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of Roma ethnicity and adverse socioeconomic status&#44; with no known personal history of disease &#40;there was no record of medical check-ups during childhood&#41; or previous diagnosis of a heart defect&#46; He was brought to the emergency department of his local hospital seven days after the onset of intermittent fever&#44; coughing fits and unquantified weight loss&#44; but no other symptoms&#46; Cardiac auscultation revealed a harsh pansystolic murmur at the left sternal border and a diastolic murmur at the right second intercostal space&#44; together with a precordial thrill&#46; Physical examination showed multiple untreated caries&#44; but no other relevant alterations including signs of congestive heart failure &#40;CHF&#41;&#46; Laboratory tests showed an active infection &#40;neutrophilic leukocytosis&#58; 24 10<span class="elsevierStyleSup">3</span>&#47;&#956;l&#44; with 20 &#215; 10<span class="elsevierStyleSup">3</span>&#47;&#956;l neutrophils&#44; and C-reactive protein 5&#46;6 mg&#47;dl&#41;&#46; 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was added to the antibiotic regime&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Despite optimized anticongestive therapy&#44; the patient remained clinically unstable and in New York Heart Association functional class II&#8211;III&#47;IV with signs of low cardiac output&#44; requiring inotropic support&#46; Four days after this clinical worsening&#44; he was referred to a surgical center where he underwent aortic valve replacement with an aortic homograft&#44; removal of the mitral valve vegetations and reconstruction of the anterior leaflet with a bovine pericardial patch&#44; and direct closure of the VSD&#46; The postoperative period was uneventful and the second antibiotic regime was maintained for a further four weeks after surgery&#44; a total of six weeks &#40;nine days with vancomycin and gentamicin and five weeks with ceftriaxone&#44; teicoplanin and rifampicin&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">There was marked echocardiographic improvement during follow-up&#46; At present&#44; three years later&#44; the patient is clinically stable under anticongestive therapy&#46; The last transthoracic echocardiogram showed mild to moderate mitral regurgitation &#40;grade I&#8211;II&#47;IV&#41;&#44; and normal biventricular function&#46; However&#44; the left atrium &#40;LA&#41; remained dilated &#40;diastolic diameter 41 mm&#44; corresponding to a <span class="elsevierStyleItalic">Z</span>-score of &#43;3&#46;21 and LA&#47;aorta ratio in M-mode Doppler of 1&#46;4&#41;&#44; with estimated pulmonary artery pressure of 40&#8211;45 mmHg&#44; indicating mild pulmonary hypertension&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">IE is rare but potentially fatal in pediatric patients&#46; In-hospital mortality is 20&#37;&#44; but is much higher in complicated cases&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Around 70&#37; of cases at pediatric ages occur in children with CHD&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> although its frequency appears to be rising&#44; due partly to the increasing number of children surviving after surgical correction of complex CHD&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The association between CHD and IE represents a lifetime risk&#44; as all forms of CHD except ostium secundum atrial septal defect predispose to IE&#46; The defects most commonly involved are tetralogy of Fallot&#44; VSD&#44; aortic valve disease&#44; transposition of the great arteries and systemic-pulmonary shunt&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The boy in the case presented had a VSD and bicuspid aortic valve&#44; both previously undiagnosed&#46; In one published series&#44; the incidence of IE in children with VSD was 1&#8211;2&#46;4 per 1000&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Staphylococcus aureus</span> is the most common causal agent in acute IE in developed countries&#46; Infection by viridans group or alpha-hemolytic streptococci &#40;which includes <span class="elsevierStyleItalic">S&#46; mitis</span>&#41; is also common&#44; particularly in children with dental disease&#44; leading to subacute disease&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> as in the case presented&#46; More recently&#44; there has been a marked increase in the incidence of IE caused by fungi or microorganisms of the HACEK group &#40;<span class="elsevierStyleItalic">Haemophilus</span>&#44; <span