Enterococcus faecalis-induced infective endocarditis: an unusual source of

infection and a rare clinical presentation

A Case Review Assignment submitted for Dr. Rasmi Abu-Helw
By: Mohamad Hamza
Lecture
Outline

INTRODUCTION
CASE PRESENTATION
INVESTIGATIONS
TREATMENT
LEARNING POINTS
Introduction

A gram-positive, gamma-hemolytic streptococcus that grows in chains is called Enterococcus faecalis. Urinary tract

infections, bacteremia, meningitis, and endocarditis are among the clinical manifestations of E. faecalis infection. With

5% to 15% of cases, Enterococcus faecalis is the third most common cause of infective endocarditis (IE). The

conventional site of infection for individuals with E. faecalis-caused infective endocarditis, which primarily affects older

men, is the genitourinary (GU) tract. Up to 25% of individuals with community-acquired E. faecalis bacteremia also have

infective endocarditis, according to population-based research.

Introduction

The DENOVA score system is the bedside screening test that has the best sensitivity (100%) to rule out infective endocarditis. C
Each scored item is allocated 1 point. The DENOVA system evaluates the following: the length of symptoms lasting ≥7

days, embolization, the number of positive blood cultures (3/3 or the majority if >3), prior heart valve disease,

unknown etiology of bacteremia, and auscultation of a heart murmur. When deciding whether to undergo

transesophageal echocardiography (TEE) in a patient with enterococcal bacteremia who has a high clinical suspicion of

infective endocarditis, the DENOVA scoring system is used.

A 69 years old female mainly complained of chest pain, shortness

of breath (SOB), and diaphoresis the night before admission. She

have a past medical history (PMH) of hypertension, type 2 diabetes

mellitus, hypersensitivity pneumonitis, right breast cancer and

Case Presentation
obesity. And a past surgical history (PSH) of gastric band

placement and right lumpectomy. Cardiovascular and respiratory

examination revealed nothing to worry about and everything was

normal. Electrocardiogram revealed an ST elevation myocardial

infarction (STEMI), cardiac workout shows elevated troponin

levels >10,000ng/dl.
 1st Day
Cardiac catheterization was performed
as a protocol for suspected acute
coronary syndrome through radial
artery.

Post cardiac cath, the patient

developed left upper quadrant
abdominal pain.
Case Investigation
 1st Day 2nd Day
Cardiac catheterization was performed
The patient developed
as a protocol for suspected acute
diaphoresis, shortness
coronary syndrome through radial
of breath, fever
artery.
(39.5C), tachycardia
and hypotension.
Blood labs workout
shows leukocytosis
(White blood cells
(WBCs) count of 16.5
x 103 cells/L and
lactate concentration
was 1mmol/L.

Post cardiac cath, the patient

developed left upper quadrant
abdominal pain.
Case Investigation
 1st Day 2nd Day Radiology Workout
Cardiac catheterization was performed  Abdominal CT: revealed splenic
The patient developed
as a protocol for suspected acute
diaphoresis, shortness infarct, high grade stenosis of the
coronary syndrome through radial
of breath, fever
artery. celiac artery and mild thickening of
(39.5C), tachycardia
and hypotension. the splenic flexure.
Blood labs workout
shows leukocytosis  TTE: revealed ejection fraction of
(White blood cells
(WBCs) count of 16.5 40%, apical and mid anteroseptal
x 103 cells/L and
lactate concentration wall hypokinesia, trace pericardial
was 1mmol/L.
effusion.

Post cardiac cath, the patient

developed left upper quadrant
abdominal pain.
Case Investigation
 3rd Day
Blood cultures exhibited growth of gram-positive
cocci in pairs and chains and a complete blood cell
count (CBC) showed an increase in the severity of
leukocytosis (WBCs count was 26 x 103 cells/L.)
Vancomycin was started in addition to previously
mentioned antibiotics and blood cultures were re-
taken after the intervention.

Case Investigation
 3rd Day
Blood cultures exhibited growth of gram-positive
cocci in pairs and chains and a complete blood cell
count (CBC) showed an increase in the severity of
leukocytosis (WBCs count was 26 x 103 cells/L.)
Vancomycin was started in addition to previously
mentioned antibiotics and blood cultures were re-
taken after the intervention.

4th Day
E. faecalis was identified as the causative
of acute coronary syndrome that is
related to infective endocarditis. After
this result, ceftriaxone 2gx2 and
ampicillin Q4 hours was started, and a
urine analysis and culture were obtained.
Case Investigation
 3rd Day
Blood cultures exhibited growth of gram-positive
cocci in pairs and chains and a complete blood cell 5th Day
count (CBC) showed an increase in the severity of
leukocytosis (WBCs count was 26 x 103 cells/L.) The patient still stable,
Vancomycin was started in addition to previously afebrile and WBCs
mentioned antibiotics and blood cultures were re- count continued to trend
taken after the intervention. downward, urine
analysis revealed
leukocytes and negative
4th Day nitrates, while urine
culture demonstrated no
E. faecalis was identified as the causative growth.
of acute coronary syndrome that is
related to infective endocarditis. After
this result, ceftriaxone 2gx2 and
ampicillin Q4 hours was started, and a
urine analysis and culture were obtained.
Case Investigation
 3rd Day
Blood cultures exhibited growth of gram-positive 6th Day
cocci in pairs and chains and a complete blood cell 5th Day
count (CBC) showed an increase in the severity of DENOVA scoring system was used to
leukocytosis (WBCs count was 26 x 103 cells/L.) The patient still stable, determine whether to perform TEE for
Vancomycin was started in addition to previously afebrile and WBCs potential infective endocarditis (IE). TEE
mentioned antibiotics and blood cultures were re- count continued to trend was performed and revealed a large 1.5 x
taken after the intervention. downward, urine 1.6cm mobile vegetation with irregular
analysis revealed borders on the mitral valve as shown in
leukocytes and negative figure 2. TEE showed mild mitral
4th Day nitrates, while urine regurgitation while no mitral stenosis
culture demonstrated no was noticed and the ejection fraction still
E. faecalis was identified as the causative growth. 40%.
of acute coronary syndrome that is
related to infective endocarditis. After
this result, ceftriaxone 2gx2 and
ampicillin Q4 hours was started, and a
urine analysis and culture were obtained.
Case Investigation
 7th Day
Blood cultures revealed again the presence of E. faecalis as the causative organism, it was susceptible to ampicillin,
gentamycin and penicillin. Brain CT scan showed a small asymptomatic focus of subarachnoid hemorrhage in the
left frontal lobe and head magnetic resonance imaging (MRI) revealed multiple emboli in the left frontal lobe. Left
spine MRI also was concerning for discitis and osteomyelitis at lumbar 1 and lumbar 2 vertebras. Carotid duplex
ultrasound showed <50% stenosis and incidentally revealed a right internal jugular vein thrombus.

