finegoldia magna, an early post-operative cause of infectious endocarditis: report of two cases and...
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Anaerobe 14 (2008) 310–312
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Anaerobe
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Short communication – Clinical microbiology
Finegoldia magna, an early post-operative cause of infectious endocarditis:Report of two cases and review of the literature
Pierre-Edouard Fournier a,*, My Van La a, Jean-Paul Casalta a, Herve Richet a, Frederic Collart b,Didier Raoult a
a Federation de Microbiologie, Hopital de la Timone, Marseille Hopital de la Timone, rue Saint Pierre, 13385 Marseille Cedex 5, Franceb Service de Cardiologie et Chirurgie Thoracique, Hopital de la Timone, Marseille, France
a r t i c l e i n f o
Article history:Received 25 August 2008Received in revised form13 November 2008Accepted 18 November 2008Available online 3 December 2008
Keywords:Blood-culture-negative endocarditisFinegoldia magnaPCR
* Corresponding author. Tel.: þ33 491 324375; fax:E-mail address: Pierre-Edouard.Fournier@univmed
1075-9964/$ – see front matter � 2008 Elsevier Ltd.doi:10.1016/j.anaerobe.2008.11.001
a b s t r a c t
We report two cases of infectious endocarditis (IE) on prosthetic valves caused by Finegoldia magna. Thediagnosis was obtained by detection of the bacterium in valvular biopsies using 16S rRNA PCR ampli-cation and sequencing, and prolonged culture. Five other cases were previously published in the liter-ature. Following analysis of these seven cases, F. magna endocarditis presented as a subacuteendocarditis, developing early (60 days) following valvular replacement (85%), with an elevatedmortality (28%). Our report highlights the potential role of F. magna in early post-surgical endocarditis onprosthetic valves.
� 2008 Elsevier Ltd. All rights reserved.
1. Introduction
Finegoldia magna (F. magna) is one of the most common gram-positive anaerobic cocci isolated from clinical specimens [1].However, cases of endocarditis are rare. Herein, we report two casesof F. magna endocarditis. In order to describe the characteristics ofthis infection, we reviewed the literature on that subject andcombined our data to those previously reported.
2. Patients and methods
2.1. Case 1
On September 25th, 2007, a patient who had undergone anaortic valve replacement with a bioprosthesis two months earlierwas admitted to hospital in Quimper, France with a 24-h history offever. On admission, the patient had a fever of 39.5 �C and a dia-stolic murmur. Three blood cultures drawn before empiricaltreatment with vancomycin (2 g/day) and gentamicin (160 mg/day)remained sterile after 14 days of incubation. Due to an aortic valveabscess associated with prosthesis disinsertion and paravalvularleakage on transesophageal echocardiography, the patient under-went a second aortic valve replacement with a mechanical
þ33 491 830390..fr (P.-E. Fournier).
All rights reserved.
prosthetic valve in the department of thoracic surgery, BrestHospital on October 1st 2007. Vancomycin and gentamicin werepost-operatively continued. Anaerobic culture from the excisedvalve yielded gram-positive cocci after 4 days of incubation onblood agar, later identified as F. magna. A valve biopsy was also sentto the Timone hospital in Marseille for 16S rRNA PCR detection aspreviously described [2,3]. The sequence obtained from the PCRproduct was 100% similar to F. magna (GenBank accession numberAB109772). The antimicrobial therapy was finally changed for high-dose amoxicillin–clavulanate (12 g/day) for 6 weeks. The patientwas considered cured and discharged 21 days after surgery.
2.2. Case 2
In June 2003, a 59-year-old woman was admitted to the TimoneHospital, Marseille, France, for vertigo and intermittent diplopia.The patient had a history of rheumatic fever. In January 2001, shehad undergone native mitral valve replacement with a mechanicalvalve for high grade mitral insufficiency. Transoesophageal echo-cardiography showed an obstructive thrombus on the mitralprosthetic valve (7 mm) associated with a mobile commissuralthrombus. A brain tomodensitometry showed cortical cerebellumand lacuna of the thalamic isthmus. Subsequently, the mechanicalvalve was replaced with a bioprosthetic valve. Post-operatively, theCRP level remained at an elevated level (163 mg/L). Gram-stainingof the excised valve showed rare gram-positive cocci. F. magna wasidentified in the excised valve using 16S rRNA PCR and sequencing
Tab
le1
Cli
nic
alfi
nd
ings
,tre
atm
ents
and
outc
omes
of7
pat
ien
tsw
ith
end
ocar
dit
isd
ue
toF.
mag
na.
