Case report
Infective endocarditis in an HIV-infected intravenous drug user
Endocardite infecciosa no VIH – fármaco intravenoso utilizado em doente infetado
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array:3 [ "nombre" => "Karolina" "apellidos" => "Mėlinytė" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "Jurgita" "apellidos" => "Savickaitė" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:4 [ "nombre" => "Daiva Emilija" "apellidos" => "Rekienė" "email" => array:1 [ 0 => "daiva.rekiene@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 3 => array:3 [ "nombre" => "Albinas" "apellidos" => "Naudžiūnas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "Aušra" "apellidos" => "Burkauskienė" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 5 => array:3 [ "nombre" => "Laima" "apellidos" => "Jankauskienė" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Lithuanian University of Health Sciences, Faculty of Medicine, Kaunas, Lithuania" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Clinic of Internal Diseases, Lithuanian University of Health Sciences, Kaunas, Lithuania" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Institute of Anatomy, Lithuanian University of Health Sciences, Kaunas, Lithuania" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Endocardite infecciosa no VIH – fármaco intravenoso utilizado em doente infetado" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introduction</span><p id="par0085" class="elsevierStylePara elsevierViewall">Despite advances in diagnosis, infective endocarditis (IE) remains a common cause of hospitalization, with high morbidity and mortality rates.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> This may be due to the changing epidemiology of IE, including increasing antimicrobial resistance, more frequent heart surgery and prosthetic valve implantation, and widespread use of intravenous drugs.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">IE was initially recognized to be a complication of intravenous drug use in the 1950s.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> It is a potentially fatal consequence of injecting illicit drugs, such as heroin, cocaine, and methamphetamine. Intravenous drug use increases IE risk through a variety of mechanisms. Drug solutions may contain particulate matter (e.g. talc) that damage cardiac valves if injected intravenously. In addition, poor injection hygiene and injecting contaminated drug solutions can introduce high circulating bacterial loads.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">4</span></a> In intravenous drug users (IDUs), the incidence of IE is 2%–5% and it is responsible for 5%–10% of deaths.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">HIV infection increases the risk of IE. In developed countries HIV infection among IDUs with IE ranges between 30% and 70%.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a> The tricuspid valve (TV) may be more susceptible to heroin use, as heroin can cause an increase in pulmonary arterial pressure, creating more turbulence at the TV.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In this article we describe an exceptional clinical case of an IE patient who was HIV-infected and also injected heroin. We compare the case with data in the literature and analyze the differences, and also review the clinical features of IE among IDUs, nonaddicts, and HIV-infected and uninfected patients.</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Case report</span><p id="par0105" class="elsevierStylePara elsevierViewall">A 28-year-old Lithuanian woman was admitted to our hospital. Her presenting complaints were bodily pain and general weakness. She had been addicted to heroin for 10 years. Her past medical history was significant for anemia and chronic pyelonephritis, leading to stage 2 renal failure, and infection with HIV for seven years. She was an alcohol abuser and a smoker. Physical examination on presentation showed body temperature of 36.8<span class="elsevierStyleHsp" style=""></span>°C, edema in the legs, pale mucous membranes, dry tongue, normal cardiac rhythm and breath sounds, respiratory rate 20/min, heart rate 88 beats/min, and blood pressure 120/80 mmHg. Laboratory tests revealed microscopic hematuria and leukocyturia and C-reactive protein (CRP) 28 mg/l, erythrocyte sedimentation rate (ESR) 45 mm/h, and hemoglobin 59 g/l. Ascites was found in the abdomen. X-ray study showed no abnormalities in the thoracic organs. On day 7 of hospital stay the patient's condition deteriorated. The X-ray showed moderate bilateral hydrothorax, with a slightly sharpened image of the lungs and an interstitial component, local infiltration of the right cardiodiaphragmatic angle, inflammatory lesions around the pleura on the left, and enlarged cardiac diameter in both directions. On day 8 echocardiography was performed, which detected vegetations on the TV and the right atrium. C-reactive protein was elevated (38.00 mg/l). Before the administration of antibiotics <span class="elsevierStyleItalic">Staphylococcus aureus</span> (sensitive to penicillin, oxacillin and erythromycin) was detected in blood culture and <span class="elsevierStyleItalic">Escherichia coli</span> (sensitive to ciprofloxacin and gentamicin) in urine culture. On the following day the patient was given ampicillin and ceftriaxone (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>), by which time her temperature had risen to 38.8<span class="elsevierStyleHsp" style=""></span>°C. After a few days echocardiography was repeated in order to assess changes, and showed decreasing ejection fraction (EF) and increasing pericardial effusion (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>, 11 days of treatment). Antibiotic therapy was changed to ceftriaxone (Oframax) only (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Sepsis, pneumonia, toxic hepatitis and infectious endocarditis were additionally diagnosed. The blood analysis was repeated, showing CRP 30.00 mg/l and white blood cell count 7.4×10<span class="elsevierStyleSup">9</span>/l. The patient's condition continued to deteriorate, with breathlessness and anasarca; an audible grade 3 systolic murmur along the parasternal line and mild congestive rales in both lower lung fields were