Case Investigation
 Esophagogastroduodenoscopy
Esophagogastroduodenoscopy
was done and revealed gastric
Treatment mucosal atrophy and
colonoscopy was done and
showed a perforation 20cm
from the anal verge and at the
rectosigmoid junction.
2#
An end-colostomy was performed and
the patient was admitted to the intensive
care unit (ICU) because she was nod
good candidate for mitral valve
replacement and signed of the service.
Admission to ICU
hypoxia and tachycardia after the
colonoscopy. Physical examination
done and revealed diffuse abdominal
tenderness, guarding and rebound
tenderness with loss of pulse
1#
Patient was immediately
underwent a noninvasive
positive pressure
ventilation and given
epinephrine.
 Treatment
Following surgery

Patient's WBCs elevated to 23 × 103 cells/L.

Stress dose of hydrocortisone given
Regular hydrocortisone 100mg started
The patient experienced a temperature spike (93C).
 Treatment
Following surgery

Patient's WBCs elevated to 23 × 103 cells/L.

Stress dose of hydrocortisone given
Regular hydrocortisone 100mg started
The patient experienced a temperature spike (93C).

At rehabilitation center

Three days following the surgery Patient developed multiorgan dysfunction syndrome.
Cardiogenic shock.  Heart Failure
She passed away.

Patient developed severe kidney damage.

Patient was sent to rehabilitation center

Ventilator Associated Pneumonia

 Stress dose of hydrocortisone given
Regular hydrocortisone 100mg started

At rehabilitation center
 Patient developed multiorgan dysfunction syndrome.
 Cardiogenic shock.  Heart Failure
 She passed away.

Patient was sent to rehabilitation center

 Treatment
Following surgery

Patient's WBCs elevated to 23 × 103 cells/L.

Stress dose of hydrocortisone given
Regular hydrocortisone 100mg started
The patient experienced a temperature spike (93C).

At rehabilitation center

Three days following the surgery Patient developed multiorgan dysfunction syndrome.
Cardiogenic shock.  Heart Failure
She passed away.

Patient developed severe kidney damage.

Patient was sent to rehabilitation center

Ventilator Associated Pneumonia

 Learning Points

 Both GU and GI causes of infective endocarditis can be

caused by Enterococcus faecalis.

 An uncommon clinical manifestation of infective endocarditis is ACS.

 the DENOVA scoring system should be used when determining if TTE

or TEE is necessary for patients with enterococcal bacteremia
 References
1. Dubin K, Pamer EG. Enterococci and their interactions with the intestinal microbiome. Microbiol Spectr 2014; 5: 10.
doi:10.1128/microbiolspec.BAD-0014-2016.
2. Khan Z, Siddiqui N, Saif MW. Enterococcus faecalis infective endocarditis and colorectal carcinoma: case of new
association gaining ground. Gastroenterology Res 2018; 11: 238–240. doi:10.14740/gr996w.
3. Berge A, Krantz A, Östlund H, et al. The DENOVA score efficiently identifies patients with monomicrobial Enterococcus
faecalis bacteremia where echocardiography is not necessary. Infection 2019; 47: 45–50. doi: 10.1007/s15010-018-1208-3.
Epub 2018 Sep 3. PMID: 30178077.
4. Seby, R., Kim, C., Khreis, M., & Khreis, K. (2022). Enterococcus faecalis-induced infective endocarditis: an unusual source
of infection and a rare clinical presentation. The Journal of international medical research, 50(7), 3000605221112019.
https://doi.org/10.1177/03000605221112019.
5. Attias D, Lepage L, Messika-Zeitoun D, et al. Acute coronary syndrome in aortic infective endocarditis. Eur J Echocardiogr
2008; 9: 727–728, 10.1093/ejechocard/jen194.
6. Maqsood K, Sarwar N, Eftekhari H, et al. Septic coronary artery embolism treated with aspiration thrombectomy: case report
and review of literature. Tex Heart Inst J 2014; 41: 437–439. Published 2014 Aug 1. doi:10.14503/THIJ-13-3386.
7. Agudelo Higuita NI, Huycke MM. Enterococcal Disease, Epidemiology, and Implications for Treatment. 2014 Feb 4. In:
Gilmore MS, Clewell DB, Ike Y, et al., editors. Enterococci: From Commensals to Leading Causes of Drug Resistant
Infection. Boston: Massachusetts Eye and Ear Infirmary; 2014.