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  • ISSN: 2373-9819
    JSM Clin Case Rep 4(2): 1102.
    Submitted: 02 May 2016; Accepted: 24 June 2016; Published: 28 June 2016
    Case Report
    Native Valve Endocarditis in a Patient with Chronic Citrobacter Prostatitis
    Michael K. Tom*, Dennis Thomas Bolger Jr and Erlaine F. Bello
    Department of Medicine, University of Hawai’i , John A. Burns School of Medicine, USA
    *Corresponding author: Michael K Tom, Department of Medicine, University of Hawai’i, John A. Burns School of Medicine,1356 Lusitana Street, UH Tower, 7th Floor, Honolulu, Hawaii, USA 96813, Tel: 1-808-586-2910; Fax: +1-808-586-7486; Email: mtom808@hawaii.edu
    Importance: Citrobacter koseri rarely causes infection in immunocompetent, nonhospitalized hosts and is rarely associated with infective endocarditis.
    Observations: We present a single case of a 77-year-old man with known chronic C. koseri prostatitis who developed blood culture-negative infective aortic valve endocarditis and C. koseri diskitis. Valve replacement was required for definitive treatment.
    Conclusions and relevance: Holding cultures for an extended period helped to identify the organism. Chronic prostatitis may be a rare but potentially serious source for infective endocarditis.
    Keywords: Endocarditis; Citrobacter; Prostatitis; Diskitis
    HACEK: Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, and Kingella, TEE: Transesophageal Echocardiogram, HD: Hospital Day, MRI: Magnetic Resonance Imaging
    Gram-negative bacilli are responsible for 1.3-10% of infective endocarditis cases and are typically associated with intravenous drug use [1] or nosocomial infection (e.g., post-cardiac surgery). HACEK-associated cases (~3%) outnumber non-HACEK (~2%). The most common non-HACEK organisms responsible are Escherichia coli and Pseudomonas aeruginosa [2,3].
    Citrobacter species are gram-negative bacilli found in soil, water, and animal and human intestinal tracts. Infection usually manifests as urinary tract (45-53%), intra- abdominal, respiratory tract, surgical site, or skin and soft tissue infections [4,5]. Infective endocarditis due to Citrobacter koseri has been previously reported in only 4 cases [6].
    Associated risk factors in those cases included intravenous drug use [7,8] and pacemakers [9]. There was a single prior case report of a patient with an indwelling urinary catheter who developed Methicillin Sensitive Staphylococcus aureusassociated prostatic abscess with subsequent discovery of infective endocarditis and pyogenic spondylitis [10].
    Case Presentation
    A 77-year-old man with past medical history significant for chronic low back pain and chronic prostatitis with prior urine cultures positive for Citrobacter koseri was admitted for one week of generalized weakness, cough, and new upper back pain. He denied any history of intravenous drug use. Upon examination, his temperature was 37.6 °C, (99.7 °F), his pulse was 115 beats per minute and regular rhythm, his respirations were 20 breaths per minute, and his blood pressure was 143/67 mm Hg. He also had hard palate petechiae, a grade III/VI systolic ejection murmur best heard in the right upper sternal border with radiation to the carotid arteries, and diffuse vague musculoskeletal pain on palpation; neurologic exam was only significant for 4/5 power in lower extremity dorsiflexion.
    Initial laboratory data were significant for a neutrophil dominant leukocytosis of 15.2x103/uL without left shift and urinalysis showing trace leukocyte esterase and moderate bacteria. Portable chest x-ray revealed a retrocardiac opacity.
    Three sets of blood cultures were negative, but were drawn after receiving empiric antibiotics of azithromycin and ceftriaxone in the emergency room for suspected pneumonia. Initial urine culture grew Citrobacter koseri on hospital day (HD) #3.
    Transesophageal echocardiography (TEE) revealed an aortic valve vegetation of 10 mm on the right coronary cusp without abscess. Thoracic magnetic resonance imaging (MRI) revealed diskitis of T9-T10 and phlegmon from T7-T12, which was aspirated for culture on HD #8. A dental consultant commented on chronic carious decay without acute infection or abscess. The patient was continued empirically on ceftriaxone and ciprofloxacin, to which C. koseri was sensitive. A seven week course of antibiotics was complicated by adverse drug effects including thrombocytopenia, neutropenia, and acute kidney injury.
    During treatment, his petechiae resolved, but his back pain worsened. Spinal phlegmon aspirate culture had late growth of C. koseri on HD #30. Repeat MRI showed an increase in size of phlgemon from C6-T12 (Figure 1). Repeat TEE showed new and mobile vegetations on the non-coronary cusp, 16mm and 13mm (Figure 2), along with a possible aortic root abscess (Figure 3). The patient underwent bioprosthetic aortic valve replacement on HD #49 and had an additional four weeks of antibiotic therapy. The aortic valve was found to have numerous vegetations and a periannular 7-8mm abscess cavity. All valve cultures were negative. The patient improved and was discharged to a rehabilitation facility.
    Figure 1 Sagittal MRI showing T9-T10 diskitis and extensive phlegmon.

    Figure 1 Sagittal MRI showing T9-T10 diskitis and extensive phlegmon.

