Infective Endocarditis as a Complication of Crohn's Disease on Immunotherapy

Abstract

A patient with a history of Crohn's disease on infliximab presented to the hospital with sepsis and a new heart murmur. He was found to have native aortic valve infective endocarditis from a rare species of group D Streptococcusin his blood. The patient was also noted to be in an acute flare of Crohn's disease. The hospital course was complicated by florid heart failure from acute aortic insufficiency. He eventually improved after source control and appropriate antibiotic therapy. S. pasteuranis bacteremia and endocarditis are attributable to the patient's immunocompromised state as a result of infliximab treatment. While S. pasteuranis is infrequently grown in blood cultures, it is commonly found in normal gut flora. We hypothesize that it gained access to the bloodstream through the epithelium in the terminal ileum, which was inflamed due to an acute flare of Crohn's disease.

Keywords: aortic valve endocarditis; crohn’s disease (cd); immunocompromised status; immunotherapy; infective endocarditis.

Figure 1. Transthoracic echocardiographic view: transverse long-axis view showing the aortic valve with a mobile echo density.

Transthoracic echocardiogram depicting a mobile echo density (red arrow) attached to the aortic valve in the transverse long-axis view.

Figure 2. Transthoracic echocardiography showing aortic insufficiency.

The echocardiogram in the parasternal long-axis view shows aortic insufficiency and aortic regurgitation (AR) jet (yellow arrow), the jet is noted to fill the left ventricular outflow tract. The flow toward the transducer is red in color, and flow away from the transducer is blue in color.

Figure 3. Transesophageal echocardiographic view showing the aortic valve with a mobile echo density (red arrow).

Figure 4. Colonoscopy images showing inflammation and ulcer in the terminal ileum.

Colonoscopy depicting erythema and ulceration in the terminal ileum (red and green arrows).

Figure 5. Colonoscopy images during follow-up showing the reduction in inflammation in the terminal ileum.

Significant reduction in the erythema and resolution of the ulceration (blue arrow) of the terminal ileum on repeat follow-up colonoscopy.