class="elsevierStyleItalic">Actinobacillus</span>&#44; <span class="elsevierStyleItalic">Cardiobacterium</span>&#44; <span class="elsevierStyleItalic">Eikenella</span> and <span class="elsevierStyleItalic">Kingella</span>&#41; in newborns and immunocompromised patients&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">There are two important factors in the pathogenesis of IE&#58; an area of endothelial damage and the presence of bacteremia&#44; even if transient&#46; Patients have some form of underlying hemodynamic abnormality&#44; such as a pressure gradient or turbulent flow between two cardiac chambers or the great vessels&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> These changes damage the endothelium&#44; which can be directly invaded by virulent microorganisms or induce thrombus formation and subsequent bacterial adhesion&#44; leading to the development of vegetations&#46; As in our patient&#44; one cause of transient bacteremia is poor oral hygiene and untreated dental caries&#44; whether or not dental procedures are performed&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The modified Duke criteria are now the most widely used to diagnosis IE&#44; and are based on the patient&#39;s medical history&#44; physical examination and complementary diagnostic exams&#44; including two or more blood cultures positive for the microorganisms typical of IE and echocardiographic evidence of endocardial involvement&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Initial empirical treatment is an antistaphylococcal penicillin together with an aminoglycoside&#44; effective against the most common microorganisms &#40;<span class="elsevierStyleItalic">S&#46; viridans</span>&#44; <span class="elsevierStyleItalic">S&#46; aureus</span> and Gram-negative bacteria&#41;&#46; The final choice of antibiotic therapy is guided by the results of susceptibility tests&#46; Treatment duration depends on the etiological agent isolated&#44; but on average ranges between four and eight weeks of intravenous antibiotics&#46; This prolonged regime is essential to ensure that bactericide concentrations reach levels effective against microorganisms with low metabolic rates in vegetations that are protected from phagocytic activity&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Surgery plays a crucial role in more severe cases&#44; notably when there is CHF refractory to medical therapy or secondary to valve dysfunction&#44; perivalvular abscess or vegetations larger than 1 cm&#44; and infection by fungi or <span class="elsevierStyleItalic">Pseudomonas</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Traditionally&#44; the accepted dogma was to avoid surgery during the active phase of the disease due to tissue friability&#44; which made surgery difficult and led to high postoperative mortality and risk of valve dysfunction&#46; This idea has now been abandoned and early surgery is now recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Our patient was transferred to a surgical center after clinical worsening secondary to various complications that are criteria for urgent surgery &#40;within a few days&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The indications for urgent surgery include&#58; &#40;1&#41; CHF with impaired left ventricular function &#40;class I recommendation&#44; level of evidence B&#41;&#59; &#40;2&#41; locally uncontrolled infection&#44; with aortic paravalvular abscess &#40;class I recommendation&#44; level of evidence B&#41; and persisting fever &#40;class I recommendation&#44; level of evidence B&#41;&#59; and &#40;3&#41; prevention of systemic embolism associated with large aortic and&#47;or mitral vegetations &#40;class I recommendation&#44; level of evidence C&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The initial surgical option was for a Ross procedure&#44; but the aortic valve had to be replaced with an aortic homograft since the aortic abscess extended anteriorly up to the pulmonary artery wall&#44; making it friable&#44; and hence the pulmonary valve could not be used in aortic position&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Finally&#44; prevention of IE is as important as diagnosis and treatment&#44; for which good oral hygiene and regular dental check-ups are essential&#46; The latest guidelines recommend a more rational use of prophylactic antibiotic therapy prior to interventional procedures&#44; limiting their use to patients with predisposing cardiac conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusion</span><p