Dual pathogen valvular endocarditis in a case of severe aortic aneurysm

Infective endocarditis (IE) is the heart valve or endocardium infection. We report a rare case of polymicrobial endocarditis, namely invasive Aspergillus spp and Acinetobacter baumannii, in a 36-year-old male with a medical history of degenerative disease of the aorta with abdominal aortic and ascending aortic aneurysms with a fulminant clinical course and fatal outcome. The treatment was challenging due to multiple comorbidities. The autopsy revealed dual pathogen endocarditis due to Acinetobacter baumannii sepsis and invasive Aspergillus spp mycosis. This report emphasizes that polymicrobial endocarditis (PE) is an infrequent finding with a poor prognosis requiring high clinical suspicion.

KEYWORDS
Endocarditis; Acinetobacter baumannii; Aneurysm; Aspergillus

Authorship

Meghna Yadav

Base Hospital, Department of Pathology, New Delhi, IndiaBase HospitalIndiaNew Delhi, IndiaBase Hospital, Department of Pathology, New Delhi, India

http://orcid.org/0000-0001-5678-4084

Rohit Tewari

Army Hospital, Department of Laboratory Science & Molecular Medicine, New Delhi, IndiaArmy HospitalIndiaNew Delhi, IndiaArmy Hospital, Department of Laboratory Science & Molecular Medicine, New Delhi, India

http://orcid.org/0000-0002-7032-1876

Tathagata Chatterjee

http://orcid.org/0000-0003-3374-2118

Authors’ contributions: Meghna Yadav, Rohit Tewari and Tathagata Chatterjee have equally contributed to the conception of the manuscript, proofread the final version and approved it for publication.

Conflict of interest: None

CorrespondenceMeghna Yadav Base Hospital, Department of Pathology Delhi Cantonment, Pin- 110010 New Delhi, India Phone: + 91 9797415805meghnay@yahoo.com

SCIMAGO INSTITUTIONS RANKINGS

Base Hospital, Department of Pathology, New Delhi, IndiaBase HospitalIndiaNew Delhi, IndiaBase Hospital, Department of Pathology, New Delhi, India

Figures

Figures (8)

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Figure 1
A and B – Gross view of the unfixed lung showing boggy and edematous surface with exudation of frothy fluid; C – Photomicrograph of lung at low magnification showing diffuse alveolar and interstitial edema with focal areas exhibiting intra-alveolar hemorrhage (H&E).

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Figure 2
Gross view of the mitral valve showing large vegetation measuring 2.5x1.9x.0.6 cm. The mitral valve showed tissue corrosion on the posterior leaflet and anterior commissure.

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Figure 3
A and B – Gross view of massive aneurysmal dilation of the sinuses of Valsalva with blood clots in the lumen (arrowheads). The surrounding tissue showed purulent material.

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Figure 4
A – Gross view of ascending aorta shows nodular lesions on the surface; B – Photomicrograph of aorta shows elastic tissue fragmentation and areas devoid of elastic tissue. No foci of inflammation, plasma cell clusters, granulomas, or giant cells were found.

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Figure 5
The ascending aorta shows thickened nodular lesions on the luminal surface measuring 1.5 cm each with local ulceration; also note the large abdominal aortic aneurysm measuring 10 cm in extension and 5.0 cm in diameter filled in by an aortoiliac prosthesis, which was extensively thrombosed above the origin of the renal arteries.

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Figure 6
Photomicrographs of the mitral valve vegetation. A – Low magnification showing destructive inflammatory infiltrate comprised predominantly of neutrophils, few lymphoplasmacytic cells and macrophages (PAS, 20 x); B – Photomicrograph of myocardial abscess in left ventricular wall showing blood, fibrin clot along with colonies of embedded bacterial organisms. Numerous broad septate hyphae suggestive of Aspergillus sp eliciting giant cell reaction and chronic inflammatory infiltrate. Histomorphological features was consistent with fresh vegetation composed of fibrin, granulation tissue and neutrophils (PAS, 40 x); C – Photomicrographs of the mitral valve vegetation showing numerous bacterial colonies infiltrating the heart muscle (H&E, 20 x); D – Photomicrographs of the mitral valve vegetation. Grocott stain shows acute angle branching hyphae with frequent septations morphologically consistent with Aspergillus sp (40 x).

