Abstract
Case report
A 75-year old woman with a medical history of coronary heart disease and hypertension was admitted presenting with epigastric pain and palpitations. Subsequent gastroscopy and biopsy led to a diagnosis of gastric fundus cancer, for which she underwent a total gastrectomy with Roux-en-Y anastomosis. Histopathological analysis confirmed the presence of moderately to poorly differentiated adenocarcinoma (Fig. 1(a)). On the seventh post-operative day (POD 7), the appearance of turbid drainage raised suspicion of anastomotic leakage. Conservative management was pursued with fasting, gastrointestinal decompression and antibiotic therapy. On POD 11, cultures from the drainage fluid isolated Enterococcus avium and Enterococcus faecium. Despite the resumption of oral feeding, our patient experienced fever and chills on POD 21 following the replacement of the drain. Blood cultures confirmed the presence of E. avium, necessitating a modification of her antibiotic regime to include vancomycin and imipenem.
(a) The histopathological image (H&E staining ×5) of the stomach. (b) Echocardiographic findings indicating severe mitral regurgitation. (c) Vegetation formation on the valve leaflet. H&E: hematoxylin and eosin.
However, after the removal of the second drain on POD 28, our patient experienced a recurrence of fever. By POD 31, she reported exacerbated chest tightness and palpitations. On POD 34, a cardiac murmur was detected, and subsequent echocardiography revealed severe mitral regurgitation accompanied by vegetations, indicating infective endocarditis with extensive involvement of multiple valve leaflets, confirmed on histopathology (Fig. 1(b) and (c)). On POD 60, a successful thoracoscopic mitral valve bioprosthesis replacement was performed. She was initially covered by a combination of vancomycin and piperacillin-tazobactam, which was subsequently de-escalated to piperacillin-tazobactam monotherapy for 4 weeks. Post-operative echocardiography revealed no paravalvular leak. At 1-year follow up, she is fully recovered.
Discussion
E. avium is typically a constituent of the normal gut flora but can lead to opportunistic infections in immuno-compromised individuals or when mucosal barriers are compromised. Its incidence as a cause of bacteraemia is low, representing approximately 0.4–1.7% of positive blood cultures,1,2 and instances of infective endocarditis are even more uncommon, with only three cases documented to date.3–5
In our case, the post-operative anastomotic leak probably allowed translocation of gut bacteria into the bloodstream, resulting in bacteraemia and subsequent endocarditis. In terms of treatment, E. avium is susceptible to numerous antibiotics but exhibits intrinsic resistance to trimethoprim-sulfamethoxazole and certain cephalosporins. Although there is no universally accepted standard, it is generally advised to proceed to surgery after 2 to 6 weeks of appropriate antibiotic therapy. 6 The decision to proceed with mitral valve replacement using a bioprosthesis, rather than repair, was influenced by considerations such as the patient's advanced age, and technical constraints.
Footnotes
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.