Commando Surgery in Infective Endocarditis by Streptococcus gallolyticus in an Adolescent: A Rare Case Report

Abstract

Infective endocarditis (IE) is a significant cause of morbidity and mortality in India, particularly in children with underlying congenital heart disease (CHD). While the global incidence of pediatric IE remains low, developing countries like India face a higher burden due to delayed diagnosis, inadequate access to specialized cardiac care, and high prevalence of rheumatic and CHD. A 14-year-old boy with no prior heart disease presented with fever, cough, and chest pain. Echocardiography showed large aortic vegetation, severe regurgitation, and root abscess. Blood culture grew Streptococcus gallolyticus. Despite antibiotics, he required urgent COMMANDO surgery with aortic valve replacement and mitral valve replacement, underscoring fulminant pediatric IE. Initially postoperatively, the patient stabilized but subsequently developed refractory ventricular tachycardia and could not be revived. This case highlights the aggressive nature of pediatric IE, the potential for rapid progression, and the importance of early diagnosis, appropriate antimicrobial therapy, and timely appropriate surgical intervention. This case shows extensive involvement of multidisciplinary action for pediatric IE with extensive cardiac involvement. Successful management clues on early diagnosis, pathogen violence causing infection, disease growth progression, appropriate antibiotics, and timely surgical intervention.

INTRODUCTION

Infective endocarditis (IE) is a significant cause of morbidity and mortality in India, especially in children with underlying congenital heart disease (CHD). While the global incidence of pediatric IE remains low, due to delayed diagnosis, inadequate access to specialized cardiac care, and high prevalence of rheumatic and CHDs, developing countries like India face a higher burden.[1] In India, CHD is thought to affect approximately 9 in every 1000 live births. Among these conditions, bicuspid aortic valve (BAV) is one of the most common congenital defects and is known to predispose individuals to endothelial injury, altered flow patterns, and a higher risk of developing IE.[2]

Although Streptococcus viridans and Staphylococcus aureus continue to be the major organisms responsible for IE in the country,[3] Streptococcus gallolyticus is being recognised more frequently. It has emerged as an important cause of IE and is characteristically associated with underlying colonic disease, such as polyps or colorectal malignancy, particularly in adults.[4]

Factors like late presentation, widespread use of empirical antibiotics before blood cultures are taken, and limited access to pediatric cardiothoracic surgery in many rural regions make the management of pediatric IE in India difficult. The lack of routine echocardiographic screening and the financial challenges posed by prolonged hospital stays and surgical procedures further delay timely diagnosis and treatment.[5] Thus, the need for early recognition, appropriate antibiotic therapy, and prompt referral for surgery when necessary is highlighted.

This report details a rare instance of S. gallolyticus IE in a 14-year-old boy with a BAV, complicated by an aortic root abscess, severe aortic and mitral regurgitation (MR), and involvement of the aortomitral curtain, ultimately requiring an urgent high-risk COMMANDO procedure.

CASE REPORT

A 14-year-old boy, weighing 45 kg and measuring 175 cm in height (body mass inde × 14.7 kg/m²), the second child of a nonconsanguineous marriage, presented to the outpatient department in March 2025 with a 1-month history of intermittent, undocumented fever, a dry cough for 20 days, and chest pain for the preceding week. He belonged to a lower-middle-income family, according to the Modified Kuppuswamy Scale. His father was a skilled labourer and his mother was a homemaker. His immunization was complete up to 10 years of age and there were no notable issues in the perinatal or developmental period. He had been born at term by normal vaginal delivery, with a birth weight of 3 kg, and had not required neonatal intensive care unit care. There was no family history of CHD.

The fever occurred intermittently and tended to worsen towards the evening. It was accompanied by chills and rigors and was partially relieved by over-the-counter medication. His dry cough intensified at night and while lying supine, but eased when he sat upright. Chest pain initially began in the epigastric region and later radiated to the left precordium and upper limb. A history of palpitations and increased effort in breathing for 2 days prior to admission was also reported. No history of rash, joint pains, sore throat, or urinary symptoms were present.

