International Journal of Cardiovascular ResearchISSN: 2324-8602

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Research Article, Int J Cardiovasc Res Vol: 4 Issue: 1

Propionibacterium Acnes Prosthetic Valve Endocarditis Caused by Unsuitable Leg Shaving. Importance of Specific Recommendations to Reduce Prosthetic Contamination

Daniel Grandmougin1*, Mazen Elfarra1, Maria-Christina Delolme2, Olivier Bouchot3, Christine Selton-Suty4, Olivier Huttin4, Hugues Blangy4, Fabrice Vanhuyse1, Nicolas Laurent1, Yhua Liu1, Jean-Pierre Villemot1, Thierry Folliguet1 and Juan-Pablo Maureira1
1Department of Cardiovascular Surgery and Transplantations, CHU-Nancy, France
2Department of Anesthesiology, CHU-Nancy, France
3Department of Cardiovascular Surgery, CHU-Dijon, France
4Department of Cardiology, CHU-Nancy, France
Corresponding author : Daniel Grandmougin, MD
Department of Cardiovascular Surgery and Heart Transplantations, ILCV Louis Mathieu - CHU Nancy-Brabois, Rue du Morvan, 54 211 Vandoeuvre-les-Nancy, France
Tel: +33- (0)3-83-15-73-67; Fax: +33-(0)3-83-15-74-29
E-mail: [email protected]
Received: October 17, 2014 Accepted: January 23, 2015 Published: January 25, 2015
Citation: Grandmougin D, Elfarra M, Delolme MC, Bouchot O, Suty CS, et al. (2015) Propionibacterium Acnes Prosthetic Valve Endocarditis Caused by Unsuitable Leg Shaving. Importance of Specific Recommendations to Reduce Prosthetic Contamination. Int J Cardiovasc Res 4:2. doi:10.4172/2324-8602.1000204

Abstract

 Propionibacterium Acnes Prosthetic Valve Endocarditis Caused by Unsuitable Leg Shaving. Importance of Specific Recommendations to Reduce Prosthetic Contamination

Introduction: Propionibaterium acnes (PA) is a bacteria associated with Acnes vulgaris and considered to have a low level of virulence. However, it has been involved in rare cases of prosthetic valve endocarditis whose diagnosis remains difficult. The origin of the prosthetic valve contamination is usually unclear. Extensive tissular damages characterize PA endocarditis. Methods and Results: We report the rare case of a PA contamination of an aortic mechanical valved conduit that required an urgent and complex stepwise surgical procedure. Investigations ascertained a highly probable source of contamination caused by leg shaving with manual razors necessitating specific dermatologic recommendations for patients with a valvular prosthesis. Conclusions: This unusual clinical presentation provided the opportunity to review the literature and characterize microbiological and clinical specificities of PA prosthetic valve endocarditis with the absolute necessity of urgent withdrawal of the prosthetic valvular material and dermatologic recommendations.

Keywords:

Keywords

Propionibacterium acnes; Prosthetic valve endocarditis; Dermatologic recommendations; Intracardiac abscess; Transesophageal echography

Introduction

Propionibacterium acnes (PA) is a Gram positive anaerobic bacteria member of the normal flora of the skin and considered to have a low level of virulence. However, over the last 30 years, PA was associated with rare cases of native valvular endocarditis or prosthetic valve endocarditis characterized by extensive and severe tissular damages such as intracardiac abscess and prosthetic valve disinsertion [1]. Diagnosis PA endocarditis is difficult and often delayed because of indolent symptoms reinforced by negativity of blood cultures. Patients with PA prosthetic valve endocarditis (PAPVE) require urgent surgical management to withdraw the indwelling prosthetic device since isolated antibiotic treatment always systematically failed in eliminating the infection because of a demonstrated ability of PA to produce biofilm. We report the exceptional case of a proven PA contamination of an aortic mechanical valved conduit complicated by extensive aortic root abscess in a 51-year-old woman. This case confirmed the major usefulness of molecular techniques for the diagnosis of PA infection. Clinical investigations elucidated the mode of contamination since the patient used to shave her legs with manual razors creating frequent bleeding cutaneous nicks with chronic release of PA into the circulation. This case emphasized the necessity to establish specific dermatologic recommendations for patients with indwelling cardiac devices such as valvular prosthesis.

