Blood Culture Negative Endocarditis: Analysis of 63 Cases Presenting over 25 Years

Overview

Journal Heart

Date 2003 Feb 20

PMID 12591823

Citations 82

Authors

C C Lamas

S J Eykyn

Affiliations

Soon will be listed here.

Abstract

Objective: To analyse cases of blood culture negative endocarditis (BCNE) seen at St Thomas' Hospital, London, between 1975 and 2000.

Methods: Data on all episodes of endocarditis with negative blood cultures seen at St Thomas' Hospital between 1975 and 2000 were collected prospectively and analysed retrospectively.

Results: Sixty three patients with BCNE were seen during the study period: 48 (76%) with native and 15 (24%) prosthetic valve infection. BCNE accounted for 12.2% of the 516 cases of endocarditis seen at St Thomas' Hospital. The diagnosis of endocarditis was clinically definite by the Duke criteria in only 21% (7 of 34) of cases of pathologically proven native valve endocarditis but in 62% (21 of 34) of cases by the St Thomas' modifications of the criteria. Comparable figures for the 11 cases of pathologically proven prosthetic valve endocarditis were 45% and 73%. Despite negative blood cultures a causative organism was identified in 31 (49%) of the 63 cases: in 15 by serology (8 Coxiella burnetii, 6 Bartonella species, and 1 Chlamydia psittaci); in 9 cases by culture of the excised valve; in 3 by microscopy of the excised valve, on which large numbers of Gram positive cocci were seen although the culture was sterile; and in the other 4 by isolation from a site other than the excised valve (2 respiratory specimens, 1 from the pacemaker tip, and 1 from an excised embolus). In addition 5 of the 6 cases of Bartonella infection were confirmed by polymerase chain reaction study of the excised valve. Two thirds of the 32 patients for whom no pathogen was identified had received antibiotics before blood was cultured. Thus truly "negative" endocarditis was very uncommon (6% of the cases).

Conclusion: If blood cultures are negative in definite or suspected endocarditis, serum should be analysed for Bartonella, Coxiella, and Chlamydia species antibodies, and the excised valve or (rarely) embolus should be analysed by microscopy, culture, histology, and relevant polymerase chain reaction. Other specimens may be relevant. The Duke criteria performed poorly in BCNE; St Thomas' additional minor criteria gave more definite diagnoses.

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References

Harrison T, Doshi N . Serological evidence of Bartonella spp. infection in the UK. Epidemiol Infect. 1999; 123(2):233-40. PMC: 2810754. DOI: 10.1017/s0950268899002927. View

Lamas C, Eykyn S . Bicuspid aortic valve--A silent danger: analysis of 50 cases of infective endocarditis. Clin Infect Dis. 2000; 30(2):336-41. DOI: 10.1086/313646. View

Roux V, Eykyn S, Wyllie S, Raoult D . Bartonella vinsonii subsp. berkhoffii as an agent of afebrile blood culture-negative endocarditis in a human. J Clin Microbiol. 2000; 38(4):1698-700. PMC: 86533. DOI: 10.1128/JCM.38.4.1698-1700.2000. View

Li J, Sexton D, Mick N, Nettles R, Fowler Jr V, Ryan T . Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis. 2000; 30(4):633-8. DOI: 10.1086/313753. View

Ellis M, Al-Abdely H, Sandridge A, Greer W, Ventura W . Fungal endocarditis: evidence in the world literature, 1965-1995. Clin Infect Dis. 2000; 32(1):50-62. DOI: 10.1086/317550. View

Kupferwasser L, Darius H, Muller A, Martin C, Mohr-Kahaly S, Erbel R . Diagnosis of culture-negative endocarditis: the role of the Duke criteria and the impact of transesophageal echocardiography. Am Heart J. 2001; 142(1):146-52. DOI: 10.1067/mhj.2001.115586. View

Connaughton M, Lang S, Tebbs S, Littler W, Lambert P, Elliott T . Rapid serodiagnosis of gram-positive bacterial endocarditis. J Infect. 2001; 42(2):140-4. DOI: 10.1053/jinf.2001.0809. View

Fenollar F, Lepidi H, Raoult D . Whipple's endocarditis: review of the literature and comparisons with Q fever, Bartonella infection, and blood culture-positive endocarditis. Clin Infect Dis. 2001; 33(8):1309-16. DOI: 10.1086/322666. View

Millar B, Moore J, Mallon P, Xu J, Crowe M, McClurg R . Molecular diagnosis of infective endocarditis--a new Duke's criterion. Scand J Infect Dis. 2001; 33(9):673-80. DOI: 10.1080/00365540110026764. View

10.

Pesanti E, Smith I . Infective endocarditis with negative blood cultures. An analysis of 52 cases. Am J Med. 1979; 66(1):43-50. DOI: 10.1016/0002-9343(79)90480-7. View

11.

Van Scoy R . Culture-negative endocarditis. Mayo Clin Proc. 1982; 57(3):149-54. View

12.

Tunkel A, Kaye D . Endocarditis with negative blood cultures. N Engl J Med. 1992; 326(18):1215-7. DOI: 10.1056/NEJM199204303261809. View

13.

Choudhury R, Grover A, Varma J, Khattri H, Anand I, BIDWAI P . Active infective endocarditis observed in an Indian hospital 1981-1991. Am J Cardiol. 1992; 70(18):1453-8. DOI: 10.1016/0002-9149(92)90299-e. View

14.

Wilmshurst P, Venn G, Eykyn S . Histoplasma endocarditis on a stenosed aortic valve presenting as dysphagia and weight loss. Br Heart J. 1993; 70(6):565-7. PMC: 1025394. DOI: 10.1136/hrt.70.6.565. View

15.

Durack D, Lukes A, Bright D . New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service. Am J Med. 1994; 96(3):200-9. DOI: 10.1016/0002-9343(94)90143-0. View

16.

Drancourt M, Mainardi J, Brouqui P, Vandenesch F, Carta A, Lehnert F . Bartonella (Rochalimaea) quintana endocarditis in three homeless men. N Engl J Med. 1995; 332(7):419-23. DOI: 10.1056/NEJM199502163320702. View

17.

Hoen B, Selton-Suty C, Lacassin F, Etienne J, Briancon S, Leport C . Infective endocarditis in patients with negative blood cultures: analysis of 88 cases from a one-year nationwide survey in France. Clin Infect Dis. 1995; 20(3):501-6. DOI: 10.1093/clinids/20.3.501. View

18.

Bouvet A . Human endocarditis due to nutritionally variant streptococci: streptococcus adjacens and Streptococcus defectivus. Eur Heart J. 1995; 16 Suppl B:24-7. DOI: 10.1093/eurheartj/16.suppl_b.24. View

19.

Hogevik H, Olaison L, Andersson R, Lindberg J, ALESTIG K . Epidemiologic aspects of infective endocarditis in an urban population. A 5-year prospective study. Medicine (Baltimore). 1995; 74(6):324-39. DOI: 10.1097/00005792-199511000-00003. View

20.

Musso D, Raoult D . Coxiella burnetii blood cultures from acute and chronic Q-fever patients. J Clin Microbiol. 1995; 33(12):3129-32. PMC: 228658. DOI: 10.1128/jcm.33.12.3129-3132.1995. View