Infective endocarditis in the setting of renal transplantation: Case report and review of the literature

Abstract

The potent immunosuppressive drugs used by transplant recipients place them at risk of infections. Data on infective endocarditis (IE) in the setting of renal transplantation (RT) are sparse. We describe a 36-year-old woman referred to a tertiary medical center for evaluation of elevated creatinine levels 1 month after a second RT. Work-up revealed the presence of all four of Duke's criteria: fever, persistent bacteremia, new-onset tricuspid regurgitation, and masses suspected to be vegetation attached to the tricuspid annulus. Symptoms resolved with antibiotic treatment and fluids. Fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) revealed hypermetabolic absorption in the femoral vascular graft that had been used for hemodialysis prior to transplantation. The graft was removed by open surgery, and the patient was discharged home in good condition with continued antibiotic treatment. Review of the literature yielded 73 previously reported cases of IE in renal transplant recipients. Several differences were noted from IE in the general population: lower male predominance, younger age (<60 years), absence in most cases of a preexisting structural cardiac anomaly, and more variable causative pathogens. Our case also highlights the importance of FDG-PET/CT for detecting the source of IE and alerts clinicians to the sometimes unexpected course of the disease in renal transplant recipients.

High Mortality and Graft Loss after Infective Endocarditis in Kidney Transplant Recipients: A Case-Controlled Study from Two Centers

“…In that respect, the epidemiology in our study is closer to that of the general population [1]. We found that digestive bacteria predominate, with Enterococci as the most frequent pathogen, as previously described in SOTRs [14][15][16][17][18][19][20][21]. A hypothetical mechanism, in the absence of an identified digestive gateway (colonoscopy was performed in most of the cases where a digestive bacterium was identified, even though we did not collect the results of this exam in our study), could be the alteration of the gut microbiota by the combination of antibiotic treatments frequently used after transplantation, and of immunosuppressive drugs.…”

“…IE in KTRs occurred mostly in younger people than in the general population [ 1 , 6 , 7 , 11 ], and on hearts without any IE-predisposing conditions, as in the general population [ 14 ]. In our series, IE only occurred on left heart valves, but right heart valve IE has also been reported in KTRs previously [ 14 ].…”

High Mortality and Graft Loss After Infective Endocarditis in Kidney Transplant Recipients: A Case-Controlled Study From Two Centers

“…In that respect the epidemiology in our study is closer to that of the general population [1]. We found that digestive bacteria predominate, with Enterococci as the most frequent pathogen as previously described in SOTRs [15][16][17][18][19][20][21]14,21]. A hypothetical mechanism, in the absence of an identified digestive gateway (colonoscopy was performed in most of the cases where a digestive bacterium was identified, even though we did not collect the results of this exam in our study), could be the alteration of the gut microbiota by the combination of antibiotic treatment frequently used after transplantation, and of immunosuppressive drugs.…”

Matched retrospective study of infective endocarditis among solid organ transplant recipients compared to non‐transplant: Seven‐year experience in a US Referral Center

“…1,2 In a literature review of endocarditis in renal transplant patients, 73 cases were detected, and while indeed S aureus was the most common pathogen, Enterococcus was found to cause the same number of infections (N = 13 [18%]). 13 IE attributable to mold has been well-described in previous reports of IE in SOT patients. 1,2 In a review of SOT patients with IE prior to 1998, fungi caused infection in 28%, and most were disseminated mold.…”

“…Regarding the microbiologic diagnosis, it has been shown that S aureus is most commonly identified as the etiologic agent in IE in the modern era, 10‐12 including in SOT patients 1,2 . In a literature review of endocarditis in renal transplant patients, 73 cases were detected, and while indeed S aureus was the most common pathogen, Enterococcus was found to cause the same number of infections (N = 13 [18%]) 13 1,2 .…”