id="par0090" class="elsevierStylePara elsevierViewall">IE at pediatric ages is generally associated with CHD&#46; Diagnosis is based on symptoms&#44; together with new echocardiographic alterations and blood cultures positive for typical microorganisms&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Antibiotic therapy is the cornerstone of treatment&#44; and should last for four to eight weeks and be administered intravenously&#46; However&#44; the most important measure is prevention&#44; based on good oral hygiene and antibiotic prophylaxis prior to high-risk invasive procedures&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Protection of human and animal subjects</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Confidentiality of data</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Right to privacy and informed consent</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A diagnosis of congenital heart disease is usually established at an early age&#44; so infective endocarditis is a rare form of presentation&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The authors describe the case of a male adolescent with a week-long history of intermittent fever and unquantified weight loss&#46; Physical examination detected pansystolic and diastolic murmurs&#44; and an associated precordial thrill&#46; Laboratory tests showed evidence of an active infection&#46; Etiological investigation revealed a perimembranous ventricular septal defect&#44; aortic regurgitation&#44; and aortic and mitral valve vegetations&#46; A diagnosis of mitral-aortic infective endocarditis was made and he was started on intravenous antibiotics and anticongestive therapy&#46; After initial clinical improvement&#44; he developed symptoms and signs of congestive heart failure&#46; Repeat echocardiography showed an extensive mitral-aortic paravalvular abscess&#46; The antibiotics were changed and anticongestive therapy was intensified&#44; and he subsequently underwent surgery&#46; The outcome has been generally favorable&#44; and at present he is asymptomatic under anticongestive therapy&#46;</p>"
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        "resumen" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">O diagn&#243;stico de cardiopatia cong&#233;nita &#233; estabelecido habitualmente em idade precoce&#44; logo&#44; a endocardite infecciosa &#233; uma forma de apresenta&#231;&#227;o rara desta patologia&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Descreve-se um caso cl&#237;nico de um adolescente com febre intermitente com uma semana de evolu&#231;&#227;o e perda ponderal n&#227;o quantificada&#46; A observa&#231;&#227;o detetou um sopro holossist&#243;lico rude e um sopro diast&#243;lico&#44; associados a um fr&#233;mito na regi&#227;o precordial&#46; Analiticamente&#44; apresentava sinais sugestivos de um processo infeccioso ativo&#46; A investiga&#231;&#227;o etiol&#243;gica revelou a presen&#231;a de uma comunica&#231;&#227;o interventricular perimembranosa restritiva&#44; bicuspidia a&#243;rtica com regurgita&#231;&#227;o a&#243;rtica e vegeta&#231;&#245;es a n&#237;vel da v&#225;lvula mitral e a&#243;rtica&#46; Perante o diagn&#243;stico de endocardite mitroa&#243;rtica&#44; iniciou antibioterapia endovenosa associada a terap&#234;utica anticongestiva&#46; Ap&#243;s melhoria cl&#237;nica inicial&#44; desenvolveu quadro de insufici&#234;ncia card&#237;aca congestiva&#46; Repetiu o ecocardiograma&#44; que mostrou abcesso paravalvular a&#243;rtico e mitral extenso&#46; A antibioterapia foi substitu&#237;da e a terap&#234;utica anticongestiva foi intensificada&#46; Foi posteriormente submetido a cirurgia card&#237;aca&#46; A evolu&#231;&#227;o tem sido favor&#225;vel&#44; mantendo-se assintom&#225;tico sob terap&#234;utica anticongestiva&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Vaz Silva P&#44; et al&#46; Endocardite infecciosa como primeira manifesta&#231;&#227;o de cardiopatia cong&#233;nita de apresenta&#231;&#227;o tardia&#46; Rev Port Cardiol&#46; 2013&#46; <span class="elsevierStyleInterRef" href="doi:10.1016/j.repc.2012.05.023">http&#58;&#47;&#47;dx&#46;doi&#46;org&#47;10&#46;1016&#47;j&#46;repc&#46;2012&#46;05&#46;023</span>&#46;</p>"
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Case report
Infective endocarditis as a form of late presentation of congenital heart disease
Endocardite infecciosa como primeira manifestação de cardiopatia congénita de apresentação tardia
Patrícia Vaz Silva
Corresponding author
patriciavazsilva@gmail.com

Corresponding author.