Pati
ent
Age
/sex
Un
der
lyin
gco
nd
itio
ns/
risk
fact
ors
Sym
pto
ms
Ech
ocar
dio
grap
hy
sign
sD
elay
sin
ceva
lve
rep
lace
men
t
Dia
gnos
tic
met
hod
sTr
eatm
ent
Ou
tcom
eR
efer
ence
s
118
/MN
ativ
em
itra
lva
lve
Feve
r,m
ult
iple
emb
oli,
infl
amm
ator
ysy
nd
rom
eM
itra
lre
gurg
itat
ion
,veg
etat
ion
No
surg
ical
inte
rven
tion
Blo
odcu
ltu
re(1
w)
Naf
cill
inþ
pen
icil
linþ
gen
tam
icin
(18
d)
then
van
com
ycin
(1w
)D
eath
[8]
277
/FB
iop
rost
het
icao
rtic
valv
eH
eart
fail
ure
,pu
lmon
ary
sub
edem
a,in
flam
mat
ory
syn
dro
me
Val
veri
ng
absc
ess,
seve
rep
arav
alvu
lar
leak
3M
onth
sA
bsc
ess
mat
eria
lcu
ltu
re(3
d)
Pen
icil
lin
Gþ
gen
tam
icin
(2w
)th
enp
enic
illi
nG
(2w
)R
ecov
ery
[9]
36
5/M
Mec
han
ical
mit
ral
valv
e/n
oin
fect
iou
sd
enta
lfo
ciFe
ver,
pu
lmon
ary
con
gest
ion
,in
flam
mat
ory
syn
dro
me
Para
valv
ula
rle
akag
e,d
ehis
cen
ce,
vege
tati
ons
23
Day
sV
alve
cult
ure
(2d
)þ16
SrR
NA
PCR
Flu
clox
acil
lin
then
van
com
ycinþ
gen
tam
icin
þri
fam
pin
(2d
)D
eath
[10
]
43
9/M
Mec
han
ical
aort
icva
lve/
no
infe
ctio
us
den
tal
foci
Infl
amm
ator
ysy
nd
rom
ePa
rava
lvu
lar
leak
age,
deh
isce
nce
,ve
geta
tion
s,ao
rtic
root
absc
esse
s2
Mon
ths
Val
vecu
ltu
re(4
d)
Van
com
ycinþ
Gen
tam
icin
then
Pen
icil
lin
Gþ
Met
ron
idaz
ole
(6w
)R
ecov
ery
[10
]
56
8/M
Mec
han
ical
aort
icva
lve
Feve
r,in
flam
mat
ory
syn
dro
me
Para
valv
ula
rle
akag
e13
Day
sA
orti
cw
all
cult
ure
(7d
)þ16
SrR
NA
PCR
Van
com
ycinþ
amik
acinþ
rifa
mp
in(7
d),
then
pen
icil
linþ
met
ron
idaz
ole
(2d
),th
enp
enic
illi
n(6
w)
then
ceft
riax
one
(2w
)
Rec
over
y[1
1]
65
5/M
Bio
pro
sth
etic
aort
icva
lve
Feve
r,in
flam
mat
ory
syn
dro
me
Val
vula
rab
sces
s,p
rost
hes
isd
isin
sert
ion
,par
aval
vula
rle
akag
e2
Mon
ths
Val
vecu
ltu
reþ
16S
rRN
APC
RV
anco
myc
inþ
gen
tam
icin
then
amox
icil
lin
–cl
avu
lan
ate
(6w
)R
ecov
ery
Pres
ent
stu
dy
75
9/F
Mec
han
ical
mit
ral
valv
eC
ereb
rova
scu
lar
acci
den
t,in
flam
mat
ory
syn
dro
me
Ob
stru
ctiv
eth
rom
bu
son
the
rin
g,an
da
mob
ile
com
mis
sura
lth
rom
bu
s
2Ye
ars
Blo
odan
dva
lve
cult
ureþ
16S
rRN
APC
R
Am
oxic
illi
n–
clav
ula
nat
e(3
0d
)R
ecov
ery
Pres
ent
stu
dy
d,D
ays;
w,w
eeks
.
