key: cord-0916393-pyq2irbr
authors: Spinoni, Enrico Guido; Degiovanni, Anna; Della Corte, Francesco; Patti, Giuseppe
title: Infective endocarditis complicating COVID-19 pneumonia: a case report
date: 2020-11-07
journal: Eur Heart J Case Rep
DOI: 10.1093/ehjcr/ytaa366
sha: 1885dd444015be683c95848ce7a295e18c4a7371
doc_id: 916393
cord_uid: pyq2irbr

BACKGROUND: During the COVID-19 outbreak, cardiovascular imaging, especially transoesophageal echocardiography (TOE), may expose healthcare personnel to virus contamination and should be performed only if strictly necessary. On the other hand, transthoracic echocardiography (TTE) and TOE represent the first-line imaging exams for the diagnosis of infective endocarditis (IE). To date, this is the first case of COVID-19 complicated by IE. CASE SUMMARY: We present the case of a 57-year-old man with severe COVID-19 pneumonia requiring mechanical ventilation. During the intensive care unit (ICU) stay, he developed fever and positive haemocoltures for methicillin-resistant Staphylococcus aureus infection. TTE did not identify endocardial vegetations. TOE was then performed and outlined IE of the aortic valve on the non-coronary cusp. Antibiotic therapy was given with progressive resolution of the septic state and improvement of inflammatory signs. After 30 days of ICU stay, the patient was transferred to the Sub-ICU and then to a rehabilitation hospital. A close follow-up has been scheduled: after full recovery, a new echocardiography will be performed (TTE and TOE, if the former is non-conclusive) to consider surgical valve repair in the case of persistence/progression of the valvular lesion or deterioration of the valve function. DISCUSSION: In COVID-19 patients, echocardiography remains the leading imaging exam for the diagnosis of IE. If the suspicion of IE is high, even in this setting of patients, TTE or TOE (if TTE is non-conclusive) are mandatory. A high degree of attention must be paid and appropriate preventive measures taken to avoid contamination of healthcare personnel.

During the intensive care unit (ICU) stay, he developed fever and positive haemocoltures for methicillin-resistant Staphylococcus aureus infection. TTE did not identify endocardial vegetations. TOE was then performed and outlined IE of the aortic valve on the non-coronary cusp. Antibiotic therapy was given with progressive resolution of the septic state and improvement of inflammatory signs. After 30 days of ICU stay, the patient was transferred to the Sub-ICU and then to a rehabilitation hospital. A close follow-up has been scheduled: after full recovery, a new echocardiography will be performed (TTE and TOE, if the former is non-conclusive) to consider surgical valve repair in the case of persistence/progression of the valvular lesion or deterioration of the valve function. In COVID-19 patients, echocardiography remains the leading imaging exam for the diagnosis of IE. If the suspicion of IE is high, even in this setting of patients, TTE or TOE (if TTE is non-conclusive) are mandatory. A high degree of attention must be paid and appropriate preventive measures taken to avoid contamination of healthcare personnel.

Infective endocarditis • Transoesophageal echocardiography • COVID-19 • Case report

• Echocardiography (transthoracic and transoesophageal) is mandatory for the diagnosis of IE also in COVID-19 patients. • In COVID-19 patients, the clinical course in the intensive care unit can be worsened by other infective complications, leading eventually to further impairment of health status and prognosis.

• Echocardiography in COVID-19 must be carefully performed with appropriate preventive measures to avoid contamination of healthcare personnel.