Clinical Material and Methods

Patient characteristics
A 51-year-old woman was admitted to the author’s institution in december 2011 with intermittent fever. She had been operated 18 months earlier from a type A aortic dissection. The ascending aorta had been replaced by a prosthetic mechanical valved conduit (Bentall procedure).
One week after this operation, the patient experienced an incomplete obstruction of the right carotid artery by the intimal flap with a tamponade necessitating a surgical drainage and a prosthetic bypass between the ascending prosthetic aorta and the right carotid artery. Postoperative outcome was uneventful and the patient was discharged with an oral anticoagulation.
In september 2011, the patient reported irregular fever without any cardiac symptoms. Transthoracic echocardiography (TTE) showed a normal function of the prosthetic aortic valved conduit. Blood cultures remained negative and a probabilistic antibiotic treatment was introduced for 3 weeks with amoxicillin and gentamycin.
Initial symptoms completely reversed until mid-november 2011, when the patient presented with an acute facial paralysis and aphasia. After few days, she completely recovered from the neurological symptoms.
Body and brain CT- scans could not explain the neurological disorders and fever. Despite negativity of imaging investigations (TTE; body and brain CT-scan) and blood cultures, the patient was discharged with a second course of probabilistic antibiotic using amoxicillin and vancomycin.
Two weeks later the patient was referred to our hospital for a persistent fever. CRP and procalcitonin did not show significantly raised levels. Additionally, leucocyte count was 6000 mm3 and electrocardiogram (ECG) showed normal sinus rhythm.
After 5 days, blood cultures indicated no growth despite a moderate fever. Therefore aerobic and anaerobic cultures were prolonged for up to 3 weeks.
10 days after admission, two blood cultures revealed a Grampositive bacillus identified as Propionibacterium acnes (PA). However, skin contamination of blood cultures could not be definitely eliminated. Molecular identification and characterization of bloodisolated PA was completed.
Although TTE ruled out prosthetic valvular endocarditis (PVE), decision was made to follow-up the patient with regular transesophageal echography (TEE).
Additionally, the patient reported regular bleeding increased by oral anticoagulation while shaving her legs with manual razors.
The patient received antibiotics resulting from antibiogram tests and remained clinically stable with however an irregular moderate fever and no concerns considering regular TEE monitoring. Antibiogram results confirmed a resistant PA to both macrolides (erythromycin) and clindamycin with specifically high minimum inhibitory concentrations. Nevertheless, it was not possible to get reliable informations for past (previous) exposure to macrolides or clindamycin. (Or history of oral treatment with macrolides or clindamycin)
While, ECG showed sinus rhythm since admission, the patient suddenly experienced sinus bradycardia with a third-degree A-V block suspecting septal extension of an infectious process.
Therefore, an urgent TEE was performed. Echocardiographic findings (Figure 1) showed a large posterior abscess fistulized into the LVOT with a posterior disinsertion of the prosthetic valve and regurgitation due to the periprosthetic dehiscence. Additionally, 5.5 mm vegetation was disclosed. Urgent surgery was decided.
Figure 1: The transesophageal echography long-axis view shows the posterior abscess (arrow N°1) fistulized into the LVOT with a 5.4 mm mobile vegetation (arrow N°2). LA: Left Atrium - AML: Anterior Mitral Leaflet
Surgical technique
CPB was established using femoral vessels. Due to close adhesions between the sternum and the heart highlighted on CT-scan, redo sternotomy was performed under CPB with an EEG monitoring. As expected, dissection of pericardial adhesions was particularly demanding. The ascending aortic prosthesis was partly mobilized along the right superior vena cava. However, it was not possible to dissect the left side of the prosthesis because of severe adhesions with the pulmonary artery.
Therefore, decision was made to use a stepwise technique for the distal anastomosis.
Mobilization of the aortic root identified an abscess extending to the roof of the left atrium and involving the entire surface of the noncoronary sinus with a disruption of the fibrous trigone and the mitral valve insertion.
The Figure 2 illustrates the different steps of the surgical procedure.
Figure 2: Illustration of the different steps of the surgical procedure. AML: Anterior Mitral Leaflet - AMV: Anterior Mitral Valve - RA: Right Atrium
Weaning from cardiopulmonary bypass required an atrioventricular pacing due to extensive septal tissular damages. Therefore, we implanted a subxyphoidal permanent pacemaker with epicardial atrioventricular leads. The patient was extubated at the 12th postoperative hour and was discharged with oral anticoagulation and antibiotherapy (cefotaxim and rifampicin) for 8 weeks. The choice and the duration of postoperative antibiotics were validated by our microbiologists and specialists in infectiology.