P.-E. Fournier et al. / Anaerobe 14 (2008) 310–312 311
(100% similarity with GenBank accession number AB109772), andby culture after 13 days of incubation. Additionally, two of threeblood cultures were positive for F. magna after 10 days of incuba-tion. The patient was treated using 12 g/day of amoxicillin–clav-ulanate for 6 weeks. The patient was discharged from hospital 27days after surgery, and is considered as cured.
2.3. Literature survey
We searched PubMed using the following terms: Finegoldia,magna, Peptostreptococcus, magnus, anaerobes, endocarditis.
3. Results and conclusions
Formerly known as Peptococcus magnus [4] or Peptos-treptococcus magnus [5], F. magna was reclassified in 1999 intoa new genus, Finegoldia that contained a single species [6]. F. magnais a member of the commensal flora of human mucocutaneoussurfaces [1]. In the literature, F. magna has mainly been described asan agent of bone and joint infections, usually in the presence ofprosthetic implants, of diabetic foot ulcer infection and of softtissue infections [1,7].
F. magna is a rare agent of endocarditis. Through an exhaustivereview of the literature, we could identify five cases of F. magnaendocarditis [8–11] (Table 1). When combining these data to thoseof our patients, the median age of patients was of 59 years old. Thesex ratio M/F was 2.5. F. magna developed on prosthetic valves in 6/7 patients (85.7% [9–11], present study). Among these six patients,the median delay between valve replacement and the onset of F.magna endocarditis was of 60 days. The clinical course wassubacute in 6/7 patients (85.7%). An inflammatory syndrome withor without fever was present in all cases. Mitral and aortic valveswere affected in all cases, and a paravalvular leakage commonlydue to valvular or paravalvular abscesses was observed on echo-cardiography in 5/6 patients (83.3%). Surgery was required in all sixpatients, one of whom died from cardiogenic shock despite anti-biotic therapy and valve surgery. A seventh patient, who sufferedfrom native mitral valve endocarditis, developed a cerebral hema-toma and died prior to valve surgery [8].
The early development of post-operative endocarditis in fivepatients was consistent with a nosocomial source of infection. Todate, various Peptostreptococcus species have been reported tocause nosocomial infections, including lung abscess, sinusitis andbone infections [12–15]. However, F. magna has not been describedas a nosocomial but rather as an opportunistic pathogen [16]. In thefive patients, we assume that the early post-operative endocarditisresulted from hematogenous seeding from the lower gastro-intestinal tract rather than the oral cavity. As a matter of fact, dentalinfections had been ruled out or treated in all five patients prior tovalvular surgery. Therefore, although none of these patientssuffered from any digestive symptom, none had colonic investiga-tion and thus we cannot exclude a lower gastro-intestinal tractsource. In the 59-year-old woman who developed endocarditis twoyears after valve replacement, a nosocomial origin is unlikely, butthe source of infection was not identified, as the patient had nohistory of tooth extraction, digestive exploration or gynecologicmanipulation during these two years.
Because of its problematic identification in clinical samplesusing routine laboratory methods, the incidence of F. magna asagent of human infections may be underestimated. F. magna growspoorly in standard automated blood culture systems [10]. Amongthe two patients in whom the bacterium was grown from blood,culture was positive after 7 and 10 days, respectively (Table 1). Incontrast, prolonged culture allowed isolation of F. magna from valvebiopsies in six cases. Of these, 16S rRNA-based PCR was successfulin the four cases in which it was performed. These results highlight
P.-E. Fournier et al. / Anaerobe 14 (2008) 310–312312
the usefulness of prolonged anaerobic blood and valve culture, andof broad range bacterial PCR from valvular biopsies for the diag-nosis of early post-operative endocarditis.
F. magna is usually susceptible to betalactams and vancomycin.For culture-negative prosthetic valve endocarditis that developswithin the first year following valve surgery, an association ofvancomycin, gentamicin, cefepime and rifampicin is recommendedby the American Heart Association [17]. Such a therapy is activeagainst F. magna but a rapid identification of this agent may promptphysicians to change their treatment for amoxicillin, and thusreduce both toxicity and costs.
In conclusion, physicians should be aware of the potential role ofF. magna as agent of subacute but severe early endocarditisfollowing valve replacement. We also emphasize the importance ofmolecular detection and prolonged culture to identify thismicroorganism.
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