Case Reports the 100 mg dose of caspofungin has been suggested, with a rationale that a higher daily dose could enhance the concentrations on target sites. The sterilization of blood cultures and the decreasing size of the vegetations showed supports initial efﬁcacy. Surgery was ﬁrstly refused due to the poor clinical condition, later it was not performed because of lack of surgical criteria (with the exception of the etiologic agent, a controversial point). A catheter related bacteraemia by E. faecalis led to vegetation colonization and probably inﬂuenced the embolization, since the higher incidence of embolic events occurs in the early course of endocarditis. 124 CARDIAC TUBERCULOMA. A CASE REPORT J. Oteo1 *, L. Alonso2 , V. Ibarra1 , I. Gallo3 , A. Beloscar2 , F.J. Fernandez2 . 1 San Pedro-CIBIR, Infectious Diseases, Logro˜ no, Spain, 2 San Pedro Hospital, Cardiology Service, Logro˜ no, Spain, 3 Los Manzanos, Cardiac Surgery, Logro˜ no, Spain Background: Tuberculosis is a worldwide high prevalent infection that involves most common lungs. Except for pericardial disease, cardiac tuberculosis is very uncommon. Methods: We described a patient from Pakistan, resident in Spain for the last 6 year, that presents as a cardiac neoplasm but that ﬁnally was diagnosed as cardiac tuberculosis (cardiac tuberculoma). We have reviewed the cases of cardiac tuberculosis other than pericardial affectation (PubMed with the topic “cardiac tuberculoma”) and we have found 56 references (2 from Spain). Case: A 48 year old Pakistani woman had been diagnosed of sternal tuberculosis in December 2005. She had fever, weight loss and pain bone for the 3 past week period. A thoracic TAC revealed a breastbone mass and M. tuberculosis was isolated by biopsy. HIV infection was excluded and the patient received treatment with RFP + INH + PZ for two months plus RFP + INH for 7 months. After 9 months a new thoracic TAC was performed and no mass was observed. The patient remained ﬁne to June of 2008 that started with anorexia, progressive weight loss and low grade fever. Two days before Hospital admission, she presented palpitations, fatigue and discomfort. EKG showed an atrial ﬂutter. A chest radiography was normal. Amiodarone therapy was administered and she recovered. A transesophageal echocardiography revealed a great and homogeneous mass, located in the atrial right. A cardiac MRI conﬁrmed the presence of a mass adhered to the right atrium wall. A diagnosis of possible lymphoma vs sarcoma was made and a surgical procedure was performed. The surgeon informs that pericardium was inﬁltrated. The right atrium showed a hard consistency mass of 6×6 cm that inﬁltrated the walls. Several samples of the mass and the pericardium were obtained. The pathologic examination showed epithelioid and Langhans giant cell granulomas with central caseating necrosis consistent with tuberculosis. Mycobacterium tuberculosis was isolated from urine culture sample. The patient started treatment with RFP + INH + PZ + ETB plus prednisone with clinical improvement. Conclusions: Tuberculoma of the heart should be considered as cause (unusual) of cardiac mass. 125 ACUTE ENDOCARDITIS DUE TO PASTEURELLA SPP. IN AORTIC PROSTHESIS: CASE REPORT A. Siqueira1 , H. Higashino1 , R. Siciliano1 *, Y. Ho1 , T. Macˆ edo1 , F. Fran¸ ca1 , T. Strabelli1 . 1 Hospital das Clínicas, University of S˜ ao Paulo, Heart institute/Infectious Diseases, S˜ ao Paulo, Brazil Introduction: Pasteurella genus bacteria are gram-negative coccobacilus that colonize canine and feline oral cavities. In humans, they are associated to soft tissue infections following dog or cat bites, but systemic infection cases such as pneumonia, osteomyelitis and endocarditis were also described. We describe a severe case of aortic prosthesis endocarditis due to Pasteurella spp. complicated by perivalvular abscess. Report: A 32 year-old patient, cowboy, living in Jordˆ ania-MG, with previous biological aortic prosthesis due to rheumatic cardiopathy.