, Joana Castro Marinho, Paula Martins, Isabel Santos, António Pires, Graça Sousa, Eduardo Castela
Serviço de Cardiologia Pediátrica, Hospital Pediátrico Carmona da Mota, Coimbra, Portugal
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of Roma ethnicity and adverse socioeconomic status&#44; with no known personal history of disease &#40;there was no record of medical check-ups during childhood&#41; or previous diagnosis of a heart defect&#46; He was brought to the emergency department of his local hospital seven days after the onset of intermittent fever&#44; coughing fits and unquantified weight loss&#44; but no other symptoms&#46; Cardiac auscultation revealed a harsh pansystolic murmur at the left sternal border and a diastolic murmur at the right second intercostal space&#44; together with a precordial thrill&#46; Physical examination showed multiple untreated caries&#44; but no other relevant alterations including signs of congestive heart failure &#40;CHF&#41;&#46; Laboratory tests showed an active infection &#40;neutrophilic leukocytosis&#58; 24 10<span class="elsevierStyleSup">3</span>&#47;&#956;l&#44; with 20 &#215; 10<span class="elsevierStyleSup">3</span>&#47;&#956;l neutrophils&#44; and C-reactive protein 5&#46;6 mg&#47;dl&#41;&#46; Transthoracic echocardiography with Doppler study was performed via a telemedicine link to our department&#44; which revealed a small perimembranous restrictive VSD&#44; a bicuspid aortic valve without stenosis but with moderate regurgitation &#40;grade III&#47;VI&#41;&#44; and aortic and mitral valve vegetations&#46; Left ventricular function was preserved&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In view of the diagnosis of mitral-aortic infective endocarditis&#44; empirical intravenous antibiotic therapy was begun with vancomycin &#40;30 mg&#47;kg&#47;day&#41; and gentamicin &#40;5 mg&#47;kg&#47;day&#41;&#44; together with oral anticongestive therapy with diuretics &#40;furosemide 1 mg&#47;kg and 25 mg spironolactone every 12 hours&#41; and an angiotensin-converting enzyme inhibitor &#40;captopril 1 mg&#47;kg every eight hours&#41;&#46; <span class="elsevierStyleItalic">Streptococcus mitis</span>&#44; susceptible to the antibiotics prescribed&#44; was isolated in blood samples collected before the start of antibiotic therapy&#46; The initial clinical course was favorable&#44; the fever subsiding on the sixth day of treatment&#46; However&#44; fever recurred during the second week of hospital stay&#44; together with signs and symptoms of CHF&#46; The antibiotics were changed to ceftriaxone &#40;60 mg&#47;kg&#47;day&#41; and teicoplanin &#40;10 mg&#47;kg&#47;day&#41;&#44; and diuretic therapy was intensified&#44; furosemide being increased to 1 mg&#47;kg every six hours and administered intravenously&#59; the dosage and form of administration of other therapy was unchanged&#46; Cultures of blood samples collected before the change in antibiotics were negative&#46; Transesophageal echocardiography was also performed at this stage&#44; which showed aortic and mitral valve vegetations &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figures 1 and 2</a>&#41;&#44; as well as a mitral-aortic paravalvular abscess&#46; Left ventricular function was also mildly impaired&#46; Rifampicin &#40;15 mg&#47;kg&#47;day&#41; was added to the antibiotic regime&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Despite optimized anticongestive therapy&#44; the patient remained clinically unstable and in New York Heart Association functional class II&#8211;III&#47;IV with signs of low cardiac output&#44; requiring inotropic support&#46; Four days after this clinical worsening&#44; he was referred to a surgical center where he underwent aortic valve replacement with an aortic homograft&#44; removal of the mitral valve vegetations and reconstruction of the anterior leaflet with a bovine pericardial patch&#44; and direct closure of the VSD&#46; The postoperative period was uneventful and the second antibiotic regime was maintained for a further four weeks after surgery&#44; a total of six weeks &#40;nine days with vancomycin and gentamicin and five weeks with ceftriaxone&#44; teicoplanin and rifampicin&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">There was marked echocardiographic improvement during follow-up&#46; At present&#44; three years later&#44; the patient is clinically stable under anticongestive therapy&#46; The last transthoracic echocardiogram showed mild to moderate mitral regurgitation &#40;grade I&#8211;II&#47;IV&#41;&#44; and normal biventricular function&#46; However&#44; the left atrium &#40;LA&#41; remained dilated &#40;diastolic diameter 41 mm&#44; corresponding to a <span class="elsevierStyleItalic">Z</span>-score of &#43;3&#46;21 and LA&#47;aorta ratio in M-mode Doppler of 1&#46;4&#41;&#44; with estimated pulmonary artery pressure of 40&#8211;45 mmHg&#44; indicating mild pulmonary hypertension&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">IE is rare but potentially fatal in pediatric patients&#46; In-hospital mortality is 20&#37;&#44; but is much higher in complicated