Concern is growing for the contamination risk of healthcare personnel performing diagnostic examinations in patients hospitalized for coronavirus disease (COVID-19), particularly during transoesophageal echocardiography (TOE). According to the American Society of Echocardiography (ASE) and the European Association of Cardiovascular Imaging (EACVI) recommendations, in the case of suspected or confirmed severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infections, 1-3 cardiovascular imaging should be considered only on an individual basis when it could substantially change the patient's management or be life saving. In any case, an appropriate comprehensive safety setting is recommended. 2, 3 Despite the high risk of contamination, TOE remains the gold standard for the diagnosis of infective endocarditis (IE) even in the current COVID-19 pandemic. When transthoracic echocardiography (TTE) is non-conclusive, in patients with a high clinical suspicion of IE, TOE should be performed (see diagnostic flowchart in Figure 1 ). 1 We present the case of a patient with SARS-CoV-2 infection complicated by acute respiratory distress syndrome (ARDS) requiring mechanical ventilation, who developed IE on the aortic valve during their intensive care unit (ICU) stay.

A 57-year-old man was admitted in hospital in mid-March 2020 presenting fever and cough in the last 7 days. He suffered an ischaemic stroke in 2015 due to a patent foramen ovale (PFO), treated with percutaneous closure.

Upon admission, he was febrile (temperature 38 C) and symptomatic for cough and dyspnoea, with normal blood pressure (125/ 80 mmHg), mild oxygen desaturation (94% in room air), and sinus tachycardia (110 b.p.m.). At physical examination, the patient showed bilateral lung crackles, no murmur, and no sign of heart failure. A nasopharyngeal swab tested positive for SARS-CoV-2 infection. Thoracic computed tomography (CT) outlined bilateral ground-glass and crazy paving pulmonary involvement.

Therapy with hydroxychloroquine and antiviral agents (lopinavir/ ritonavir) was empirically started, with poor benefit. After 3 days of hospitalization, the patient developed worsening hypoxaemia nonresponsive to ventilation with continuous positive air pressure (CPAP) with a PaO 2 /FiO 2 ratio <100 compatible with ARDS, i.e. an acute diffuse inflammatory lung injury with non-cardiogenic pulmonary oedema. He was transferred to the ICU, where mechanical ventilation was initiated.

During ICU stay, the patient developed paroxysmal atrial fibrillation and was treated with low molecular weight heparin.

After 10 days of ICU stay, the patient re-developed fever; three sets of haemoculture were performed and resulted positive for methicillin-resistant Staphylococcus aureus (MRSA) infection.

TTE was performed, with a poor ultrasound window, that was not conclusive for IE and showed mild mitral regurgitation and mild impairment of left ventricular systolic function (ejection fraction 45%). This was ascribed to sepsis-and ARDS-related myocardial dysfunction, as no significant rise in serial high-sensitivity troponin levels was observed and no regional wall motion abnormality was described. Given the high clinical suspicion for IE (isolation of MRSA, persistently high inflammatory markers, and patient frailty) and the presence of the PFO occlusion device, the patient underwent TOE. This exam was performed by a limited number of healthcare operators, i.e. one echocardiographer and one nurse, at the bedside in the contaminated ICU area ( Figure 2) . The personnel involved in TOE used the following personal protective equipment (PPE): an isolating waterrepellent gown, a double pair of long gloves, safety face shield, advanced masks (FFP3), and knee length shoe covers. Moreover, to avoid contamination, appropriate removal of the PPE after the exam was performed. TOE outlined the presence of endocarditis vegetation (6 Â 7 mm in diameter, Figure 3 ) on the non-coronary cusp of the aortic valve, and excluded paravalvular abscess, abnormalities on the surface of the PFO closure device, or significant dysfunction in other cardiac valves. Colour Doppler examination revealed a tiny perforation of the body of the cusp in proximity to the vegetation (Figure 4) , responsible for a mild, eccentric, regurgitant jet, without signs of significant left ventricular volume overload or dilatation.

ICU stay was also complicated by ventilator-associated pneumonia due to Klebsiella pneumoniae infection, with bilateral areas of increased density at the repeated lung CT ( Figure 5) .