Results

Microbiological results of operative materials (vegetation and prosthetic mechanical valve) remained negative with PAS and Gram staining.
Presence and identification of the bacteria within the vegetation and the prosthetic valve were definitely confirmed by amplification and sequencing of 16S rDNA.
Specific recommendations about skin decontamination and epilation of the legs were given to the patient.
At 32 months after surgery the patient remains completely asymptomatic. The last echography control showed an LVEF of 55% and normally functioning aortic valve prosthesis, without paravalvular leak.

Discussion

Propionibacterium species are members of the normal flora of human skin and the mouth. Propionibacterium acnes (PA) is a Gram positive microaerophilic bacteria usually considered to have a low level of virulence. Nevertheless, it can be associated with severe infective endocarditis of native and prosthetic valves [1-4]. Even if it remains a rare cause of proven endocarditis, its actual prevalence is probably underestimated [5,6].
In 2006, a review of literature [1] identified only 28 papers describing 33 cases. 26 cases (78.8%) were definite by Duke Criteria and (21.2%) were considered as possible.
Eventually, about 50 cases have been reported in the literature [1-3]. The real incidence of PA endocarditis is not known, but probably ranges from 0.3 cases and 1.4 cases per year [4-6].
Clayton [1] reported an incidence of 0.4 cases per year over a period of 8 years in a population of approximately 700 000.
However, this case highlights the predisposition of this low-grade pathogen to create tissular damages such as intracardiac abscesses and prosthetic valve dehiscence [4,7-10].
Serious infections due to PA are rarely reported and may have ubiquitous expression such as prosthetic joint infection, osteomyelitis, endophtalmitis, and central nervous system infections [1,4,6].
In cardiology, even if PA may contaminate native valves, nevertheless an indwelling medical device (prosthetic heart valve, annuloplasty rings or pace-maker) is often involved [1,3,11]. Jakab [6] in a retrospective review from 20 patients with clinical and microbiological evidence of a PA infection reported that the predominant predisposing conditions were a surgery from 2 weeks to 4 years preceding the infection and the implantation of indwelling foreign bodies.
Among the 33 cases of Propionibacterium endocarditis reviewed by Clayton [1] in 2006, 14 cases (42.4%) involved native valves, 16 (48.5%) involved prosthetic valves and 3 (9.1%) were associated with other intracardiac prosthetic material. Ten of the 14 patients (71.4%) with native valve infection had an underlying cardiac factor predisposing to infection, such as trivial valvular leakage, mitral prolapse, moderate aortic valve insufficiency, or atrial septal defect. The infecting organism was PA in 29 cases (87.88%).
The diagnosis remains difficult to establish because PA endocarditis is usually associated with a relatively long history with minimal clinical signs of infection. This is typified in our case, as the patient presented with an indolent clinical course, low leucocyte count, moderately raised CRP, negative culture results and normal repeat TTE.
In published cases, the median CRP at presentation was 51mg/L (range 3-262 mg/L) [1-5,7-11].
Our experience validated the superiority of TEE since repeat TTE failed to detect any abscess or vegetation. TEE has a sensitivity of 82% to 96% compared with 17% to 36% for TTE in detecting PVE [12].
If TTE is generally recommended as the first routine imaging exam in most patients with suspected infective endocarditis, nevertheless in patients with indwelling cardiac devices, it is recommended to begin with TEE to achieve a prompt diagnosis that may be delayed with TTE because of frequent shadowing that interfere with an adequate visualization of prosthetic valve vegetation, abscess, fistulae and paraprosthetic leaks [13-15].
Case series and review of PA endocarditis showed that the pathogenic potential of PA is becoming increasingly apparent. Therefore, prompt diagnosis and urgent surgical management are essential [1,3,4,6].
Between 1998 and 2005, the Leeds endocarditis service database reported three lethal cases of PA endocarditis despite an intensive surgical management [1-3,8,16].
Wallace [16] and Mohsen [8], reported a respective mortality at 21-46%, 27.3% and 20%.
Lethal complications of PAPVE are usually related to the severity of tissue damages that require redo operations with long and complex procedures [1-4,7-10,16]. Among 16 patients with PAPVE, intracardiac abscesses associated with valve dehiscence were commonly encountered in 52.9% [1].
Many laboratories routinely incubate blood cultures for 5 days. In order to isolate PA from blood samples, it is recommended to prolonge cultures for up to 2 weeks, since the median incubation period is usually 7 days (range 5-14 days) [1-5,8].