He was conscious, alert, and tachypneic, receiving oxygen at 2 L/min via nasal prongs on arrival. His vital signs showed a heart rate of 138 beats/min, respiratory rate of 48/min, blood pressure of 113/39 mmHg, and oxygen saturation of 98%. His peripheral pulses were bounding. Cardiovascular examination showed a gallop rhythm and a pansystolic murmur. Respiratory examination revealed bilaterally equal air entry; the abdomen was soft with mild hepatomegaly (liver palpable 3 cm below the right costal margin). Neurological status was normal.

Initial 2D echocardiography revealed a large (32 mm × 18 mm), mobile echogenic vegetation attached to the aortic valve with flail left coronary cusp (LCC), severe aortic regurgitation (AR), severe MR, and dilated left atrium (LA) and left ventricle. A ruptured aortic root abscess extending into the aortomitral intervalvular fibrosa (MAIVF) with a suspected fistula to the LA was noted. Mild tricuspid regurgitation, mild pericardial effusion, and severe pulmonary arterial hypertension were also observed. Three blood cultures were drawn from different sites before initiating antibiotics. One culture yielded S. gallolyticus, suggesting probable IE. Initial empiric antibiotics included vancomycin and ceftriaxone, later escalated to meropenem, teicoplanin, and linezolid due to persistent fever and hemodynamic instability. Ophthalmologic evaluation showed no evidence of embolic signs.

Cardiac computed tomography (CT) angiography showed cardiomegaly, dilated left heart chambers, vegetations on both aortic valve cusps, and a hypodense periaortic collection tracking along the aortomitral curtain [Figure 1]. There was no definite fistulous communication to the LA. Bilateral pleural effusion and basal lung ground-glass opacities were also seen. On repeat echocardiography by the pediatric cardiology team, a 26 mm × 22 mm vegetation was seen on the aortic valve, along with echogenic material on the atrial side of the anterior mitral leaflet [Figure 2]. The aortic valve appeared bicuspid but was presumed to be structurally distorted due to endocarditis, rather than congenital. Based on the patient’s height and weight, body surface area was calculated to be 1.48 m² (Mosteller formula). Z-scores for indexed echocardiographic parameters are shown below [Table 1].

Figure 1.

Axial computed tomography showing a hypodense peri-aortic collection consistent with an abscess

Figure 2.

Echocardiography showing mass adhered to aortic valve

Table 1.

Z scores indexed echocardiographic parameters

Parameter	Measured (mm)	Z-score	Interpretation
Aortic root	22	−1.74	Borderline small for BSA
LA	42	+2.57	Dilated
LV EDD	58	+2.75	Significantly dilated

LA=Left atrium, BSA=Body surface area, LV=Left ventricle, EDD=End-diastolic diameter

These findings were consistent with severe left-sided volume overload, secondary to eccentric severe AR and MR. The patient was shifted to the pediatric intensive care unit for monitoring and stabilization. Despite being afebrile on admission, recurrent high-grade fever spikes resumed. Empiric antibiotic therapy was revised to cover resistant organisms based on clinical progression and initial microbiologic findings. Progressive volume overload was noted with worsening tachypnea, bounding pulses, and increasing hepatomegaly. He was managed with intravenous (IV) furosemide infusion (0.5 cc/h), oral aldactone, and enalapril (0.2 mg/kg/day). In view of persistent hypotension and declining cardiac output, inotropic support was initiated with adrenaline (0.2 µg/kg/min), milrinone (0.5 µg/kg/min), and levosimendan (0.1 µg/kg/min).

With echocardiographic and CT findings confirming aortic root abscess, MAIVF involvement, and severe regurgitant lesions, an emergency COMMANDO operation was planned. After thorough counseling, the patient was transferred to the cardiothoracic unit, where he underwent aortic root abscess debridement, aortomitral curtain reconstruction with bovine pericardium, aortic valve replacement (AVR, 23 mm SJM Regent), and mitral valve replacement (MVR, 27 mm SJM Masters). Intraoperatively, large vegetations (2.5 cm × 2 cm) were found over the LCC and anterior mitral leaflet, with the root abscess extending into the roof of the LA [Figure 3].

