Infective endocarditis has variable clinical presentations and may present with rheumatologic manifestations.
Infective endocarditis due to high level
aminoglycoside resistant enterococci represents a severe therapeutic challenge as none of the currently recommended treatment regimens are bactericidal against these isolates. In this report, a case of
infective endocarditis with double aetiology, high level
aminoglycoside resistant Enterococcus faecalis together with methicillin-resistant
coagulase-negative staphylococci (MR-CNS), presenting with
leukocytoclastic vasculitis and rapidly progressive
glomerulonephritis, has been presented. A 48-years-old woman was admitted to our hospital with malaise and non-pruritic purpural rush on her lower extremities. On admission she had no
fever or
leukocytosis. Skin biopsy showed
leukocytoclastic vasculitis and
steroid therapy was started. On 12th day of admission rapidly progressive
glomerulonephritis was diagnosed and she received
plasmapheresis and haemodialysis support. Transthoracic echocardiography (TTE) demonstrated 1 x 1.5 cm vegetation on the mitral valve. An initial diagnosis of
infective endocarditis was made and empirical treatment with
vancomycin and
gentamicin was started. All blood cultures yielded high level
aminoglycoside resistant E. faecalis and additionally two of them yielded MR-CNS.
Vancomycin was administered in combination with high dose
ampicillin and repeated blood cultures taken after administration of
ampicillin, revealed no growth. The patient remained afebrile, renal functions improved and a repeat TTE done on 20th day of
ampicillin therapy showed waning of the vegetation. On 42nd day of treatment repeat TTE showed new vegetation on the mitral valve and severe valve insufficiency, so the patient was scheduled for mitral valve replacement. She was treated for 12 weeks with
vancomycin and
ampicillin and recovered successfully. In conclusion;
infective endocarditis should be considered in the differential diagnosis of
leukocytoclastic vasculitis and rapidly progressive
glomerulonephritis. Physicians should document their treatment outcomes and experience with high level
aminoglycoside resistant enterococcal
infective endocarditis, which is a therapeutic challenge, so that the best therapeutic options can be identified.