The patient was initially treated with teicoplanin and ceftazidime/ avibactam; teicoplanin was later replaced by linezolid because of low haematic drug levels and after 7 days fosfomycin was added. Antibiotic therapy led to improvement of the clinical status, with reduction of inflammatory markers, mainly C-reactive protein and procalcitonin.

Considering the SARS-CoV-2 infection and based on the lack of severe aortic valve dysfunction, as well as the absence of endocarditis-related complications, a multidisciplinary team of cardiologists, cardiac surgeons, and anaesthesiologists decided that there was no need for urgent valve repair. . . . . . . . .

After 30 days of ICU stay, the patient was transferred to the Sub-ICU as his clinical conditions had improved. TOE was not repeated, as it would not be likely to change the patient's management. The patient was then transferred to a rehabilitation hospital. At 1 month after the diagnosis of IE, a TTE was performed showing a smaller vegetation with no sign of significant regurgitation. A new TTE was scheduled at 2-month follow-up that will evaluate the need of surgical valve repair in the case of persistence/progression of the lesion.

SARS-CoV-2 infection is associated with interstitial pneumonia and respiratory failure up to ARDS, especially in patients with previous cardiovascular diseases. [4] [5] [6] We present here the case of IE caused by MRSA, complicating a SARS-CoV-2 infection in a young patient admitted to our ICU for interstitial pneumonia requiring mechanical ventilation. TOE was performed because the suspicion of IE was high (i.e. sepsis due to MRSA in a fragile patient) and because the exam could have changed the patient's management. 1-3 TOE showed a vegetation on the aortic valve and excluded both paravalvular complications (i.e. a paravalvular abscess) and involvement of the previously implanted PFO closure device. These findings allowed us to set up an appropriate antibiotic therapy that turned out to be effective.

In COVID-19 patients with high suspicion of IE, TTE and TOE are mandatory for the diagnosis. In these cases, the safest setting for echocardiographers and other healthcare workers should be ensured in order to avoid contamination. 2,3 Accordingly, TOE was performed by a limited number of operators using adequate PPE. The care of the echocardiography machine was also crucial; a singleuse see-through plastic full cover was used to reduce the instrument contamination, although this impaired the quality of the images. After the exam, PPE must be properly removed and instruments/materials, including the echocardiography paper, should remain in the contaminated zone.

We want to underline that TOE was performed in a completely unusual setting, i.e. in the hallway of the Emergency Department, where additional ICU beds were hosted for COVID-19 patients, because the regular ICU was overcrowded. The echocardiography machine had only a monochromatic printer and was not provided with an online storage connection. Finally, the use of external USB storage devices was not allowed, in order to reduce the risk of contamination of 'clean' areas. Considering these limitations, the only way to collect images was sticking the images printed during the examination to the window of the ICU cubicle and taking photos of these pictures from outside the contaminated room by an external operator, as shown in Figure 2 .

TOE represents the gold standard exam for diagnosing IE in patients with SARS-CoV-2 infection. The exam should be performed using all the proper PPE to avoid contamination of operators and instruments.

Enrico Guido Spinoni was born in Turin, Italy, in 1992. He graduated as an MD in the School of Medicine of Turin University in 2017 with his thesis entitled: 'Transcatheter ablation of atrial fibrillation in patients with hypertrophic cardiomyopathy'. He is currently Resident in the Department of Thoracic, Heart and Vascular Diseases of University of Eastern Piedmont, Novara, Italy. Since the COVID-19 outbreak in Italy in February 2020, he has volunteered to work in the Sub-ICU of Maggiore della Carità Hospital treating COVID-19 patients. 

ESC Scientific Document Group. 2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM)

ASE Statement on protection of patients and echocardiography service providers during the 2019 novel coronavirus outbreak: endorsed by the American College of Cardiology

COVID-19 pandemic and cardiac imaging: EACVI recommendations on precautions, indications, prioritization, and protection for patients and healthcare personnel

Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China

Coronavirus disease 2019 (COVID-19) and cardiovascular disease