Figure 3.

Intraoperative picture showing vegetation

Postoperatively, the patient was managed in the Cardio-Vascular Thoracic Surgery intensive care unit on inotropic support. He was extubated on postoperative day 2 and remained stable briefly. On postoperative day 4, he developed sudden-onset ventricular tachycardia, unresponsive to advanced resuscitation efforts, and was declared deceased.

DISCUSSION

In children, IE is an uncommon condition that can cause serious morbidity and death. Recent years have seen a shift in the epidemiology of IE in children, with rheumatic heart disease becoming much less common and CHD emerging as the primary risk factor from the industrialized world. The growing use of central venous catheters (CVCs), particularly in preterm children with chronic illnesses, is probably the cause of the higher prevalence of IE in children without previous heart disease.[6]

The pathophysiology of IE is thought to be primarily caused by transitory bacteremia and damaged cardiac endothelium. Sterile platelets-fibrin thrombus (nonbacterial thrombotic endocarditis) is caused by damaged endothelium, which is typically the outcome of turbulent blood flow in CHD. This thrombus is then colonized and replicated from the contaminated vegetation by the temporary bacteremia (from dental procedures or everyday activities like brushing one’s teeth).[7] Uncertainty surrounds the pathophysiology of IE in children who do not have a history of heart disease, a CVC, or other recognized risk factors, as in this instance. These kids may have modest structural heart abnormalities that are asymptomatic and go undetected.[8]

Anorexia, weight loss, fever, and other constitutional symptoms of several months of evolution are the predominant manifestations, followed by heart failure or embolisms. It is rare to find classic indications like Osler’s nodules or Roth’s patches. Compared to other forms of endocarditis, atypical bacteria have a greater prevalence of complications and mortality. It is thought that the subacute presentation or possibly unique microbiological conditions of these microorganisms are responsible for the increased frequency of problems. Up to 64% of instances have been observed to affect the aortic and mitral valves.[9]

Sepsis, extracardiac infections (like osteomyelitis and renal abscess), immune complex depositions (like glomerulonephritis), and embolization (like stroke) are a few examples of extracardiac consequences.[10] Finally, in order to avoid IE, the American Heart Association advises concentrating mostly on dental and oral hygiene rather than prophylactic antibiotic use. For cardiac conditions that have the highest risk of negative outcomes from IE, such as: repair of the heart valve with a prosthetic valve or material; prior IE; certain CHD (such as unrepaired cyanotic CHD and repaired CHD with prosthetic material or device within the first 6 months after the procedure); and recipients of heart transplants who experience cardiac valvulopathy, antibiotic prophylaxis is advised prior to high-risk dental procedures.[11]

The European Society of Cardiology advises using ceftriaxone 2 g/day IV for 4 weeks, amoxicillin 100–200 mg/kg/day, or penicillin G 12–18 million units per day to treat IE. However, after following the American and European criteria for treatment, many deaths from the condition have been documented. Even with in vitro efficacy, up to 41% of cases result in treatment failure, 17% relapse, and nearly 27% of patients need a prosthetic valve. With just 40% of Granulicatella isolates found to be penicillin-sensitive and over 50% exhibiting intermediate ranges of sensitivity, nutritional variant streptococci have recently shown a propensity to develop penicillin resistance.[12]

CONCLUSION

This case shows extensive involvement of multidisciplinary action for pediatric IE with extensive cardiac involvement. Successful management clues on early diagnosis, pathogen violence causing infection, disease growth progression, appropriate antibiotics, and timely surgical intervention. Given the emerging recognition of S. gallolyticus in pediatric IE, this case also raises concerns about its potential gastrointestinal associations in the Indian population, emphasizing the need for further research in this area.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.