Native Valve Endocarditis Due to Bartonella henselae in a Middle-Aged Human Immunodeficiency Virus-Negative Woman

Abstract

We report the case of a human immunodeficiency virus-negative woman who developed native valve endocarditis of the aortic valve due to Bartonell henselae infection. The diagnosis was established using serology and PCR analysis of excised aortic valve tissue. CASE REPORTA 38-year-old woman having a remote history of intravenous drug use was admitted to Lyndon B. Johnson Hospital in May 2000 after she presented to the emergency room. She complained of fever, nausea, vomiting, and nonbloody diarrhea over a 2-week period associated with fatigue and generalized weakness. She lived in Texas and owned a fully grown cat and two kittens. Initial examination of the patient revealed a temperature of 39°C, a grade 3/6 diastolic murmur, and splenomegaly. Laboratory evaluation showed the following values: white blood cell count, 2.4 ϫ 10 9 /liter; hemoglobin level, 11.9 g/dl; platelet count, 62 ϫ 10 9 /liter. In addition, a chest radiograph showed moderate cardiomegaly but no effusions or infiltrates. Because of a high level of suspicion that the patient had infective endocarditis, transthoracic echocardiography was performed on the day of admission, which demonstrated the presence of a large, mobile vegetation on a bicuspid aortic valve.Initially, the patient received empirical treatment for infective endocarditis with a combination of vancomycin and gentamicin. Twenty-four hours later, a transesophageal echo test was performed, revealing a 2-cm vegetation attached to both cusps of the bicuspid aortic valve, moderate aortic regurgitation, dilatation of the ascending aorta without evidence of abscess formation, and concentric left ventricular hypertrophy. Two weeks after that, a total of six sets of blood cultures collected by adult isolator tubes prior to and after initiation of antibiotic treatment yielded no growth. Additionally, serum specimens were collected for infectious serology, including agents of culture-negative endocarditis. Subsequently, the patient's hospital course was complicated by the development of glomerulonephritis secondary to her infective endocarditis and nonoliguric acute renal failure due to aminoglycoside toxicity. The serum creatinine level peaked at 3.5 mg/dl. Bartonella serology using an indirect immunofluorescence assay (IFA; Microbiology Reference Laboratory, Cypress, Calif.) showed the following titers: Bartonella henselae immunoglobulin M (IgM), 1:20 (reference range, negative, Ͻ1:20); B. henselae IgG, 1:512 (reference range, negative, Ͻ1:64); Bartonella quintana IgM, 1:20 (reference range, negative, Ͻ1:20); B. quintana IgG, 1:512 (reference range, negative, Ͻ1:64). When a serology result positive for Bartonella species was reported, the patient's antibiotic regimen was changed to ceftriaxone and azithromycin. Serological tests for Brucella, Chlamydia, and Coxiella species, other common etiological agents of culture-negative endocarditis, were negative.Because of the patient's persistent febrile episodes and the presence of no obvious source other than her infective endocarditis, she underwe...

Bartonella Species, an Emerging Cause of Blood-Culture-Negative Endocarditis

“…In one series of 348 cases of BCNE from France, Bartonella species accounted for 28% of the cases (86). Almost all of the patients had fever as a presenting symptom, whereas about 50 to 70% had symptoms of heart failure such as exertional dyspnea and about 50% had insidious weight loss (86,(252)(253)(254). Physical examination findings typically include cardiac murmur, and the aortic valve either in isolation or with another valve is the most frequently affected valve, including in the pediatric age group (255)(256)(257)(258).…”

Chronic Bartonellosis in Cats

“…56 Immunocompromised people may develop atypical CSD and more severe forms of Bartonella-associated disease, which may be fatal if left untreated. These include bacillary angiomatosis, 59 parenchymal bacillary peliosis, relapsing fever with bacteraemia, 60 endocarditis, [61][62][63] neuroretinitis, 64 aseptic meningitis 65 and uveitis. 66…”

Bartonellosis in cats: a role in uveitis?

“…Bartonella henselae, the most studied of the Bartonella species, causes cat scratch disease, bacillary angiomatosis, bacillary peliosis, relapsing bacteremia with fever, meningitis, neuroretinitis and endocarditis in humans. [5][6][7][8][9] Such a definitive cause and effect association between infection with one or more Bartonella spp in the cat and clinical disease has not been proven to date.…”