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hepatomegaly and a moderately sized splenic infarction&#46; Transthoracic echocardiography revealed thickening of the aortic valve cusps and two nodular formations causing mild to moderate aortic regurgitation&#46; It also showed a 15-mm vegetation on the anterior leaflet of the mitral valve causing severe destruction of tissue and severe mitral regurgitation&#44; tricuspid valve leaflet thickening with a 13-mm mobile vegetation and severe tricuspid regurgitation&#46; The pulmonary valve cusps were also thickened and mild to moderate pulmonary regurgitation was visualized&#59; global left ventricular hypokinesis was noted&#46; Brain scans were unremarkable&#46; <span class="elsevierStyleItalic">Gemella morbillorum</span> was isolated in three blood cultures drawn on admission&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The patient had one major &#40;evidence of infection on echocardiogram&#41; and four minor criteria &#40;predisposition&#44; fever&#44; vascular phenomena and positive blood culture&#41; of the modified Duke classification and a definite diagnosis of endocarditis was made&#46; A course of six weeks of vancomycin and two weeks of gentamicin was started and the patient underwent open-heart surgery with mitral and aortic valve replacement &#40;biologic prostheses&#41; and tricuspid valve annuloplasty&#46; No microorganisms were isolated in native valve cultures&#46; Follow-up imaging scans documented pulmonary consolidation and resolution of the subphrenic abscess&#44; with small splenic infarct sequelae being discernible in abdominal scans&#46; Blood tests showed normal hematocrit and significant reduction in inflammatory parameters&#46; The patient was discharged after concluding antibiotic therapy with complete resolution of heart failure symptoms and no need for diuretic therapy&#44; and under oral anticoagulant and antiplatelet therapy which he maintained for three months&#46; He was followed in the internal medicine and cardiothoracic outpatient clinic&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">Endocarditis has an annual incidence of 3&#8211;10 cases per 100 000&#44; predominantly affecting individuals between 70 and 80 years old&#44; most of whom are male&#46; In recent decades its incidence has risen steadily&#44; due not only to advances in diagnostic techniques but also to nosocomial infections &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figures 1&#8211;4</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Gemella</span> is a genus of six Gram-positive bacteria species&#44; found in the mucous membranes of various animals&#44; including humans&#46; Endocarditis caused by <span class="elsevierStyleItalic">G&#46; morbillorum</span> is a rare condition&#44; with about 24 cases being reported in the relevant medical literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> This anaerobic bacterium&#44; with negative catalase test&#44;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> is very difficult to identify microbiologically by standard methods and has a highly variable presentation&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Part of the normal oropharyngeal&#44; gastrointestinal and urinary tract bacterial flora&#44; it is rarely responsible for infections in humans&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> However&#44; it can cause septicemia&#44; meningitis&#44; arthritis and endocarditis&#44; which usually follow a subacute or chronic course&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> More rarely&#44; it may also be responsible for pulmonary infections&#44; including abscess&#44; necrotizing pneumonia and pleural empyema&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">G&#46; morbillorum</span> endocarditis particularly affects males between 20 and 80 years old&#44; usually with poor dental hygiene or with a history of recent dental procedures&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> digestive tract examination&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> immunosuppression&#44; intravenous drug use&#44; diabetes&#44; hepatic and renal impairment or cardiac disease such as valve disease&#44; myxoma&#44; or hypertrophic cardiomyopathy&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5&#44;8</span></a> Penicillin or vancomycin associated with gentamicin is recommended for endocarditis due to this microorganism&#44; and prognosis is favorable when it is started promptly and accompanied&#44; when appropriate&#44; by surgical intervention&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In the present case&#44; the patient&#39;s predisposition due to valvular disease and gastrointestinal endoscopic examination may have been responsible for his disease&#46; Symptoms developed insidiously&#44; with progressive