cases&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Around 70&#37; of cases at pediatric ages occur in children with CHD&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> although its frequency appears to be rising&#44; due partly to the increasing number of children surviving after surgical correction of complex CHD&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The association between CHD and IE represents a lifetime risk&#44; as all forms of CHD except ostium secundum atrial septal defect predispose to IE&#46; The defects most commonly involved are tetralogy of Fallot&#44; VSD&#44; aortic valve disease&#44; transposition of the great arteries and systemic-pulmonary shunt&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The boy in the case presented had a VSD and bicuspid aortic valve&#44; both previously undiagnosed&#46; In one published series&#44; the incidence of IE in children with VSD was 1&#8211;2&#46;4 per 1000&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Staphylococcus aureus</span> is the most common causal agent in acute IE in developed countries&#46; Infection by viridans group or alpha-hemolytic streptococci &#40;which includes <span class="elsevierStyleItalic">S&#46; mitis</span>&#41; is also common&#44; particularly in children with dental disease&#44; leading to subacute disease&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> as in the case presented&#46; More recently&#44; there has been a marked increase in the incidence of IE caused by fungi or microorganisms of the HACEK group &#40;<span class="elsevierStyleItalic">Haemophilus</span>&#44; <span class="elsevierStyleItalic">Actinobacillus</span>&#44; <span class="elsevierStyleItalic">Cardiobacterium</span>&#44; <span class="elsevierStyleItalic">Eikenella</span> and <span class="elsevierStyleItalic">Kingella</span>&#41; in newborns and immunocompromised patients&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">There are two important factors in the pathogenesis of IE&#58; an area of endothelial damage and the presence of bacteremia&#44; even if transient&#46; Patients have some form of underlying hemodynamic abnormality&#44; such as a pressure gradient or turbulent flow between two cardiac chambers or the great vessels&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> These changes damage the endothelium&#44; which can be directly invaded by virulent microorganisms or induce thrombus formation and subsequent bacterial adhesion&#44; leading to the development of vegetations&#46; As in our patient&#44; one cause of transient bacteremia is poor oral hygiene and untreated dental caries&#44; whether or not dental procedures are performed&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The modified Duke criteria are now the most widely used to diagnosis IE&#44; and are based on the patient&#39;s medical history&#44; physical examination and complementary diagnostic exams&#44; including two or more blood cultures positive for the microorganisms typical of IE and echocardiographic evidence of endocardial involvement&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Initial empirical treatment is an antistaphylococcal penicillin together with an aminoglycoside&#44; effective against the most common microorganisms &#40;<span class="elsevierStyleItalic">S&#46; viridans</span>&#44; <span class="elsevierStyleItalic">S&#46; aureus</span> and Gram-negative bacteria&#41;&#46; The final choice of antibiotic therapy is guided by the results of susceptibility tests&#46; Treatment duration depends on the etiological agent isolated&#44; but on average ranges between four and eight weeks of intravenous antibiotics&#46; This prolonged regime is essential to ensure that bactericide concentrations reach levels effective against microorganisms with low metabolic rates in vegetations that are protected from phagocytic activity&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Surgery plays a crucial role in more severe cases&#44; notably when there is CHF refractory to medical therapy or secondary to valve dysfunction&#44; perivalvular abscess or vegetations larger than 1 cm&#44; and infection by fungi or <span class="elsevierStyleItalic">Pseudomonas</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Traditionally&#44; the accepted dogma was to avoid surgery during the active phase of the disease due to tissue friability&#44; which made surgery difficult and led to high postoperative mortality and risk of valve dysfunction&#46; This idea has now been abandoned and early surgery is now recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Our patient was transferred to a surgical center after clinical worsening secondary to various complications that are criteria for urgent surgery &#40;within a few days&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The indications for urgent surgery include&#58; &#40;1&#41; CHF with impaired left ventricular function &#40;class I recommendation&#44; level of evidence B&#41;&#59; &#40;2&#41; locally uncontrolled infection&#44; with aortic paravalvular abscess &#40;class I recommendation&#44; level