Lactobacillus jensenii mitral valve endocarditis: Case report, literature review and new perspectives

Abstract

Lactobacillus is a facultative anaerobic Gram-positive rod usually found in the normal microbiota of the gastrointestinal and genitourinary tract. Frequently dismissed as a contaminant, it is implicated in several diseases. We describe a rare case of endocarditis caused by Lactobacillus jensenii in an immunocompetent 40 year-old male patient , with a history of mitral valve repair. He presented complaining of asthenia and his laboratory results showed a moderate increase in inflammatory markers. A trans-thoracic echocardiography confirmed a vegetation on the posterior leaflet of the mitral valve, with associated severe mitral insufficiency. Blood cultures revealed the significant growth of L. jensenii. The patient developed an acute abdomen with intestinal ischemia and occlusion of the superior mesenteric artery, requiring urgent surgical laparotomy. A cerebral MRI showed multiple minor emboli in the frontal and left parietal cortex. The patient consequently underwent surgery to have his mitral valve replaced with a mechanical valve. L. jensenii was isolated in culture from the mitral valve and from a mesenteric artery thrombus. After one week of combined amoxicillin and gentamicin therapy, ampicillin alone was continued for a total of six weeks and the patient could be discharged in a good general condition. Only five cases of L. jensenii are described in literature, and they mainly affect immunocompromised hosts. In our case, a long delay between the start of symptoms and the full onset of the disease was observed. tolerance of Lactobacilli to penicillin is a key determinant of therapy choice.

Lactobacilli Infection Case Reports in the Last Three Years and Safety Implications

“…The retrospective studies of Arbarillo et al, Nwanyanwu et al, and Yelin et al [ 60 , 61 , 62 ] suggested that the true prevalence of infections caused by lactobacilli is higher than estimated only on the basis of case reports. In addition, in many of the reports analyzed here it was stated that lactobacilli are often disregarded as infective agents since they are considered culture contaminants [ 24 , 34 , 61 ].…”

“…Lactobacilli were isolated from blood [ 15 , 16 , 17 , 18 , 20 , 21 , 22 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 49 , 52 , 55 , 56 , 57 ], diseased valve tissue [ 23 ], abscess fluids [ 48 , 51 , 52 , 54 , 57 , 58 ], cerebrospinal fluid (CSF) [ 46 ], marrow [ 30 ], arthrocentesis aspiration fluid [ 53 ] in anaerobiosis and, in some cases, also in aerobiosis [ 15 , 34 ]. Use of automated microbial detection system, i.e., BACT/ALERT 3D or the BACTEC systems (BioMérieux) with incubation at 35 °C were mentioned in some reports [ 23 , 31 , 34 ]. The case reports that described the identification procedures mostly referred to standardized instrumental techniqu...…”

“…Most of the cases of endocarditis had a deceitful and slow onset, with or without fever, with symptoms varying among patients and including weight loss, fatigue, dyspnea, cough, chills, sweats, abdominal pain with nausea and vomiting, lumbar pain, syncope, with valvular vegetations becoming detectable after many days or even months from the beginning of symptoms [ 14 , 15 , 16 , 17 , 18 , 20 , 22 , 23 , 27 , 29 , 30 , 31 , 32 , 34 ]. In many cases replacement of the aortic valve [ 15 , 16 , 17 , 18 , 20 , 21 , 26 , 28 , 30 , 35 ], in one case replacement of the mitral valve [ 25 ], and in another case replacement of both aortic and mitral valves [ 23 ] were necessary.…”

“…Complications observed in cases of endocarditis comprised: Multilevel discitis [ 18 , 29 ]; Occlusion of the superior mesenteric artery for a thrombus, requiring urgent surgical laparotomy, associated to emboli in the brain cortex [ 34 ]; Splenic infarct, possibly caused by septic emboli [ 18 , 20 , 23 ]; Multiple embolic strokes with acute-to-subacute infarct in the brain parietal lobe and a rapidly progressive glomerulonephritis (RPGN) [ 24 ]; Splenic abscess [ 20 ]; Glomerulonephritis and thrombotic microangiopathy [ 19 ]; Microabscesses in the psoas [ 29 ]; Embolic stroke and presumed lumbar vertebral osteomyelitis [ 33 ]; Recurrent transient ischemic attacks possibly related to a central embolic source causing left side lower extremity weakness and expressive aphasia [ 15 ]; Peroneal mycotic pseudoaneurysm supposed to be caused by seeding of blood-borne bacteria to the vasa vasorum of the artery wall or septic emboli from the infected heart valve [ 35 ]; Acute respiratory failure and septic shock [ 17 ]; Infarction secondary to septic embolism and ruptured mycotic brain aneurysm suspected to be caused by septic embolism from the aortic valve vegetation with right-sided hemiplegia and aphasia [ 14 ]; Ankle arthritis with cutaneous eruption [ 22 ]. …”

“…Occlusion of the superior mesenteric artery for a thrombus, requiring urgent surgical laparotomy, associated to emboli in the brain cortex [ 34 ];…”