Case Presentation:
A 46‐year‐old man presented with a 2‐month history of fatigue, worsening dyspnea, and lower extremity swelling. He had a prosthetic aortic valve implanted 10 years ago and was noncompliant with anticoagulation. His medical history was also pertinent for intravenous drug abuse. He denied having had sexually transmitted diseases in the past and was not currently sexually active. Cardiac examination revealed an ejection systolic murmur at the aortic area with prosthetic valve clicks and no other physical signs to suggest endocarditis. Initial laboratory data revealed a hematocrit of 17% and MCV of 69 with acute renal failure. A trans‐thoracic echocardiogram revealed an elevated gradient across the prosthetic aortic valve, suggesting valve malfunction. Blood cultures on arrival and 4 days after admission grew Neisseria gonorrhoeae (NG). Ceftriaxone was instituted for gonococcal endocarditis (GE), and 5 days later the patient underwent aortic valve replacement. There was no evidence of vegetation or thrombus on the prosthesis, nor was NG recovered from the removed valve. His postoperative recovery was uneventful, and he was discharged to complete 4 weeks of antibiotic treatment.
Discussion:
An aerobic gram‐negative diplococcus, NG causes disseminated gonococcal infection (DGI) in 0.3% to 5% of infected individuals. GE occurs in 1% to 2% with DGI. GE is more common among men in younger age groups, although DGI is more common in women. Most patients with DGI have no prior genitourinary symptoms, and only about 1 in 8 have had prior valvular heart disease. The valves most commonly involved are the aortic, pulmonary, and mitral valves in order of frequency. Host factors such as complement deficiency predispose to DGI. Transthoracic echocardiogram helps to identify valvular vegetation that can be followed for assessing response to treatment, although transesophageal echocardiogram may be more informative in the initial evaluation. In the preantibiotic era, GE almost always had a fulminant course with an invariably fatal outcome. Currently patients have a subtle presentation, although rapid deterioration may occur if diagnosis is delayed. Right‐sided GE has a favorable response to medical therapy compared with aortic and mitral valve involvement, which may require surgery. Nonpathogenic Neisseria species are isolated more frequently than gonococci in infective endocarditis and have a propensity to infect abnormal or prosthetic valves more commonly than native valves. The treatment for prosthetic valve GE is extrapolated from that of native valve GE.
Conclusions:
We report a case of prosthetic valve GE with only 1 other case having been previously reported. Our diagnosis was based on sustained bacteremia in the presence of malfunctioning prosthetic valve that differs from the previous reported case where symptoms of DGI with evidence of systemic embolization and prosthetic valvular vegetations requiring valve replacement were also present.
Author Disclosure:
S. Somasundara, none; R. Prasad, none; W. J. Many, Jr., none.