Enterococcus faecalis infective endocarditis in anorexia nervosa complicated by multiorgan failure: a case report

Abstract

Background

Infective endocarditis is characterized by vegetations on the cardiac valves and can lead to serious complications, including heart failure. Anorexia nervosa is associated with cardiovascular abnormalities. To our knowledge, only five cases of anorexia nervosa requiring valve surgery for infective endocarditis have been reported. Herein, we describe the case of a patient with anorexia nervosa who developed infective endocarditis complicated by severe mitral regurgitation and multiorgan failure.

Case presentation

A 40-year-old woman with anorexia nervosa (body mass index: 10.5 kg/m²) presented with fatigue and edema. Transthoracic echocardiography revealed severe mitral regurgitation and large vegetations on the mitral valve. Infective endocarditis was suspected, and the patient was admitted. The following day, she developed disseminated intravascular coagulation and multiorgan failure, necessitating emergent surgery. The operation was performed via a median sternotomy, and mitral valve replacement was performed using a bioprosthetic valve. Postoperatively, blood and mitral valve cultures grew Enterococcus faecalis. Empiric vancomycin and meropenem were initiated on postoperative day 0; it de-escalated to ampicillin and ceftriaxone on postoperative day 9 and discontinued on postoperative day 36. The patient developed massive hematochezia and hemorrhagic shock on postoperative day 8. Emergent colonoscopy revealed a hemorrhagic rectal ulcer, and surgical hemostasis was achieved. Recurrent hematochezia occurred whenever oral intake was reintroduced; therefore, a colostomy was performed on postoperative day 34. Her nutritional status improved, and she was discharged on postoperative day 98. To date, no recurrence or re-infection of E. faecalis infective endocarditis has occurred.

Conclusions

In patients with infective endocarditis and anorexia nervosa, investigating potential infection sources while considering malnutrition-related complications is essential.

Background

Infective endocarditis (IE) is characterized by vegetations on the cardiac valves or endocardium and may lead to complications, including embolism and heart failure. The all-age incidence of IE significantly increased from 1990 to 2019, but the mortality rate remained unchanged [1]. According to the European Society of Cardiology guidelines, patients at intermediate risk of IE include those with non-rheumatic degenerative valve disease [2].

Anorexia nervosa (AN) predominantly affects adolescent girls and is associated with multisystem complications, including cardiovascular, endocrine, and reproductive abnormalities. Echocardiographic studies have shown that patients with AN often exhibit structural and functional cardiac changes, including reduced left ventricular mass, mitral valve prolapse (MVP), and pericardial effusion [3]. Despite these cardiac structural changes, reports of patients with AN who have undergone valve surgery for IE remain limited. Furthermore, to our knowledge, no case reports exist of AN with IE progressing to multiorgan failure (MOF) in which the patient survived following surgical intervention.

Herein, we report the case of a patient with AN who developed IE complicated by severe mitral regurgitation (MR) and MOF.

Case presentation

A 40-year-old woman with AN presented to an internist with fatigue and lower limb edema. Transthoracic echocardiography revealed severe MR and a large vegetation on the mitral valve. She was suspected of having IE and was admitted. The following day, the patient developed disseminated intravascular coagulation (DIC) and MOF, prompting an urgent consultation with a cardiovascular surgeon for emergent surgery.

Upon consultation, physical examination of the patient revealed the following: blood pressure, 84/50 mmHg (mean arterial pressure, 61.3 mmHg); heart rate, 95 bpm (on dobutamine 3.85 µg/kg/min and noradrenaline 0.13 µg/kg/min); body temperature, 36.5 °C; respiratory rate, 24 breaths/min; oxygen saturation, 100% on oxygen at 6 L/min; Glasgow coma scale, 14; body weight, 26 kg; height, 157 cm; and body mass index, 10.5 kg/m². Cardiac auscultation revealed a holosystolic murmur. The lower limbs had redness and swelling, but we did not observe any pus. Laboratory test results are summarized in Table 1.

Table 1.