Our case illustrates the specificity of PA endocarditis since 8 days were necessary to isolate PA from blood samples, almost 12 weeks after the initial clinical presentation. This is an evidence of a slow-growing bacterium whose involvement in endocarditis at the early phase is difficult to assess.
Additionally, its presence in operative tissues often needs to be confirmed by molecular biology techniques such as polymerase chain reaction (PCR) [17] and sequencing of 16S rDNA [18,19]. However, there may be a paucity of positive microbiological results and therefore doubt can be cast upon the validity of the diagnosis [20]. In this particular situation, microbiological results have to be ranked with Duke Criteria particularly in patients with cardiac indwelling implants.
Our experience of PAPVE highlighted the severity of the tissular destruction that required a long surgical procedure with a complex reconstruction of the posterior aspect of the aortic root.
If histological findings were compatible with chronic infection, nevertheless PAS (Periodic Acid Schiff) and Gram stains failed to show any microorganism [21].
Finally, the microorganism was identified only by sequencing of 16S rDNA, while standard cultures remained negative, thus confirming that antibiotic treatment easily suppresses the microorganism but does not eliminate it.
The review of literature showed that only surgery for valvular replacement with antibiotic treatment led most patients to be cured, whereas isolated antibiotic treatment controlled the symptoms but almost never succeeded in eliminating the infection even in native valve endocarditis. The fact that antibiotic treatment is not sufficient to obtain a cure indicates the involvement of a biofilm.
The specific clinical behavior and tissular damages of PAPVE probably result from an obvious emergence of antibiotic-resistant PA leading to a modification in the susceptibility profiles, as suggested by Grech [22], and worsened by its low virulence and ability of PA to produce biofilm [23]. The capacity of PA to form biofilm on different materials or devices has been demonstrated in vitro on valve prostheses [24] but also in vivo on joint prostheses or catheters [25,26].
Bacteria, imbedded in the biofilm and then protected against phagocytosis, would activate macrophages which release enzymes that could injure the host tissue, causing frequent periprosthetic dehiscence.
Additionally, protection of the bacteria within the biofilm, would explain the low frequency of infective symptoms, only present when bacteria are released into the circulation.
The presence of biofilm might explain why standard cultures of cardiac prosthesis often fail to confirm the presence of PA due to the lack of growth of the bacteria imbedded in it.
These complex mechanisms underscore the usefulness of molecular techniques for the diagnosis of infection caused by fastidious microorganisms such as PA.
In our patient, the microbiological contamination probably originated from regular cutaneous trauma due to leg shaving with manual razors that were characterized by obvious bleedings. These bleedings, increased by oral anticoagulation, were likely to create suitable conditions that facilitated chronic release of PA into the circulation and a contamination of the valvular prosthesis.
Specific dermatologic recommendations were given to the patient with the necessity to achieve a skin decontamination before epilation and use an electric lady epilator.

Conclusion

PA is a gram positive anaerobic bacillus member of the normal flora of skin and mouth. It is considered of low virulence and often classified as contaminant of microbiological specimens.
However, its pathogenic potential is often overlooked since it can cause serious infections and has been linked to limited number cases of PVE with a high mortality.
Clinical course is frequently insidious with poor signs of infection and hence diagnosis may be delayed. In PAPVE cardiac and neurological symptoms predominate respectively secondary to valvular dysfunction or embolization. PA endocarditis is associated with the difficulty in isolating the microorganism. Prolonged anaerobic cultures for up to two weeks are required in order to isolate the pathogen from blood. TEE is recommended as the first imaging exam in PAPVE to prevent a delay in the diagnosis.
Due to severe tissular damages and life-threatening complications, PAPVE require antibiotic treatment and urgent withdrawal of the prosthetic valvular material. In female patients with valvular mechanical prosthesis who require oral anticoagulation, specific dermatologic recommendations to avoid skin contamination following epilation are urgently necessary.

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