CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 2, March 2012
AFRICA
e5
Case Report
Infective endocarditis and spondylodiscitis due to
posterior nasal packing in a patient with a bioprosthetic
aortic valve
H GUNGOR, MF AYİK, I GUL, S YİLDİZ, O VURAN, S ERTUGAY, H KANYİLMAZ, U ERTURK
Abstract
Infective endocarditis (IE) is a severe form of heart valve
disease and is associated with a poor prognosis and high risk
of mortality. We report the first known case of bioprosthetic
aortic valve endocarditis associated with spondylodiscitis as
a result of posterior nasal packing coated with antibiotics but
without systemic antibiotic prophylaxis.
Keywords:
infective endocarditis, nasal packing, spondylodis-
citis
Submitted 27/10/10, accepted 16/2/11
Cardiovasc J Afr
2012;
23
: e5–e7
DOI: 10.5830/CVJA-2011-002
Infective endocarditis (IE) is a severe form of heart valve disease
and is associated with a poor prognosis and high risk of mortal-
ity. It has been reported to occur in 1 to 6% of cases with valve
prostheses. IE is associated with a high risk of complications
such as splenic infarction, glomerulonephritis, cerebral embo-
lus and rheumatological and musculoskeletal manifestations.
1
Spondylodiscitis is rarely observed as a complication of IE and
the frequency of this association can vary from 0.6 to 2.2%. As
reported in the literature, when patients with spondylodiscitis
were screened for IE, up to 15% were diagnosed with it.
2,3
Epistaxis can occur due to local and systemic causes, includ-
ing nasal packing. According to published studies, the use of
systemic antibiotic prophylaxis after nasal packing is under
debate. We report the first known case of bioprosthetic aortic
valve endocarditis associated with spondylodiscitis as a result of
posterior nasal packing without systemic antibiotic prophylaxis.
Case report
An 83-year-old man was admitted to the emergency room with
a history of fever, weight loss and back pain of three months.
General examination revealed anxiety, blood pressure of 120/80
mmHg, heart rate 116 beats/min and a temperature of 37.9°C.
Cardiovasculary examination showed a grade of 2/6 systolic
ejection murmur radiating to the axilla, heard over the aortic and
mitral area. All other system examinations were normal except
for his lumbar spine from the L3 to S1 level, where movement
was restricted due to pain.
Routine blood investigation revealed a haemoglobin level of
9.7 g/dl, platelets of 169 000 /mm
3
and total leukocyte count
of 8 540 cells/mm
3
. Serum biochemistry showed an aspartate
aminotransferase level of 38 U/dl, C-reactive protein level 7.11
mg/dl, erythrocyte sedimentation rate of 68 mm/h, blood urea
nitrogen 69 mg/dl, creatinine 1.8 mg/dl, albumin 3.1 g/dl, and
globulin 4.0 g/dl. Other laboratory parameters and urine analysis
were normal.
A chest radiography showed cardiomegaly and aortic arch
calcification. His electrocardiogram showed no abnormality.
His past medical history included bioprosthetic aortic valve
implantation for degenerative aortic valve stenosis and coro-
nary artery bypass graft surgery for proximal LAD stenosis
(LIMA–LAD) four months previously. On the seventh day of
his stay at the Cardiovascular Surgery Department, he developed
spontaneous, severe epistaxis, and a posterior nasal pack coated
with nitrofurazone was placed but he did not receive systemic
antibiotic prophylaxis. Four days after the first nasal packing,
he developed a second episode of epistaxis and a posterior nasal
pack coated with antibiotics was again placed but no systemic
antibiotic prophylaxis was given.
At the emergency room, blood and urine specimens were
taken for culture and we performed transthoracic echocardiog-
raphy (TTE), which showed a mass of 0.3
×
0.8 cm in diameter,
consistent with vegetation on the left ventricular outflow tract
(LVOT) side of the bioprosthetic non-coronary valve.
After echocardiographic examination, he was admitted to the
intensive care unit. Transesophageal echocardiography (TEE)
was immediately performed, with confirmation of a vegetation
of 0.7
×
0.3 cm in diameter on the LVOT side of bioprosthetic
non-coronary aortic cusp (Fig. 1). All consecutive blood cultures
were positive for
Streptococcus viridans
and it was susceptible to
penicilin
in vitro
. IE was diagnosed and intravenous penicilin at
a dose of 5 million U every four hours and a rifampicin capsule
300 mg/day was administered.
Hasan Gungor, MD, Department of Cardiology, Ege
University, Izmir, Turkey
H GUNGOR, MD,
I GUL, MD
S YİLDİZ, MD
O VURAN, MD
U ERTURK, MD
Department of Cardiovascular Surgery, Ege University,
Izmir, Turkey
MF AYİK, MD
S ERTUGAY, MD
Department of Neurosurgery, Ege University, Izmir, Turkey
H KANYİLMAZ, MD
