Case Presentation:

A 61–year–old man was admitted with a three–week history of productive cough, fever, chills, night sweats and fatigability. He experienced progressive pleuritic chest pain and dyspnea. His past medical history was significant for CAD S/P bypass surgery and a pacemaker placed for bradycardia 10 years ago. Patient denied any IV drug abuse. Vital signs were as follow: T 38.0°C, BP 111/67, PR 97, RR 22 and O2 saturation 96% on room air. Chest examination showed scattered crackles bilaterally and a 2/6 systolic ejection murmur at the right sternal border which remained unchanged during the hospital stay. The rest of examination was unremarkable. Laboratory results showed Hgb of 9.0 g/dl and WBC count of 7.2 × 10⁹/l. Despite treatment with antibiotics for presumed pneumonia, he remained febrile with worsening cough and lethargy. CT scan chest showed multiple pulmonary nodules, infiltrates and cavities bilaterally consistent with septic emboli. His ESR was 85 and CRP 179. TEE revealed vegetations on the aortic and tricuspid valves. Two separate sets of blood cultures performed 3 days apart grew Corynebacterium jeikeium. The diagnosis of C. jeikeium dual valve infective endocarditis was made. Vancomycin was added to his management. Few days later, his fever improved and his lung infiltrates by follow up CT scan started to fade away. He was treated with intravenous antibiotics for an additional 6 weeks. Physical examination, TEE and surveillance blood cultures were negative at the 3–month follow–up, and the patient had been well since.

Discussion:

Staphylococcal and b–hemolytic streptococcal species are the most common components of skin flora that can cause infective endocarditis (IE). Corynebacteria, particularly Corynebacterium jeikeium the other component of skin flora rarely produces IE. This bacterium, a gram–positive rod that is a strict aerobe, is known to cause mechanical prosthetic valve infection and vancomycin is generally required to treatment this multidrug–resistant organism. Our literature review showed 40 cases of C. jeikeium endocarditis were reported. They all had at least one predisposing condition for the development of IE. The majority of patients (74%) had involvement of a prosthetic heart valve. Reported two cases had either percutaneous coronary intervention or pacemaker similar to our patient. The aortic valve was affected in 46% (the highest) and tricuspid valve in 5%. Our case represents the only case with combined aortic and tricuspid valve involvements. Overall, the mortality attributed to C. jeikeium IE was 33%.

Conclusions:

Despite rarity, Corynebacterium jeikeium can be a virulent skin flora which can cause infective endocarditis. Isolation of this organism in the blood and in the proper clinical setting should not be considered as contamination and should promote rapid evaluation with trans–esophageal echocardiography. It has a high mortality rate and more commonly infects prosthetic valves.

Figure 1Panel A and B: CT scan of chest showed multiple bilateral pulmonary nodules and infiltrates, some of which are cavitating, and are compatible with septic pulmonary emboli (arrows). Panel C: transesophageal echocardiogram (TEE) illustrating mobile echodensity (vegetation) on the tricuspid valve (arrow) and pacemaker wire crossing through the right atrium and tricuspid valve (arrow head). (RA: right atrium, RV: right ventricle). Panel D: TEE illustrating vegetation on the aortic valve (arrow). (Ao: Aorta).