The results of laboratory tests on consultation

Laboratory tests	Units	Normal range	Results
White blood cell	/µL	3,300 – 8,600	8,200
Hemoglobin	g/dL	11.6 – 14.8	8.7
Platelets	× 104/µL	15.8 – 34.8	1.8
PT-INR			1.35
Fibrinogen	mg/dL	200 – 400	88
FDP	µg/mL	– 5.0	13.4
C-reactive protein	mg/dL	0.00 – 0.14	15.03
Total protein	g/dL	6.6 – 8.1	4.9
Albumin	g/dL	4.1 – 5.1	2.1
Total bilirubin	mg/dL	0.4 – 1.5	2.7
Blood urea nitrogen	mg/dL	8.0 – 20.0	94.5
Creatinine	mg/dL	0.46 – 0.79	4.31
PaO2	mmHg	80 – 100	204
FiO2	%		41.0
P/F ratio		400 –	497.5

PT-INR: Prothrombin Time-International Normalized Ratio

FDP: Fibrin/fibrinogen degradation products

PaO₂: Partial pressure of arterial oxygen

FiO₂: Fraction of inspired oxygen

Transthoracic echocardiography revealed an ejection fraction of 77.7% without regional wall motion abnormalities, severe MR, and vegetations measuring 30 × 21 mm on the anterior mitral leaflet and 18 × 12 mm on the posterior mitral leaflet (Fig. 1). Computed tomography (CT) revealed no intracranial hemorrhage or emboli. The patient was diagnosed with IE and severe MR complicated by DIC and MOF and underwent emergent mitral valve replacement (MVR).

Fig. 1.

Preoperative transthoracic echocardiography. Transthoracic echocardiography revealed an ejection fraction of 77.7% without regional wall motion abnormalities, a 30 × 21-mm vegetation on the anterior mitral leaflet (white arrow), an 18 × 12-mm vegetation on the posterior mitral leaflet (arrowhead), and severe mitral regurgitation

The surgery was performed via a median sternotomy with cardiopulmonary bypass, established after inserting arterial and venous cannulas into the ascending aorta and the superior and inferior vena cavae, respectively. After aortic cross-clamping, the left atrium was opened under cardioplegic arrest. The vegetation on the mitral valve was extensive, whereas a small portion of the posterior mitral valve leaflets remained intact. Infected leaflets with vegetation, along with the mitral subvalvular tissues, were completely excised. MVR was performed using a 23-mm bioprosthetic valve (MITRIS RESILIA; Edwards Lifesciences, Irvine, CA, USA) (Fig. 2). The total operation time was 337 min, with cardiopulmonary bypass and aortic clamp times of 152 and 127 min, respectively. The estimated blood loss was 1080 mL, with intraoperative transfusion consisting of 12, 4, and 20 units of red blood cells, fresh frozen plasma, and platelets, respectively.

Fig. 2.

Intraoperative findings. Vegetation was attached to the mitral valve overall, whereas a small portion of the posterior mitral valve leaflets remained intact. Infected leaflets with vegetation (black arrowhead) and mitral subvalvular tissues were completely excised. Mitral valve replacement was performed using a 23-mm bioprosthetic valve (MITRIS RESILIA; Edwards Lifesciences). MVR, mitral valve replacement

In the early postoperative period, the patient received numerous transfusions, resulting in the improvement of the DIC by postoperative day (POD) 3. On POD 1, the patient experienced convulsions, and head CT revealed an acute subdural hematoma with a midline shift, likely caused by DIC (Fig. 3). Emergent hematoma evacuation was not performed, but the patient was monitored. The subdural hematoma improved without surgery by POD 39.

Fig. 3.

Head computed tomography on postoperative days 1 and 39. Head computed tomography revealed an acute subdural hematoma with a midline shift on postoperative day 1. Without surgical evacuation, the hematoma had improved by postoperative day 39

The patient’s postoperative respiratory status was stable; however, owing to concerns about the potential worsening of the subdural hematoma, preparations were made for possible respiratory arrest. A follow-up head CT confirmed no worsening of the subdural hematoma, and the patient was extubated on POD 7. The patient’s hemodynamics stabilized, and the noradrenaline was weaned within 24 h while maintaining a mean arterial pressure ≥ 65 mmHg. The patient had significant urine output, and both blood urea nitrogen and creatinine levels improved without the need for continuous renal replacement therapy.