    Figure 2 Transesophageal echocardiogram showing a 16mm aortic valve vegetation.

    Figure 2 Transesophageal echocardiogram showing a 16mm aortic valve vegetation.

    Figure 3 Transesophageal echocardiogram showing an aortic root abscess.

    Figure 3 Transesophageal echocardiogram showing an aortic root abscess.

    The incidence of culture-negative endocarditis increased from 7-10% in the early 1990s to ~20% in the mid-2000s. Less than 45% of cases have antibiotic pretreatment [11]. Literature review about diagnostic yield of extending blood culture incubation times is controversial [12]. There is no data regarding extended phlegmon culture incubation time, however this was requested because of the possibility, albeit low, of isolating the pathogen. The late growth of C. koseri in the spinal phlegmon aspirate aided in narrowing antibiotic coverage to avoid further complications.
    The patient met the 2008 American College of Cardiology and American Heart Association guidelines for valve replacement based on presence of an aortic abscess, persistent vegetations despite appropriate antibiotic therapy, and mobile vegetations in excess of 10 mm [13]. Teh decision of optimal timing of valve replacement was difficult in view of extensive diskitis and phlegmon. The neurosurgical consultant felt the patient was not amenable to surgery due to the extent of spinal involvement and stable neurological exam. Despite negative admission blood cultures and aortic valve vegetation and abscess cultures, the patient’s persistent C. koseri in his urine and spinal phlegmon suggested widely disseminated infection with high likelihood of hematogenous seeding and infection of the aortic valve. In this case, the suspicion for an aortic abscess and large vegetation on echocardiogram were enough to take the patient to surgery despite concern that another possible source was not under control and that the replacement valve could become infected.
    The limitations of this case include that there were no positive blood cultures, the vegetation and aortic abscess biopsy and culture did not reveal any organism, and that there were multiple infected sites. However, given the patient’s history and presentation, we conclude that chronic prostatitis can be a rare but serious cause of infective endocarditis. Controversy exists regarding extending the length of time blood and other cultures are held, but may increase the yield of identifying the suspected pathogen when blood cultures and suspected sites of dissemination are sterile.
    There are no relevant disclosures. Dr. Michael K. Tom had full access to all of the patient data and takes responsibility for the integrity and accuracy of the represented information.
    1. Raza SS, Sultan OW, Sohail MR. Gram-negative bacterial endocarditis in adults: state-of-the-heart. Expert Rev Anti Infect Ther. 2010; 8: 879- 885
    2. Morpeth S, Murdoch D, Cabell CH, Karchmer AW, Pappas P, Levine D, et al. Non-HACEK gram-negative bacillus endocarditis. Ann Intern Med. 2007; 147: 829-835.
    3. Witchitz S, Regnier B, Witchitz J, Schlemmer B, Bouvet E, Vachon F. Gram negative bacilli endocarditis. Pathol Biol (Paris). 1982; 30: 569- 575.
    4. Samonis G, Karageorgopoulos DE, Kofteridis DP, Matthaiou DK, Sidiropoulou V, Maraki S, et al. Citrobacter infections in a general hospital: characteristics and outcomes. Eur J Clin Microbiol Infect Dis. 2009; 28: 61-68.
    5. Hodges GR, Degener CE, Barnes WG. Clinical significance of citrobacter isolates. Am J Clin Pathol. 1978; 70: 37-40.
    6. Dzeing-Ella A, Szwebel TA, Loubinoux J, Coignard S, Bouvet A, Le Jeunne C, et al. Infective endocarditis due to Citrobacter koseri in an immunocompetent adult. J Clin Microbiol. 2009; 47: 4185-4186.
    7. Tellez I, Chrysant GS, Omer I, Dismukes WE. Citrobacter diversus endocarditis. Am J Med Sci. 2000; 320: 408-410.
    8. Plantholt SJ, Trofa AF. Citrobacter freundii endocarditis in an intravenous drug abuser. South Med J. 1987; 80: 1439-1441.
    9. Martínez A, Miguélez M, Laynez P, Romero R. [Pacemaker-cable endocarditis and spondylodiscitis caused by Citrobacter koseri. Conservative treatment]. Enferm Infecc Microbiol Clin. 2001; 19: 39- 40
    10. Matsumoto M, Shigemura K, Yamamichi F, Nakano Y, Miyake H, Tanaka K, et al. [A case of prostate abscess with sepsis, infectious endocarditis and pyogenic spondylitis]. Hinyokika Kiyo. 2012; 58: 565-568.
    11. Werner M, Andersson R, Olaison L, Hogevik H. A clinical study of culture- negative endocarditis. Medicine (Baltimore). 2003; 82: 263- 273.
    12. Baron EJ, Scott JD, Tompkins LS. Prolonged incubation and extensive subculturing do not increase recovery of clinically significant microorganisms from standard automated blood cultures. Clin Infect Dis. 2005; 41: 1677-1680.
    13. Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD, et al. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2008; 118: e523-661.
    Cite this article: Tom MK, Bolger DT Jr, Bello EF (2016) Native Valve Endocarditis in a Patient with Chronic Citrobacter Prostatitis. JSM Clin Case Rep 4(2): 1102.
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