detected. Secondary myocarditis was diagnosed. Serum CD4+ cell count was 651/mm<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a>, and antiviral therapy for HIV was not initiated. In order to assess the effect of antibiotic therapy, blood and urine cultures were re-evaluated. On day 8 bacteria were not detected in urine culture, but <span class="elsevierStyleItalic">S. epidermidis</span> was detected in blood cultures. Antibiotic therapy was changed to a combination of oxacillin and gentamicin (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). On day 20 the echocardiogram showed significantly decreasing EF (10%) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The ECG showed sinus rhythm and inverted T waves in leads I, aVL, V5, and V6. An elevated D-dimer level (2.25 μg/ml) was detected. Repeat chest X-ray showed progression of pleuritic lesions on the right (hydrothorax), the right lung being almost completely covered with liquid, and the mediastinum displaced to the left, covering the lower left lung field. While still in a critical condition, the patient was given vancomycin (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>), which led to regression of the abnormalities, bacteria being undetectable in blood culture. On day 44 the ECG showed sinus rhythm, and there was reversal of T-wave inversion in leads I, aVL, and V5-V6. On the chest X-ray the hydrothorax had disappeared. After treatment with vancomycin, echocardiography revealed a significant recovery of EF (from 10% to 50%) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>, 48 days of treatment).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">S. aureus</span> is the causative agent in the majority of IE cases in IDUs.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a> It is the most common pathogen in isolated TV endocarditis, accounting for 50%–60% of cases among IDUs. However, in our case, <span class="elsevierStyleItalic">S. aureus</span> affected not only the TV; vegetations also appeared on the aortic valve (AoV). Less common infectious agents include methicillin-resistant <span class="elsevierStyleItalic">S. aureus</span> (MRSA), <span class="elsevierStyleItalic">Streptococcus bovis</span> and other streptococci species, and fungi.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Because material is injected intravenously, the first valves to screen particulate matter would be on the right side of the heart. In the present case the patient was addicted to heroin for 10 years. The question arises: why did the patient only develop infective endocarditis to after so many years? Some authors argue that since cocaine has a shorter half-life than heroin it requires more frequent dosing, increasing the bacterial load and incidence of endocarditis.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a> According to the literature, if infective endocarditis affects the TV, the prognosis is much more favorable than when it damages the MV or AoV. In the present case the TV was the most seriously damaged valve, but vegetations 6–7 mm in length were also observed on the noncoronary and right coronary leaflets of the AoV, leading to complications involving both sides of the heart. A study by Chambers et al. comparing the clinical presentation of IE among intravenous drug addicts and nonaddicts showed that intravenous drug addicts were younger and had less underlying diseases than nonaddicts.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a> In the case presented the patient survived, but according to data in the literature, no other intravenous drug user with so many complications and such a severe condition has survived. There are few clinical studies that analyze the influence of HIV infection in IDUs with IE. Two studies showed that the risk of IE for those infected with HIV is increasing. It is associated with decreased CD4+ cell counts, and among HIV-infected patients with CD4+ cell counts of less than 200 cells/μl or with AIDS criteria, the mortality rate is much higher.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">6,8</span></a> In the present case, despite the patient's diagnosis of HIV infection seven years previously, there was no significant immunosuppression (CD4+ count 651 cells/μl).</p><p id="par0120" class="elsevierStylePara elsevierViewall">Diagnosis of IE is based on the Duke criteria, which are divided into major and minor criteria. A clinical diagnosis of IE requires two major, one major and three minor, or five minor criteria.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a> In the case presented, vegetations and regurgitation were detected on transthoracic echocardiography and blood cultures were positive for a typical organism, <span class="elsevierStyleItalic">S. aureus</span> (two major criteria), and the patient was an intravenous drug user (one minor criterion). Due to the presence of two major Duke criteria, a clinical diagnosis was made of infective endocarditis. The key echocardiographic finding in right-sided endocarditis is that of vegetation(s) in association with the TV or rarely the pulmonary valve. Tricuspid vegetations are often large, in excess of 2 cm.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> In the case presented, transesophageal echocardiography was not performed, since transthoracic echocardiography showed vegetations on the TV and AoV, the largest being 29 mm. Diagnosis of IE takes into consideration such indicators as increased ESR and C-reactive protein, splenic enlargement and microscopic hematuria. In our case, CRP of 38 mg/l, ESR of 45 mm/h and hematuria (800/ml) were detected.</p><p id="par0125" class="elsevierStylePara elsevierViewall">Most patients have a benign presentation and the main concern for treatment will be the choice of appropriate antibiotics. This essentially depends on the likely microorganisms, the valves involved and the types of injected drugs the patient has used. In our case only treatment with vancomycin was effective, after which the patient's condition began to improve rapidly.