Empiric antibiotics, including vancomycin (0.5 g every 24 h, IV) and meropenem (0.5 g every 24 h, IV), were started on POD 0. Blood and mitral valve cultures on POD 0 confirmed Enterococcus faecalis. The empiric antibiotics were de-escalated to ampicillin (2.0 g every 6 h, IV) and ceftriaxone (2.0 g every 12 h, IV) on POD 9 and discontinued on POD 36.

Nutritional support included total parenteral and enteral nutrition initiated on POD 1 and 5, respectively. On POD 8, the patient developed massive hematochezia and hemorrhagic shock. Emergent colonoscopy revealed an acute hemorrhagic rectal ulcer, and surgical hemostasis was achieved (Fig. 4). Recurrent hematochezia occurred whenever oral intake was reintroduced. Given the need to address malnutrition, a colostomy was performed on POD 34. Post-colostomy, no further hematochezia occurred, even with resumed dietary intake. Colonoscopy on POD 65 showed improvement of the rectal ulcer. The patient’s nutritional status improved, and she was discharged on POD 98. To date, no recurrence or reinfection of E. faecalis IE has occurred.

Fig. 4.

Colonoscopic findings. Colonoscopy performed on postoperative day 8 revealed a deep, isolated rectal ulcer with active bleeding approximately 2 cm from the anal verge (white arrow). After nutritional improvement, colonoscopy was performed on postoperative day 65, which revealed a healing rectal ulcer scar with evidence of mucosal recovery (white arrowhead)

Discussion and conclusions

This case shows the complex intersection of AN, severe malnutrition, rectal ulcers, and E. faecalis IE, leading to MOF (Fig. 5). The pathophysiology of IE involves endocardial injury, followed by bacteremia and microbial colonization of the damaged heart tissue [4]. To our knowledge, only five surgical cases of IE associated with AN have been reported (Table 2) [5–9]. Notably, all cases, including the present one, exhibited mitral valve vegetations with severe MR, indicating consistent endocardial injury of the mitral valve. We suspected that the preceding MVP caused the endocardial injury. Johnson et al. reported MVP in 37.0% of patients with AN [10], whereas Smythe et al. suggested that the loss of left ventricular mass distorts left ventricular structure and atrioventricular tissues, resulting in valvular dysfunction [3]. Moreover, Mont et al. demonstrated that AN-induced cardiac structural and functional abnormalities are reversible after refeeding [11]. Therefore, MVP may develop in patients with AN during periods of significant weight loss.

Fig. 5.

Clinical reasoning of this case. Anorexia nervosa caused severe malnutrition with mitral valve prolapse and rectal ulcers (a potential source of E. faecalis bacteremia). The bacteremia resulted in left-sided infective endocarditis with two downstream pathways: septic shock progressing to disseminated intravascular coagulation, and severe mitral regurgitation causing cardiogenic shock, both leading to multiorgan failure. Emergent mitral valve replacement was performed, resulting in subsequent hemodynamic recovery and survival

Table 2.

Reported surgical case of infective endocarditis with anorexia nervosa

Case	Age	Sex	BMI (kg/m2) at admission	Chief Complaint	Causative microorganism	Vegetation site	Treatment	Outcome	Author
1	31	F	6.7	Increasing weakness	Not available	Mitral valve	Mitral valve replacement (Bioprosthetic valve)	Survival	2002 Beholz 5)
2	34	F	12.5	Unfavorable control anorexia nervosa and fever	Streptococcus agaractiae	Mitral valve	Mitral valve repair	Survival	2006 Ando 6)
3	33	F	9.4	Severe malnutrition and electrolyte disturbances	Staphylococcus aureus	Mitral valve	Mitral valve repair	Survival	2007 Zimmermann-viehoff 7)
4	14	F	9.8	Weight loss	Staphylococcus aureus	Mitral valve	Mitral valve repair	Death	2024 Esmaeili 8)
5	19	F	13.9	Fatigue, volitional anorexia, and weight loss	Streptococcus sanguinis	Mitral valve Tricuspid valve	Mitral valve replacement (Mechanical valve) Tricuspid valve repair	Survival	2024 Soh 9)
This Case	40	F	10.2	Fatigue and lower limb edema	Enterococcus faecalis	Mitral valve	Mitral valve replacement (Bioprosthetic valve)	Survival

