International Journal of Infectious Diseases 97 (2020) 143–144

Contents lists available at ScienceDirect

International Journal of Infectious Diseases

journal homepage: www.elsevier.com/locate/ijid

Medical Imagery

A rare cause of infective endocarditis and stroke: Filamentous

vegetation due to Granulicatella adiacens

A 29-year-old healthy female presented with a left-sided
stoke and mitral valve (MV) regurgitation. Computer tomogra-
phy and a subtraction angiogram of the brain revealed a right
frontal and parietal branch middle cerebral artery mycotic
aneurysm with right frontal lobe hemorrhage. Endovascular
intracranial embolization was done. A transthoracic
echocardiogram showed a 0.8–0.9 cm mass on the MV valve
leaflet, with filamentous vegetation in the atrium adjacent to the
pulmonary vein opening (Figure 1). No vegetation was observed
after empirically treating for 4 weeks with intravenous
Penicillin, initially combined with Gentamycin for 2 weeks.
She is awaiting MV replacement.

Figure 1. Echocardiogram with parasternal long-axis views. Panel A: Prolapsed mitral valve (Red arrow) with filamentous vegetation in the left atrium (Blue arrow). Panel B:
Resolution of left atrium vegetation, following a month of intravenous Penicillin combined with an initial 2 weeks of Gentamycin treatment.

https://doi.org/10.1016/j.ijid.2020.05.096
1201-9712/© 2020 The Author(s). Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
144 C.J. Opperman, J. Hitzeroth / International Journal of Infectious Diseases 97 (2020) 143–144
The nutrition variant streptococci (NVS), Granulicatella
adiacens, was cultured from blood. NVS are etiological agents in
4–6% (Patel et al., 2017) of streptococcal infective endocarditis.
Classical infective endocarditis clinical signs are rarely seen with
NVS. Vegetations tend to be smaller and embolization more
prominent (Shailaja et al., 2013). They are notoriously difficult to
culture, requiring special media supplements. Infective endocar-
ditis cases with NVS have high mortality rates, treatment failure,
relapse, and antibiotic resistance (Verdecia et al., 2019). NVS
cardiac vegetations grow slowly and result in structural
abnormalities such as filament formation, thick cell walls, and
multivalvular involvement (Patil et al., 2019).
Conflict of interest
No conflict of interest to declare.
Funding source
None.
Ethical approval
Patient’s data was anonymized.
Appendix A. Supplementary data
Supplementary material related to this article can be found, in the
online version, at doi:https://doi.org/10.1016/j.ijid.2020.05.096.
References
Patel SN, Austin AM, Siebert H, Siddiqi F, Soares D, Kus JV. Susceptibility profiles of
nutritionally variant streptococci (NVS) recovered from invasive cases in
Ontario, Canada. JAMMI 2017;2(2):11–5, doi:http://dx.doi.org/10.3138/
jammi.2.2.03.
Patil SM, Arora N, Nilsson P, Yasar SJ, Dandachi D, Salzer WL. Native valve infective
endocarditis with osteomyelitis and brain abscess caused by Granulicatella
adiacens with literature review. Case Rep Infect Dis 2019;2019:4962392, doi:
http://dx.doi.org/10.1155/2019/4962392.
Shailaja TS, Sathiavathy KA, Unni G. Infective endocarditis caused by Granulicatella
adiacens. Indian Heart J 2013;65(4):447–9, doi:http://dx.doi.org/10.1016/j.
ihj.2013.06.014.
Verdecia J, Vahdat K, Isache C. Trivalvular infective endocarditis secondary to
Granulicatella adiacens and Peptostreptococcus spp. IdCases 2019;17:e00545,
doi:http://dx.doi.org/10.1016/j.idcr.2019.e00545.
Christoffel J. Oppermana,*
Jens Hitzerothb
a
Division of Medical Microbiology, National Health Laboratory
Service, University of Cape Town and Groote Schuur Hospital, Cape
Town, South Africa
b
Division of Cardiology, Department of Medicine, University of Cape
Town and Groote Schuur Hospital, Cape Town, South Africa
* Corresponding author.
E-mail addresses: Stefanopperman1@gmail.com,
christoffel.opperman@nhls.ac.za (C. Opperman).
Received 23 April 2020
Received in revised form 21 May 2020
Accepted 24 May 2020