At hospital admission, he had fever for 8 days, myalgia, jaundice, abdominal pain and diarrhea. He had been in direct contact with a litter of cats 10 days prior to the onset of the condition. During the physical exam he was jaundiced, with tachycardia and tachypnea, had systolic murmur (4+/6+) and pain to palpation of the right hypochondrium. A transesophageal echocardiogram did not show vegetations and empiric ceftriaxone and oxacillin were prescribed. He had partial improvement in the ﬁrst week, maintaining daily febrile peaks. Pasteurella spp. was identiﬁed in 4 hemocultures and the antibiotic was changed to ampicillin/sulbactam. After 10 days, still febrile, he showed onset of orthopnea. A new ECG revealed a 1st degree ventricular atrium blockade (VAB), and a transesophageal echocardiogram showed an image compatible to perivalvar abscess. He underwent surgery for valvar replacement leading to the remission of the fever and dyspnea. He was discharged from hospital after 6 weeks of ampicillin/sulbactam treatment by intravenous route. Discussion: In literature, there are 33 cases descriptions of endocarditis due to Pasteurella spp. but only four in valve prosthesis. The described lethality is 35% and the need for valvular replacement 29%. In 50% of the previous reports, a prior close contact with cats or bites was described. Probably, the therapeutic success in this case was due to the association of early speciﬁc antibiotic therapy with valve replacement surgery. Although rare, Pasteurella spp. must be considered as an etiology for infectious endocarditis, particularly when faced with a suggestive epidemiologic antecedent. 126 RELAPSING ENDOCARDITIS DUE TO GRANULICATELLA ADIACENS ¨ zenci1 , D. Salaj2 , H. Fang1 , K. Westling1 *. 1 Karolinska University V. O Hospital/Huddinge, Division of Infectious Diseases, Stockholm, Sweden, 2 Nacka, Nacka Geriatric Clinic, Stockholm, Sweden A 75-year-old woman, with mild COPD, osteoporosis and hypertrophic cardiomyopathy presented a history of fever and cough during the last few days. The clinical ﬁndings at the emergency ward included fever >38.0ºC, somnolence, tachypnea (20/minute), a systolic heart murmur and infra-scapular crepitations to the left. A raised CRP, 88 mg/L was noted. After samples for blood cultivation were taken, she was given cefuroxime IV. Preliminary diagnosis was pneumonia and a subsequent bedside chest X-ray conﬁrmed a left dorsal inﬁltrate. On the day of transferral to the geriatric clinic, gram-positive cocci were observed in each of the four blood cultivation bottles. The condition was now reassessed as an infective endocarditis. The patient quickly recovered clinically, a trans-thoracic echocardiography was performed 12 days after admission, showing no vegetations. The gram-positive cocci were identiﬁed by PCR/16 S rRNA as Granulicatella adiacens (MIC for benzylpenicillin = 0.125 mg/ml). The patient returned home with advanced home care providing with ceftriaxone. The IV antibiotics were discontinued after a total of four weeks. At follow-up after two months, samples of blood culture was performed and gram-positive cocci were later isolated. The patient was transferred to the Clinic of Infectious Diseases. On admission her temperature was 37.8ºC, a systolic heart murmur was noticed, C-reactive protein was 15 g/l. Antibiotic treatment in form of benzylpenicillin (MIC 0.125 mg/ml) and gentamicin was initiated. Transesophageal echocardiography revealed a vegetation 0.5 cm in diameter on the mitral valve. In total 6 of 6 blood culture bottles grew gram-positive cocci, identiﬁed by PCR/16 S r RNA as G. adiacens (MIC for benzylpenicillin = 0.125 mg/ml). Combination antibiotic treatment with benzylpenicillin and gentamicin was continued for 2 weeks at with benzylpenicillin alone for another 2 weeks. Dental examination revealed a periapical osteitis and dental extraction was made. At follow-up three weeks after antibiotic treatment was completed the patient had no fever and blood cultures showed no growth. G. adiacens is a member of nutritionally variant streptococci (NVS) It is related with high bacterial failure a high rate of relapse after therapy and higher mortality. This patient with hypertrophic cardiomyopathy, a risk factor infective endocarditis, relapsed on single treatment with ceftriaxone; this shows that combination therapy is needed.