BMI: Body mass index

Normal ranges are based on the Common Reference Intervals endorsed by the Japanese Committee for

Clinical Laboratory Standards (JCCLS) and adopted by our institutional laboratory

Østergaard et al. reported that Enterococcus species are associated with higher rates of recurrent bacteremia and recurrent IE and that recurrence with the same species often reflects incomplete eradication of the primary or secondary focus, such as malignancy [12]. In our case, initial examinations (oral examination, body surface inspection, and chest-to-abdomen CT) did not reveal the primary focus. However, the patient developed massive hematochezia on POD 8, and an emergent colonoscopy revealed an acute hemorrhagic rectal ulcer, which was identified as the primary focus. Colostomy was performed to control the primary focus and improve the patient’s nutritional status, after which no recurrence or reinfection by E. faecalis IE was observed. Takahashi et al. suggested that hypoalbuminemia and reduced rectal mucosal blood flow are major contributors to the etiology of hemorrhagic rectal ulcers [13]. In this case, we hypothesize that severe malnutrition with hypoalbuminemia led to rectal mucosal ischemia and ulcer formation, serving as the primary infection source. Additionally, the onset of IE, severe MR, and DIC may have exacerbated the rectal mucosal ischemia, resulting in rectal bleeding and hemorrhagic shock. We therefore recommend a thorough investigation of potential infection foci in patients with IE and AN, taking into consideration malnutrition-related complications.

According to the European Society of Cardiology guidelines, surgical intervention in acute IE is indicated for heart failure, uncontrolled infection, or the prevention of septic embolization [2]. However, no established surgical guidelines exist for IE complicated by DIC. Yokoyama et al. compared surgical and medical treatment outcomes in such patients and concluded that valve surgery should not be delayed, as most patients who are managed conservatively often require emergent surgery, and their clinical outcomes are worse than those of patients undergoing early surgery [14]. In our case, although we considered performing emergent surgery or medical treatment with mechanical support, we instead performed emergent MVR, which was successful. Thus, we recommend performing prompt emergent valve surgery in patients with IE with DIC, AN, and severe malnutrition.

Selecting appropriate surgical strategies for patients with AN, such as mitral valve repair, MVR with a mechanical valve, or MVR with a bioprosthetic valve, is also important. Mitral valve repair is generally preferred because it does not require the use of warfarin postoperatively. However, repair may sometimes be difficult to perform when the infection is widespread. In our case, MVR was performed because the infection had extended widely, resulting in the loss of the normal structure of the mitral valve. The choice between a mechanical and a bioprosthetic valve was discussed with the patient and her husband, and a bioprosthetic valve was selected because the patient was concerned about regular warfarin use. Thus, when patients with AN and their families express concerns about regular intake of warfarin, mitral valve repair or MVR with a bioprosthetic valve should be considered, regardless of guideline or age-based recommendations.

The findings in this report are limited by the lack of comprehensive preoperative assessments, such as nutritional status or psychiatric evaluation, owing to the emergent nature of the case.

In summary, we reported a case of a patient with AN who developed IE complicated by severe MR and MOF, required emergent MVR, and survived. We recommend the investigation of the infectious focus in patients with IE and AN, considering malnutrition-related complications. This case further underscores that successful management requires strict multidisciplinary coordination among cardiovascular surgery, infectious disease specialists, critical care, neurosurgery, gastroenterology, and nutrition services.

Abbreviations

IE

Infective endocarditis

NA

Anorexia nervosa

MVP

Mitral valve prolapse

MOF

Multiorgan failure

MR

Mitral regurgitation

MVR

Mitral valve replacement

DIC

Disseminated intravascular coagulation

CT

Computed tomography

POD

Postoperative day

Author contributions

TH prepared the draft of the report and collected the data. YK performed surgery. TH performed the postoperative management. EN and YK edited and supervised the study. All the authors reviewed and revised the manuscript. All the authors have read and approved the final manuscript.

Funding

There is no funding source.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Institutional ethics approval was waived owing to the anonymized nature of this case report. Informed consent was obtained from the patient included in this study.

Consent for publication

Written informed consent was obtained from the patient for the publication of this case report and the associated images.

Competing interests

The authors declare no competing interests.