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Figure 7
Gross view of the enlarged left kidney, weighing 210 gm (MRV: 170 g). Note a wedge-shaped subcapsular pale area indicating septic infarct measuring 2.1x1.4x 0.4 cm.

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Figure 8
Photomicrographs of the kidney. A – showing features of infarcts in widespread coagulative necrosis (preserved ghost lines) (H&E 20 x); B – Left renal septic emboli with fungal hyphae. Thrombi was seen in the vessels at the apex of the infarct. The thrombi showed blood, fibrin and septate hyphae consistent with Aspergillus spp. (PAS, 40 x).

Figure 1 A and B – Gross view of the unfixed lung showing boggy and edematous surface with exudation of frothy fluid; C – Photomicrograph of lung at low magnification showing diffuse alveolar and interstitial edema with focal areas exhibiting intra-alveolar hemorrhage (H&E).

Figure 2 Gross view of the mitral valve showing large vegetation measuring 2.5x1.9x.0.6 cm. The mitral valve showed tissue corrosion on the posterior leaflet and anterior commissure.

Figure 3 A and B – Gross view of massive aneurysmal dilation of the sinuses of Valsalva with blood clots in the lumen (arrowheads). The surrounding tissue showed purulent material.

Figure 4 A – Gross view of ascending aorta shows nodular lesions on the surface; B – Photomicrograph of aorta shows elastic tissue fragmentation and areas devoid of elastic tissue. No foci of inflammation, plasma cell clusters, granulomas, or giant cells were found.

Figure 5 The ascending aorta shows thickened nodular lesions on the luminal surface measuring 1.5 cm each with local ulceration; also note the large abdominal aortic aneurysm measuring 10 cm in extension and 5.0 cm in diameter filled in by an aortoiliac prosthesis, which was extensively thrombosed above the origin of the renal arteries.

Figure 6 Photomicrographs of the mitral valve vegetation. A – Low magnification showing destructive inflammatory infiltrate comprised predominantly of neutrophils, few lymphoplasmacytic cells and macrophages (PAS, 20 x); B – Photomicrograph of myocardial abscess in left ventricular wall showing blood, fibrin clot along with colonies of embedded bacterial organisms. Numerous broad septate hyphae suggestive of Aspergillus sp eliciting giant cell reaction and chronic inflammatory infiltrate. Histomorphological features was consistent with fresh vegetation composed of fibrin, granulation tissue and neutrophils (PAS, 40 x); C – Photomicrographs of the mitral valve vegetation showing numerous bacterial colonies infiltrating the heart muscle (H&E, 20 x); D – Photomicrographs of the mitral valve vegetation. Grocott stain shows acute angle branching hyphae with frequent septations morphologically consistent with Aspergillus sp (40 x).

Figure 7 Gross view of the enlarged left kidney, weighing 210 gm (MRV: 170 g). Note a wedge-shaped subcapsular pale area indicating septic infarct measuring 2.1x1.4x 0.4 cm.

Figure 8 Photomicrographs of the kidney. A – showing features of infarcts in widespread coagulative necrosis (preserved ghost lines) (H&E 20 x); B – Left renal septic emboli with fungal hyphae. Thrombi was seen in the vessels at the apex of the infarct. The thrombi showed blood, fibrin and septate hyphae consistent with Aspergillus spp. (PAS, 40 x).

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Hospital Universitário da Universidade de São Paulo Hospital Universitário da Universidade de São Paulo, Av. Prof. Lineu Prestes, 2565 - Cidade Universitária, 05508-000 - São Paulo - SP - Brasil, (16) 3307-2068, (16) 3307-2068 - São Paulo - SP - Brazil
E-mail: autopsy.hu@gmail.com

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Dual pathogen valvular endocarditis in a case of severe aortic aneurysm

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[1] Authors’ contributions: Meghna Yadav, Rohit Tewari and Tathagata Chatterjee have equally contributed to the conception of the manuscript, proofread the final version and approved it for publication.