. It is also possible that
colonic carcinogenic metaboli tes and
chronic inflammatory mediators
change the local conditions and disrupt the capillary channels which allow the
entry of bacterial into the blood
stream.The subsequent bacteremia
leads to seeding in – different parts of
the body, –particularly in the h eart
valves, the bones, and the vertebral
discs. A decrease in immunity,
described in the elderly, in those with
co-morbidities (particularly diabetes
mellitus, chronic liver disease and
rheumatic disorders) and in those
treated with immunosuppressants,
favors severe infections 11.
S gallolyticus endocarditis is
different from other endocarditis
because it is highly susceptible to
intravenous antibiotics and is therefore
considered as ‖benign‖. Even then it
affects valves of patients who are not

327 known to h ave cardiac valvular
abnormalities 12, 13, 14 . In our
patient, a previously normal aortic
valve was damaged by S gallolyticus
endocarditis. The predilection of
infection is the aortic valves, but the
mitral as well as the tricuspid valves
may also be aff ected, singly or in
combination. The vegetations tend to
be larger than those produced by other
organisms and were noted in our
patient. Patients with persistent
bacteremia and those with documented
embolism or with resistant heart failure
need to have a v alvular replacement.
Early valvular replacement may be
needed in patient with massive
vegetations and recurrent embolisms.
Colonoscopy is indicated in the context
of S gallolyticus bacteremia or
endocarditis to look for colonic
neoplastic changes. If the e xamination is normal, a repeat colonoscopy should
be scheduled in 4 to 6 months, with
regular surveillance subsequently. The
patient should also be evaluated for
liver disease and possibly extra colonic
malignancy. However, frailty and co –
morbidities may p reclude invasive
investigations and operative
management.
In conclusion, the presented case
informs the physicians about the risk of
spontaneous infective endocarditis in
non-drug -addicted patients, withouta
history of congenital or acquired
valvular heart disease. Immune –
depression, as well as nutritional
habitssuch as frequent consumption of
uncooked meat and fresh milk
products, might have an impact on S.
gallolyticus intestinal colonization and
subsequent bacteremia and IE.

REFERENCES

1. Naber CK, Bauhofer A, Block M,
Buerke M, Erbel R, Graninger W,
Herrmann M. S2-Leitlinie zur
Diagnostik und Therapie der
infektiösen Endokarditis. Z Kardiol
2004; 93: 1005 -1021.
2. Sillanpää J, Nallapareddy SR, Singh
KV, Ferraro MJ, Murray BE. Adherence
characteristics of endocarditis -derived
Streptococcus gallolyticus ssp.
gallolyticus ( Streptococcus bovis
biotype I) isolates to host extracellular
matrix proteins. FEMS Microbiol Lett
2008; 289: 104 -109. Sillanpää J,
Nallapareddy SR, Singh KV, Ferraro
MJ, Murray BE. Adherence
characteristics of endocarditis -derived
Streptococcus gallolytic us ssp.
gallolyticus (Streptococcus bovis
biotype I) isolates to host extracellular
matrix proteins. FEMS Microbiol Lett
2008; 289: 104 -109.
3. Schlegel L, Grimont F, Ageron E,
Grimont PA, Bouvet A. Reappraisal of
the taxonomy of the Streptococcus
bovis/S treptococcus equinus complex
and related species: description of
Streptococcus gallolyticus subsp.
gallolyticus subsp. nov., S. gallolyticus
subsp. macedonicus subsp. nov. and S. gallolyticus subsp. pasteurianus subsp.
nov. Int J Syst Evol Microbiol 2003;
53:631 -645.
4. Tripodi MF, Fortunato R, Utili R,
Triassi M, Zarrilli R. Molecular
epidemiology of Streptococcus bovis
causing endocarditis and bacteremia in
Italian patients. Clin Microbiol Infect
2005; 11: 814 -819.
5. Hoen B, Chirouze C, Cabell CH,
Selton-Suty C, Duchene F, Olaison L,
Miro JM, Habib G, Abrutyn E, Eykyn S,
et al. Emergence of endocarditis due to
group D streptococci: findings derived
from the merged database of the
International Collaboration on
Endocarditis. Eur J Clin Microbiol
Infect D is 2005; 24: 12 -16.
6. Klein RS, Recco RA, Catalano MT,
Edberg SC, Casey JI, Steigbigel NH.
Association of Streptococcus bovis
with carcinoma of the colon. N Engl J
Med 1977; 297: 800 -802
7. Ferrari A, Botrugno I, Bombelli E,
Dominioni T, Cavazzi E, Dioni gi P.
Colonoscopy is mandatory after
Streptococcus bovis endocarditis: a
lesson still not learned. Case report.
World J Surg Oncol 2008; 6: 49.
8. Corredoira JC, Alonso MP, Garcia JF,

328 Casariego E, Coira A, Rodriguez A,
Pita J, Louzao C, Pombo B, Lopez MJ,
et al. Clinical characteristics and
significance of Streptococcus salivarius
bacteremia and Streptococcus bovis
bacteremia: a prospective 16 -year
study. Eur J Clin Microbiol Infect Dis
2005; 24: 250 -255.Corredoira JC, Alonso
MP, Garcia JF, Casariego E, Coi ra A,
Rodriguez A, Pita J, Louzao C, Pombo
B, Lopez MJ, et al. Clinical
characteristics and significance of
Streptococcus salivarius bacteremia
and Streptococcus bovis bacteremia: a
prospective 16 -year study. Eur J Clin
Microbiol Infect Dis 2005; 24: 250 -255.
9. Zarkin BA, Lillemoe KD, Cameron JL,
Effron PN, Magnuson TH, Pitt HA. The
triad of Streptococcus bovis
bacteremia, colonic pathology, and
liver disease. Ann Surg 1990; 211: 786 –
791.
10. Beck M, Frodl R, Funke G.
Comprehensive study of strains
previo usly designated Streptococcus
bovis consecutively isolated from
human blood cultures and emended
description of Streptococcus
gallolyticus and Streptococcus
infantarius subsp. coli. J Clin Microbiol
2008; 46: 2966 -2972.
11. Moellering RC Jr, Watson BK, Kun z LJ.
Endocarditis due to group D
streptococci. Comparison of disease
caused by Streptococcus bovis with
that produced by the enterococci. Am J
Med. 1974; 57: 239 –50.
12. Ruoff KL, Miller SI, Garner CV, Ferraro
MJ, Calderwood SB. Bacteremia with
Streptoco ccus bovis and Streptococcus
salivarius: clinical correlates of more
accurate identification of isolates. J Clin
Microbiol. 1989; 27: 305 –8.
13. Herrero IA, Rouse MS, Piper KE,
Alyaseen SA, Steckelberg JM, Patel R.
Reevaluation of Streptococcus bovis
endocard itis cases from 1975 to 1985 by
16S ribosomal DNA sequence analysis.
J Clin Microbiol 2002;40: 3848 – 50.