To the editors:
Infective endocarditis (IE) is an inflammatory process of infectious origin that affects cardiovascular structures. The term endarteritis is currently included in the definition of infective endocarditis.
Granulicatella elegans is a rare cause of infective endocarditis, which has a subacute presentation of the disease, with nonspecific symptoms and mild elevation of inflammatory biomarkers. It is associated with a high-mortality rate in adults.1 In the pediatric age group, there are 3 cases of IE described by Granulicatella spp., associated with congenital heart disease: 1 with pulmonary atresia with intact interventricular septum and mild Ebstein’s malformation already operated,2 another one with Shone’s syndrome and the last one with infundibular pulmonary stenosis.1 Our case represents the fourth case worldwide with IE caused by Granulicatella spp., in congenital heart disease, and the first with patent ductus arteriosus (PDA).
We report an 8-year-old female patient with a history of PDA was diagnosed at another hospital at 3 years of age. She was referred from another hospital with a 7-month history of fever, predominantly during the evening, between 38.4°C and 38.6°C. On admission hyperdynamic precordium with thrill, normal S2, left infraclavicular continuous murmur grade 4/6, slightly grainy sound, calling attention to a metallized acoustic component and wide pulses.
Three blood cultures tested positive after 48 hours. Gram staining of the blood culture revealed Gram-positive cocci, that were, nonsporulating in pairs and short chains and, pleomorphic (Fig. 1A). Blood cultures were identified with Granulicatella elegans nutritionally variant streptococci using a commercial kit MALDI Sepsityper (Bruker Daltonics). Little growth on sheep-blood agar in a microaerophilic atmosphere after 72 hours.
Vegetations were not found on the transthoracic echocardiogram (TTE) at admission, but after 30 days reveled; image suggestive of vegetation attached the pulmonary trunk (13 mm × 3 mm) (Fig. 1B).
After completing 40 days of ceftriaxone, the vegetation was removed percutaneously, on the 58th day, the PDA was closed with Amplatzer ADO 8/6.
Despite advances in diagnosis and treatment, infective endocarditis in the 21st century can be a life-threatening disease with high morbidity and mortality.1 Cyanogenic congenital heart disease, left heart lesions and atrioventricular defects are associated with an increased risk of IE in childhood.3
In children, the most frequent microorganism in subacute IE is Streptococcus viridans group4; however, in the second group nutritionally variant Streptococcus species (NVS) have been identified as etiological agents responsible for 5% of the cases with bacteriologic diagnosis.5
Physicians should suspect subacute IE in patients presenting with intermittent fever of prolonged evolution, constitutional symptoms, and changes in auscultatory phenomena in the context of children with congenital heart disease, despite having negative initial blood culture and absence of initial IE findings on echocardiogram.
Granulicatella spp., IE has a subacute presentation with a mild increase in inflammatory biomarkers, and its morbidity and mortality can be significant. The modified Duke criteria are of great value; however, in some patients with subacute IE the diagnosis can be missed, therefore, the clinical features should be considered when a patient has a fever of unknown origin.
1. De Luca M, Amodio D, Chiurchiù S, et al. Granulicatella bacteraemia in children: two cases and review of the literature. BMC Pediatr. 2013;13:2–7.
2. Holloway V, Jacob G, Hayes N. Challenges in the diagnosis and management of Granulicatella elegans endocarditis in a 9-year-old child. BMJ Case Rep. 2021;14:e2400793–e2400796.
3. Rushani D, Kaufman JS, Ionescu-Ittu R, et al. Infective endocarditis in children with congenital heart disease: cumulative incidence and predictors. Circulation. 2013;128:1412–1419.
4. García-Arribas D, Olmos C, Vivas D, et al. Endocarditis infecciosa. Med. 2017;12:2380–2395.
5. Reyes C, Elizabeth Barthel M. Granulicatella spp. Rev Chil Infectol. 2015;32:359–360.