worsening of heart failure and petechiae&#44; and diagnosis was only achieved due to the acute symptoms of a subphrenic abscess caused by the splenic infarct secondary to endocarditis&#46; The pulmonary consolidation discovered on CT scans occurred by transdiaphragmatic dissemination&#46; <span class="elsevierStyleItalic">G&#46; morbillorum</span> bacteremia and the favorable outcome after the institution of appropriate therapy confirm that this was the pathogen involved&#44; despite the lack of blood culture identification in other specimens&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Notwithstanding the institution of prompt and appropriate tailored antibiotic therapy&#44; the patient had an initially unfavorable outcome&#44; and urgent surgery was needed due to acute heart failure caused by the destruction of the anterior leaflet of the mitral valve and regurgitation of the other valves&#46; Surgery also substantially reduced the risk of new septic emboli arising from the presence of &#62;10-mm vegetations&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">With this case&#44; the authors wish to highlight the insidious and variable nature of this clinical entity&#44; and the need for a high level of clinical suspicion&#44; based on a thorough and methodical history&#44; as well as appropriate complimentary exams for a correct diagnosis&#46; Prompt institution of antibiotic therapy and&#44; when appropriate&#44; cardiac surgery&#44; confer a favorable prognosis&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The authors present a rare case of subacute endocarditis caused by <span class="elsevierStyleItalic">Gemella morbillorum&#46;</span> A 72-year-old man&#44; with a history of hypertension&#44; aortic valve disease and upper and lower endoscopy six months previously&#44; was admitted due to fever and abdominal pain&#46; He also complained of long-standing dyspnea on exertion and petechiae on his lower limbs&#46; Imaging scans showed a consolidation in the lower left lung field&#44; a splenic infarct and a left subphrenic abscess&#46; Transthoracic echocardiogram findings were highly suggestive of endocarditis affecting three valves&#44; with destruction of the mitral valve anterior leaflet&#46; <span class="elsevierStyleItalic">G&#46; morbillorum</span> was identified in three blood cultures and was considered the etiologic pathogen&#46; Due to the patient&#39;s worsening condition&#44; he underwent cardiac surgery&#44; aiming to control the infection and to resolve the associated mechanical complications&#46; This case highlights the need for a complete and thorough history to arrive at likely diagnostic hypotheses that&#44; together with complementary exams&#44; will lead to correct diagnosis and the prompt institution of appropriate therapy&#46;</p>"
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        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Os autores apresentam um caso de endocardite subaguda causada por um agente raro&#44; <span class="elsevierStyleItalic">Gemella morbillorum</span>&#46; Trata-se de um homem 72 anos com hipertens&#227;o arterial e valvulopatia a&#243;rtica&#44; submetido a endoscopias digestivas seis meses antes&#46; Admitido por febre e dor abdominal&#46; Concomitantemente apresentava cl&#237;nica compat&#237;vel com insufici&#234;ncia card&#237;aca descompensada associada a pet&#233;quias com semanas de evolu&#231;&#227;o&#46; Os exames imagiol&#243;gicos mostraram consolida&#231;&#227;o da base pulmonar esquerda&#44; enfarte espl&#233;nico e abcesso subfr&#233;nico esquerdo&#46; O ecocardiograma transtor&#225;cico mostrou altera&#231;&#245;es sugestivas de endocardite de tr&#234;s v&#225;lvulas com destrui&#231;&#227;o do folheto anterior da v&#225;lvula mitral&#46; A emboliza&#231;&#227;o espl&#233;nica&#44; em prov&#225;vel contexto de endocardite&#44; complicou com abcesso subfr&#233;nico esquerdo e dissemina&#231;&#227;o para o t&#243;rax&#46; Foi isolado em tr&#234;s hemoculturas <span class="elsevierStyleItalic">Gemella morbillorum</span>&#44; admitido como o agente infecioso envolvido&#46; Evolu&#231;&#227;o desfavor&#225;vel com necessidade de cirurgia urgente para controlo de foco e resolu&#231;&#227;o de complica&#231;&#245;es mec&#226;nicas dela decorrentes&#46; Destaca-se a necessidade de uma anamnese completa para a coloca&#231;&#227;o de hip&#243;teses de diagn&#243;stico assertivas&#44; que complementadas com exames adequados possibilitam uma abordagem terap&#234;utica adequada e curativa&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Godinho AR&#44; Tom&#233; E&#44; Vaz A&#44; et al&#46; Endocardite por <span class="elsevierStyleItalic">Gemella</span>&#58; uma entidade agressiva&#46; Rev Port Cardiol&#46; 2013&#59;32&#58;1027&#8211;1030&#46;</p>"
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