Recurrent Infective Endocarditis due to Aggregatibacter aphrophilus and Staphylococcus lugdunensis

Abstract

Uncommon microorganisms are increasingly being recognized as causative agents of paediatric infectious endocarditis (IE). We report a 4-year old girl with congenital heart disease, who suffered from 2 IE episodes secondary to Aggregatibacter aphrophilus (formerly Haemophilus aphrophilus) and Staphylococcus lugdunensis, both rarely reported pathogens in this age group. The patient was initially successfully treated with prolonged intravenous antibiotic courses, however removal of the Contegra valved conduit during the second episode was required due to recurrence of fever and development of pulmonary embolism despite completion of antibiotic therapy. A. aphrohilus is a member of the fastidious gram negative microorganisms of the HACEK group (Haemophilus spp., Aggregatibacter spp, Cardiobaterium hominis, Eikenella corrodens and Kingella kingae), that colonize the oropharynx and are a recognised cause of IE. Prognosis of children with IE due to HACEK group members varies, half of them suffering from complications and mortality rates of 10–12.5%. Although S. lugdunensis belongs to coagulase negative staphylococci (CONS), it behaves more like S. aureus species rather than CONS. This microorganism is a well-described cause of endocarditis in adult patients, associated with high requirements of surgical procedures and mortality (42–78%). In conclusion, paediatric IE can be caused by uncommon microorganisms associated with severe complications and potential fatality. The isolation of S. lugdunensis or A. aphrophilus in febrile patients should be considered clinically relevant and cardiac involvement must be ruled out. Those patients with proved IE will require prolonged intravenous antibiotic courses and in complicated cases surgical intervention.

Zusammenfassung

Ungewöhnliche Mikroorganismen, als Ursache pädiatrischer infektiöser Endokarditiden (IE) werden zunehmend berichtet. Wir berichten über ein 4 Jahre altes Mädchen mit angeborenem strukturellem Herzfehler, welche zwei sekundäre, durch A. aphrophilus (früher Haemophilus aphrophilus) und Staphylococus lugdunensis verursachte, IE erlitt, wobei die kausale Identifizierung dieser Keime sehr ungewöhnlich in dieser Altersgruppe ist. Bei diesem Kind war ein konservativer Therapieansatz mit langdauernder intravenöser Antibiotikagabe inital erfolgreich, erneute Fieberschübe und Auftreten einer pulmonarer Embolien während der zweiten IE Episode machten jedoch die Enfernung des “Contegra valved conduit” erforderlich. A. Aphrophilus gehört zu den Gram-negativen Mikroorganismen der HACEK Gruppe (Haemophilus spp., Aggretatbacter spp., Cardiobacterium hominis, Eikenella corrodens und Kingella kingae), welche den Oropharynx kolonisieren und als Erreger der IE bekannt sind. Die Prognose für HACEK bedingte IE im Kindesalter ist sehr variable mit Folgeschäden in der Hälfte der Patienten und einer Mortalitätsrate von 10-12.5%. Obwohl S. lugdunensis zu den koagulase negativen Staphylokokken gehört, zeigt dieser Mikroorganismus ein S. aureus ähnliches Virulenzverhalten. Bei S. lugdunensis handelt es sich um einen gut beschriebenen Verursacher der IE im Erwachsenenalter, welcher gehäuft chirurgische Interventionen benötigt und mit hohen Mortalitätsraten (42-78%) verbunden ist. Pädiatrische IE können durch ungewöhnliche Keime verursacht und mit schweren Komplikationen und potentieller Letalität assoziert sein. Zusammenfassend sollte die Identifikation von S. lugdunensis oder A. aphrophilus in Blutkulturen febriler Kinder als klinisch relevant betrachtet und kardiologische Untersuchungen erwägt werden. Patienten mit bestätigter IE erfordern eine prolongierte antibiotische Behandlung und möglicherweise kardiochirurgischer Interventionen.

Key words

infectious endocarditis - congenital heart disease - Staphylococcus lugdunensis - Aggregatibacter aphrophilus

Schlüsselwörter

infektiöse Endokarditis - angeborene Herzfehler - Staphylococcus lugdunensis - Aggregatibacter aphrophilus

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