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. 2018 Dec 6;2(4):yty142.
doi: 10.1093/ehjcr/yty142. eCollection 2018 Dec.

Successful treatment of healthcare-associated Mycobacterium chimaera prosthetic infective endocarditis: the first Spanish case report

Isabel Zegri-Reiriz  1 , Marta Cobo-Marcos  1 , Begoña Rodriguez-Alfonso  2 , Rosario Millán  3 , Fernando Dominguez  4 , Alberto Forteza  5 , Pablo Garcia-Pavia  4 , Antonio Ramos-Martinez  6
Affiliations

Successful treatment of healthcare-associated Mycobacterium chimaera prosthetic infective endocarditis: the first Spanish case report

Isabel Zegri-Reiriz et al. Eur Heart J Case Rep. .

Abstract

Background: Since 2011, several cases of health care-related disseminated Mycobacterium chimaera infection outbreaks have been reported subsequent to cardiac surgery. Diagnosis is difficult and the prognosis is extremely poor despite long-term antibiotic treatment and surgery.

Case summary: We report a Spanish case of M. chimaera infective endocarditis (IE) with disseminated infection. The patient was treated with long-term antibiotic therapy, valve replacement, and the novel use of interferon-gamma as adjuvant therapy. In addition, [18F]-fluorodeoxyglucose (FDG) positron emission tomography (PET) was used in combination with computed tomography (CT) to facilitate the diagnosis as well as to determine the duration of antibiotics and success of treatment.

Discussion: Diagnosing M. chimaera IE is difficult and requires a high index of clinical suspicion. Controlling the infection is even more difficult. Interferon-g used adjuvant to surgery and antibiotic therapy could be useful in achieving this goal. Given that the appropriate duration of antibiotics is unknown, FDG PET/CT could also be a valuable tool for determining when antibiotic therapy can be withdrawn.

Keywords: Aortic valve surgery; 18Fluorodeoxyglucose positron emission tomography combined with computed tomography; Case report; Infective endocarditis; Interferon-gamma 1b; Mycobacterium chimaera.

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Figures

Figure 1
Figure 1
[18F]-fluorodeoxyglucose positron emission tomography combined with computed tomography (FDG-PET/CT). (A) FDG-PET, CT, and PET/CT fusion images during first admission showing focal uptake in the anterior surface of the prosthetic aortic valve (crossmark). Bilateral pleural effusion is also present (star). (B) FDG-PET, CT, and PET/CT fusion images during second admission, 8 months later, showing increased intensity of the FDG deposit in the aortic valve (crossmark). Again, persistent bilateral pleural effusion is evident (star). (C) FDG-PET/CT study 3 months after aortic valve replacement. There is no evidence of pathological uptake affecting the aortic valve. A diffuse uptake in the heart chamber walls was noted due to physiological incorporation of FDG. Mild right pleural effusion persisted (star). (D) FDG-PET, CT, and PET/CT fusion images performed before stopping the antibiotic treatment, 13 months after aortic valve replacement. There was no uptake in the prosthetic valve. Mild right pleural effusion was still present (star).
Figure 2
Figure 2
(A). Ziehl–Neelsen stain showing the presence of numerous acid-fast bacilli in the explanted aortic bioprosthesis infected with Mycobacterium chimaera. (B) FDG-PET/CT fusion images and maximum intensity projection of the inferior limbs showing a high intensity focal FDG uptake in muscular tissue of the left thigh (arrow). (C) FDG-PET/CT fusion images and maximum intensity projection of the whole body 3 months after aortic valve replacement showing the persistence of muscle uptake, but with decreased intensity (arrow). (D) FDG-PET/CT fusion images and maximum intensity projection of the whole body 13 months after aortic valve replacement. Absence of uptake in the thigh (arrow).
See this image and copyright information in PMC

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