Multimodal assessment in polymicrobial infective endocarditis with silent spondylodiscitis and cerebral embolism

Abstract Infective endocarditis (IE) is a rare but severe disease, due to an infection of the endocardial surface of the heart. The annual incidence ranging from 3 to 7 per 100 000 person-years, with an overall mortality rates of 25%. Staphylococci and Streptococci accounted for approximately 80% of IE cases. Enterococci are the third leading cause accounted for approximately 5-18% of all cases and are increasingly linked to health-care contact. The increasing number of cardiovascular electronic devices, prosthetic valves implants along with frequent invasive diagnostic or therapeutic procedures performed in elderly, may also contribute to the rise of IE in this population. Blood cultures and echocardiographic findings are the cornerstone of the IE diagnosis, confirmed or rejected according to modified Duke criteria. Other imaging modalities as Cardiac Computed Tomography, Cardiac Magnetic Resonance Imaging and 18Ffluorodeoxyglucose Positron Emission Tomography - Computed Tomography (18FDG-PET/CT) can determine a more correct diagnosis and identify many of the endocarditis-related complications. Here, we describe a patient with aortic prosthetic valve and Enterococcus faecalis (EF) IE. Cerebral and spinal MRI and 18FDG-PET/CT, performed during the hospitalization, showed multi-organ silent periferic embolization. Furthermore, the cultural examination of the valvular surgical specimen revealed a methicillin-sensitive Staphylococcus aureus suggestive for polymicrobial endocarditis. Some Authors demonstrated a possible false-positive valve culture due to a postoperative contamination. Since contaminated cultures usually yield microorganisms compatible with endocarditis, such as coagulase-negative Staphylococci, viridans group Streptococcus species, may be difficult for the physician not to treat the patient. This case represents need for high level of suspicion to diagnose IE. Multimodality assessment improves the diagnosis and allows the detection of the complications. Moreover, a multidisciplinary team and specialized centers determine a better patient’s outcome.