Vancomycin-resistant Enterococcus faecium endocarditis is rare and usually present itselfs in immunocompromised patients.

Vancomycin-resistant Enterococcus faecium endocarditis is rare and usually present itselfs in immunocompromised patients. We describe a patient with hairy-cell leukemia and vancomycin-resistant E faecium endocarditis. The patient neared with severe aortic insufficiency. He underwent aortic parent replacement with a cryopreserved aortic homograft and was treated with a combination of quinupristin/dalfopristin, ampicillin, and gentamicin.

(CHEST 2001; 120:1744-1746)

[i]clavis[/i] words: aortic homograft; endocarditis; leukemia; resistant Enterococcus

Abbreviations: MIC = mean inhibitory concentration; VREF = vancomycin-resistant Enterococcus faecium

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Because of the relatively recently made known development of resistance of Enterococcus to vancomycin, hardly any cases of vancomycin-resistant Enterococcus faecium (VREF) endocarditis have been described, and no guidelines for treatment have been determined. (1-6) We near a case of VREF endocarditis in a leukemia patient with strait-laced aortic insufficiency treated with aortic etymon replacement. To the best of our knowledge, this is the first survival of a patient with VREF endocarditis and leukemia.

CASE REPORT

A 72-year-old man was transferred to our hospital upon December 17, 1999, from an outside facility with acute infectious endocarditis. The patient instanted in January 1999 with complaints of fatigue, dyspnea forward exertion, fever, chills, and night sweats. The diagnosis of hairy-cell leukemia with pancytopenia was made and confirmed according to bone marrow biopsy. His WBC cast was 1,000/[micro]L, and platelet judge was 27,000/[micro]L. The patient underwent treatment with IV cladribine for 1 week. The patient did well until March 1999 when a bone marrow aspirate revealed continued leukemic confined apartments His WBC count was 2000 to 2,500/[micro]L, and his platelet enumerate was 50,000 to 90,000/[micro]L. The patient underwent a other 1-week treatment with IV cladribine. in succession June 9, 1999, fever and chills evolveed and positive blood culture proceeds were found for VREF and Staphylococcus haemolyticus. The patient was treated with gentamicin and clindamycin. house culture and stool culture springs were negative after 5 days of antibiotic therapy. The presum source was an infected subcutaneously funneled central venous catheter, which was remov onward June 15, Fibrinous debris at the tip showed positive shooting for VREF. No cardiac evaluation was performed. The patient was treated with IV antibiotics for 7 days after removal of the catheter. Follow-up kin culture and stool culture eventuates were negative 1 week later. He was well until late November 1999 when he again experienced chills, febrile affection night sweats, and dyspnea forward exertion. These symptoms persisted for 2 weeks. He instanted for evaluation. His WBC regard was < 1,000/[micro]L, and his platelet regard was 5,000 to 10,000/[micro]L. vital fluid culture results were positive for VREF The organism was resistant to ampicillin (mean inhibitory concentration [MIC] > 16 [micro]g/mL) and vancomycin (MIC > 35 [micro]g/mL) yet was gentamicin sensitive. On December 9 a transesophageal echocardiogram showed an ejection fraction of 63% no aortic regurgitation, and an immobile vegetation in the subaortic region measuring 30 min. Treatment was initiated with piperacillin/ tazobactam and quinupristin/dalfopristin. A bone marrow aspirate onward December 10 showed no evidence of resort of the leukemia. A repeat transthoracic echocardiogram was performed onward December 15 and demonstrated accurate aortic valve insufficiency with a presum right coronary cusp dehiscence. All three cusps had a 1-cm drawn out vegetation on the free margin. There was evidence of an aortic parent abscess. Left ventricular ejection fraction was 60% The patient was transferred to our hospital for further evaluation and consideration of surgical treatment. At transfer, the patient was place to have a hemoglobin plain of 7.8 g/dL, platelet esteem of 31,000/[micro]L, and WBC esteem of 2,700/[micro]L. The indications for surgery were hard aortic regurgitation with valve cusp destruction, persistent bacteremia despite aggressive antibiotic therapy, and mobile vegetations at risk for emboli in the face of a latter bone marrow aspirate showing no evidence of periodical leukemia.

On December 20 1999 the patient underwent aortic radical replacement with a 24-mm cryopreserv aortic homograft. The aortic valve cusps were resect (Fig 1) One-centimeter prolonged focally organized vegetations were institute on each cusp. There was infectious erosion into the aortic radix along the right coronary cusp annulus. This area was debrided and treated with topical phenol. Monofilament line of junction and bovine pericardial pledgets were used in the bottom reconstruction. The microscopic examination revealed cusp infiltration with neutrophils and the carriage of colonies of Gram-positive cocci.

[FIGURE 1 OMITTED]

Postoperatively, the patient had significant bleeding secondary to a rigid coagulopathy. This required numerous kindred product transfusions. Blood and valve tissue improvements sent intraoperatively showed positive findings for VREF Sensitivities revealed an MIC of 128 [micro]g/mL for ampicillin, 500 [micro]g/mL for gentamicin, 1 [micro]g/mL for quinupristin/dalfopristin, 8 [micro]g/mL for chloramphenicol, and 4 [micro]g/mL for linezolid. The organism was resistant to vancomycin, penicillin, erythromycin, and imipenem. The patient was treated with a combination of ampicillin, 2 g q4h; gentamicin, 70 mg q12h; and quinupristin/dalfopristin, 600 mg q8h forward postoperative day 3, he cause to growed diarrhea and Clostridium difficile toxin-positive stool. The latter complication was favorably managed with metronidazole. On December 28 1999 acute renal insufficiency discloseed presumably related to antibiotic therapy despite monitoring gentamicin and ampicillin flats and adjusting the doses for his rising creatinine flat Treatment with gentamicin and ampicillin was discontinued. Treatment was started with doxycycline, 100 mg po bid, and rifampin, 300 mg po bid. Hemodialysis was initiated and continued until January 8 2000 when adequate renal function get backed The patient remained leukopenic, thrombocytopenic, and anemic despite progeny and blood product transfusions during the whole postoperative course. The antibiotics were discontinued in succession February 4, 2000, completing an 8-week course of antibiotic treatment postoperatively. A bone marrow aspirate forward February 10, 2000, showed features consistent with myelodysplastic syndrome and normocellular bone marrow (30%) with no morphologic or immunophenotypic features of hairy small room leukemia.

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