of evidence B&#41; and persisting fever &#40;class I recommendation&#44; level of evidence B&#41;&#59; and &#40;3&#41; prevention of systemic embolism associated with large aortic and&#47;or mitral vegetations &#40;class I recommendation&#44; level of evidence C&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The initial surgical option was for a Ross procedure&#44; but the aortic valve had to be replaced with an aortic homograft since the aortic abscess extended anteriorly up to the pulmonary artery wall&#44; making it friable&#44; and hence the pulmonary valve could not be used in aortic position&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Finally&#44; prevention of IE is as important as diagnosis and treatment&#44; for which good oral hygiene and regular dental check-ups are essential&#46; The latest guidelines recommend a more rational use of prophylactic antibiotic therapy prior to interventional procedures&#44; limiting their use to patients with predisposing cardiac conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusion</span><p id="par0090" class="elsevierStylePara elsevierViewall">IE at pediatric ages is generally associated with CHD&#46; Diagnosis is based on symptoms&#44; together with new echocardiographic alterations and blood cultures positive for typical microorganisms&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Antibiotic therapy is the cornerstone of treatment&#44; and should last for four to eight weeks and be administered intravenously&#46; However&#44; the most important measure is prevention&#44; based on good oral hygiene and antibiotic prophylaxis prior to high-risk invasive procedures&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Protection of human and animal subjects</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Confidentiality of data</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Right to privacy and informed consent</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A diagnosis of congenital heart disease is usually established at an early age&#44; so infective endocarditis is a rare form of presentation&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The authors describe the case of a male adolescent with a week-long history of intermittent fever and unquantified weight loss&#46; Physical examination detected pansystolic and diastolic murmurs&#44; and an associated precordial thrill&#46; Laboratory tests showed evidence of an active infection&#46; Etiological investigation revealed a perimembranous ventricular septal defect&#44; aortic regurgitation&#44; and aortic and mitral valve vegetations&#46; A diagnosis of mitral-aortic infective endocarditis was made and he was started on intravenous antibiotics and anticongestive therapy&#46; After initial clinical improvement&#44; he developed symptoms and signs of congestive heart failure&#46; Repeat echocardiography showed an extensive mitral-aortic paravalvular abscess&#46; The antibiotics were changed and anticongestive therapy was intensified&#44; and he subsequently underwent surgery&#46; The outcome has been generally favorable&#44; and at present he is asymptomatic under anticongestive therapy&#46;</p>"
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        "resumen" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">O diagn&#243;stico de cardiopatia cong&#233;nita &#233; estabelecido habitualmente em idade precoce&#44; logo&#44; a endocardite infecciosa &#233; uma forma de apresenta&#231;&#227;o rara desta patologia&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Descreve-se um caso cl&#237;nico de um adolescente com febre intermitente com uma semana de evolu&#231;&#227;o e perda ponderal n&#227;o quantificada&#46; A observa&#231;&#227;o detetou um sopro holossist&#243;lico rude e um sopro diast&#243;lico&#44; associados a um fr&#233;mito na regi&#227;o precordial&#46; Analiticamente&#44; apresentava sinais sugestivos de um processo infeccioso ativo&#46; A investiga&#231;&#227;o etiol&#243;gica revelou a presen&#231;a de uma comunica&#231;&#227;o interventricular perimembranosa restritiva&#44; bicuspidia a&#243;rtica com regurgita&#231;&#227;o a&#243;rtica e vegeta&#231;&#245;es a n&#237;vel da v&#225;lvula mitral e a&#243;rtica&#46; Perante o diagn&#243;stico de endocardite mitroa&#243;rtica&#44; iniciou antibioterapia endovenosa associada a terap&#234;utica anticongestiva&#46; Ap&#243;s melhoria cl&#237;nica inicial&#44; desenvolveu quadro de insufici&#234;ncia card&#237;aca congestiva&#46; Repetiu o ecocardiograma&#44; que mostrou abcesso paravalvular a&#243;rtico e mitral extenso&#46; A antibioterapia foi substitu&#237;da e a terap&#234;utica anticongestiva foi intensificada&#46; Foi posteriormente submetido a cirurgia card&#237;aca&#46; A evolu&#231;&#227;o tem sido favor&#225;vel&#44; mantendo-se assintom&#225;tico sob terap&#234;utica anticongestiva&#46;</p>"
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ISSN: 21742049
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Revista Portuguesa de Cardiologia (English edition)
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