Autopsy and Case Reports
Autopsy and Case Reports
Article / Autopsy Case Report

Infective endocarditis with left to right intracardiac fistula due to Streptococcus anginosus - a rare complication caused by an even rarer bacterium

Robert Forster; Fernando Peixoto Ferraz de Campos; Silvana Maria Lovisolo; Vera Demarchi Aiello; João Augusto dos Santos Martines

Downloads: 6
Views: 1266


Although infective endocarditis (IE) has been described in reports dating from the Renaissance, the diagnosis still challenges and the outcome often surprises. In the course of time, diagnostic criteria have been updated and validated to reduce misdiagnosis. Some risk factors and epidemiology have shown dynamic changes since degenerative valvular disease became more predominant in developed countries, and the mean age of the affected population increased. Despite streptococci have been being well known as etiologic agents, some groups, although rare, have been increasingly reported (e.g., Streptococcus milleri.) Intracardiac complications of IE are common and have a worse prognosis, frequently requiring surgical treatment. We report a case of a middle-aged diabetic man who presented with prolonged fever, weight loss, and ultimately severe dyspnea. IE was diagnosed based on a new valvular regurgitation murmur, a positive blood culture for Streptococcus anginosus, an echocardiographic finding of an aortic valve vegetation, fever, and pulmonary thromboembolism. Despite an appropriate antibiotic regimen, the patient died. Autopsy findings showed vegetation attached to a bicuspid aortic valve with an associated septal abscess and left ventricle and aortic root fistula connecting with the pulmonary artery. A large thrombus was adherent to the pulmonary artery trunk and a pulmonary septic thromboemboli were also identified.


Endocarditis, Bicuspid Aortic Valve, , Aorta-pulmonary artery fistula, Pulmonary Embolism, Autopsy


Pearce JMS. Cerebral embolism in endocarditis: William Senhouse Kirkes (1823-64). J Neurol Neurosurg Psychiatry. 2003;74:1570. [].

Osler W. The Gulstonian Lectures, on Malignant Endocarditis. BMJ. 1885;1:467-70. [].

Durack DT, Lukes AS, Bright DK. New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service. Am J Med. 1994;96:200-9. [].

Li J, Sexton DJ, Mick N, et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis. 2000;30:633-8. [].

Bor DH, Woolhandler S, Nardin R, Brusch J, Himmelstein DU. Infective endocarditis in the US. 1998-2009: a nationwide study. PLoS ONE. 2013;8:e60033. [].

Fedeli U, Schievano E, Buonfrate D, Pellizzer G, Spolaore P. Increasing incidence and mortality of infective endocarditis: a population-based study through a record-linkage system. BMC Infect Dis. 2011;11:48-54. [].

Correa de Sa DD, Tleyjeh IM, Anavekar NS, et al. Epidemiological trends of infective endocarditis: a population-based study in Olmsted County, Minnesota. Mayo Clin Proc. 2010;85:422-6. [].

Nesseler N, Launey Y, Mallédant Y. Infective endocarditis. N Engl J Med. 2013;369:784-5. [].

Movahed MR, Hashenzadeh M, Jamal MM. Significant increase in the prevalence of non-rheumatic aortic valve disease in patients with type 2 diabetes mellitus. Exp Clin Endocrinol Diabetes. 2007;115:105-7. [].

Chirillo F, Bacchion F, Pedrocco A, et al. Infective endocarditis in patients with diabetes mellitus. J Heart Valve Dis. 2010;19:312-20.

Lamas CC, Eykyn SJ. Bicuspid aortic valve: a silent danger: analysis of 50 cases of infective endocarditis. Clin Infect Dis. 2000;30:336-41. [].

Ward C. Clinical significance of the bicuspid aortic valve. Heart. 2000;83:81-5. [].

Baumgartner H, Dabritz S. Congenital heart disease in adulthood. Med Klin (Munich). 2008;103:135-42.

Gray T. Streptococcus anginosus Group: clinical significance of an important group of pathogens. Clin Microbiol Newsl. 2005;27:155-9. [].

Lefort A, Lortholary O, Casassus P, et al. Comparison between adult endocarditis due to beta-hemolytic streptococci (serogroups A, B, C, and G) and Streptococcus milleri: a multicenter study in France. Arch Intern Med. 2002;162:2450-6. [].

Facklan RR. The major differences in the American and British Streptococcus taxonomy schemes with special reference to Streptococcus milleri. Eur J Clin Microbiol. 1984;3:91-3. [].

Whitworth JM. Lancefield group F and related streptococci. J Med Microbiol. 1990;33:135-51. [].

Levandowski RA. Streptococcus milleri endocarditis complicated by myocardial abscess. South Med J. 1985;78:892-3. [].

Wallis DE, Venezio FR, Montoya A, Cook FV, Scanlon PJ. Streptococcus MG-intermedius endocarditis. South Med J. 1986;79:1313-4. [].

Woo PCY, Tse H, Chan K, et al. “Streptococcus milleri” endocarditis caused by Streptococcus anginosus. Diagn Microbiol Infect Dis. 2004;48:81-8. [].

Kitada K, Inoue M, Kitano M. Experimental endocarditis induction and platelet aggregation by Streptococcus anginosus, Streptococcus constelatus and Streptococcus intermedius. FEMS Immunol Med Microbiol. 1997;19:25-32. [].

Habib G, Hoen B, Tornos P, et al. Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009). Eur Heart J. 2009;30:2369-413. [].

Mansur AJ, Grimberg M, Da Luz PL, Bellotti G. The complications of infective endocarditis. A reappraisal in the 1980s. Arch Intern Med. 1992;152:2428-32. [].

Kahveci G, Bayrak F, Pala S, Mutlu B. Impact of bicuspid aortic valve on complications and death in infective endocarditis of native aortic valves. Tex Heart Inst J. 2009;36:111-6. [].

Omari B, Shapiro S, Ginzton L, et al. Predictive risk factors for periannular extension of native valve endocarditis. Clinical and echocardiographic analyses. Chest. 1989;96:1273-9.

Tribouilloy C, Rusinaru D, Sorel C. Clinical characteristics and outcome of infective endocarditis in adults with bicuspid aortic valves : a multicentre observational study. Heart. 2010;96:1723-9.

Choussat R, Thomas D, Isnard R, et al. Perivalvular abscesses associated with endocarditis: clinical features and prognostic factors of overall survival in a series of 233 cases: Perivalvular Abscesses French Multicentre Study. Eur Heart J. 1999;20:232-41. [].

Anguera I, Miro JM, Evangelista A, et al. Periannular complications in infective endocarditis involving native aortic valves. Am J Cardiol. 2006;98:1254-60. [].

Obón Azuara B, Zalba Etayo B, Gutiérrez Cía I, Villanueva Anadón B. [Aorto pulmonary fistula: left-sided infective endocarditis in HIV and intravenous drugs abuser patient. Review of the literature]. An Med Interna. 2007;24:547-50. Spanish. PMid:17056342. []10.1016/j.amjcard.2006.06.016

Hershenson JA, Baker PB, Rowland DG. Ruptured Myocardial Abscess Causing Left Ventricle to Pulmonary Artery Communication in an Infant With Community-Associated Methicillin-Resistant Staphylococcus aureus Endocarditis. Arch Pathol Lab Med. 2011;135:1057-60. [].


Publication date:

569696ab64cc8b5cda711bd9 autopsy Articles

Autops Case Rep

Share this page
Page Sections