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusions</span><p id="par0130" class="elsevierStylePara elsevierViewall">A severe and exceptional clinical case was presented. The patient was an intravenous drug user, had IE, was HIV-infected, and had damaged TV and AoV. Heart, respiratory and renal failure were rapidly progressing. Despite additional complications, the patient's condition improved significantly after administration of vancomycin, with a significant recovery of EF (from 10% to 50%). Although the patient was given ceftriaxone, oxacillin and gentamicin, only vancomycin produced a good result. It is important to note that even in a patient with a such severe condition, immunosuppression was not detected (CD4+ count 651 cells/μl). The patient was relatively young, and was therefore more likely to survive.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Protection of human and animal subjects</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Confidentiality of data</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Right to privacy and informed consent</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflict of interest</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres572378" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec589458" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres572377" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec589459" "titulo" => "Palavras-chave" ] 4 => array:3 [ "identificador" => "sec0005" "titulo" => "Introduction" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] ] ] 5 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 7 => array:3 [ "identificador" => "sec0025" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Right to privacy and informed consent" ] ] ] 8 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflict of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-11-27" "fechaAceptado" => "2015-03-08" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec589458" "palabras" => array:4 [ 0 => "Infective endocarditis" 1 => "HIV" 2 => "Intravenous drug use" 3 => "Tricuspid valve" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec589459" "palabras" => array:4 [ 0 => "Endocardite infecciosa" 1 => "VIH" 2 => "Utilização de fármaco intravenoso" 3 => "Válvula tricúspide" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Infective endocarditis is a common complication among injecting drug users. Disease risk among these patients is increased by the spread of HIV infection. In the following article, we discuss the exceptional clinical presentation of a 28-year-old patient who used intravenous drugs (heroin) for 10 years, had been infected with HIV for seven years and as a complication had developed <span class="elsevierStyleItalic">Staphylococcus aureus</span> infective endocarditis.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The patient came to the hospital in serious condition, complaining of bodily pain, swelling of the legs and general weakness. During hospitalization, besides infective endocarditis, she was also diagnosed with anemia, toxic hepatitis, renal failure, ascites, sepsis, and pneumonia. A completely disrupted tricuspid valve, damaged aortic valve, and fibrosis of the mitral valve were detected. Echocardiographic and radiologic data showed that the patient's condition continued to deteriorate day by day, with significant progression of heart failure, ejection fraction decreasing from 45% to 10%, and development of myocarditis, hydrothorax and pericarditis. However, this progressive worsening of the patient's condition ceased when vancomycin was administered. To the authors’ knowledge, this is the first such case described in the literature in which significant improvement was observed despite the patient's complex condition with associated complications.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A endocardite infecciosa é uma complicação comum entre os consumidores de drogas injetáveis. O risco desta doença nestes pacientes aumenta com a propagação da infeção do VIH. Neste artigo, discute-se a apresentação clínica de uma jovem doente que consumiu drogas intravenosas (heroína) durante dez anos e que há sete anos que está infetada pelo VIH. Para além disso, desenvolveu endocardite infecciosa causada por <span class="elsevierStyleItalic">Staphylococcus aureus</span>. De 28 anos de idade apresentou-se no hospital em estado grave, queixando-se de dores no corpo, pernas inchadas e de um estado geral de fraqueza.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Durante o internamento, para além da endocardite infecciosa, foi-lhe também diagnosticado – anemia, hepatite tóxica, insuficiência renal, ascite, sepsis e pneumonia. Foram também detetadas interrupção total da válvula tricúspide, válvula aórtica danificada e fibrose da válvula mitral. De acordo com a avaliação ecocardiográfica e dados radiológicos, a situação da doente continuou a deteriorar-se: a insuficiência cardíaca progrediu significativamente, a fração de ejeção diminuiu de 45% para 10% e desenvolveram-se miocardite, hidrotórax e pericardite. No entanto, apesar da situação grave da doente progredir de modo contínuo, houve uma melhoria assim que lhe foi administrada vancomicina. De acordo com os autores, este será o primeiro caso clínico descrito na literatura que revelou uma melhoria significativa apesar da situação complexa da doente com demais complicações.</p></span>" ] ] "nomenclatura" => array:1 [ 0 => array:3 [ "identificador" => "nom0005" "titulo" => "<span class="elsevierStyleSectionTitle" id="sect0025">List of abbreviations</span>" "listaDefinicion" => array:1 [ 0 => array:1 [ "definicion" => array:16 [ 0 => array:2 [ "termino" => "AoV" "descripcion" => "<p id="par0005" class="elsevierStylePara elsevierViewall">aortic valve</p>" ] 1 => array:2 [ "termino" => "CHF" "descripcion" => "<p id="par0010" class="elsevierStylePara elsevierViewall">congestive heart failure</p>" ] 2 => array:2 [ "termino" => "CRP" "descripcion" => "<p id="par0015" class="elsevierStylePara elsevierViewall">C-reactive protein</p>" ] 3 => array:2 [ "termino" => "EF" "descripcion" => "<p id="par0020" class="elsevierStylePara elsevierViewall">ejection fraction</p>" ] 4 => array:2 [ "termino" => "ESR" "descripcion" => "<p id="par0025" class="elsevierStylePara elsevierViewall">erythrocyte sedimentation rate</p>" ] 5 => array:2 [ "termino" => "HF" "descripcion" => "<p id="par0030" class="elsevierStylePara elsevierViewall">heart failure</p>" ] 6 => array:2 [ "termino" => "ICU" "descripcion" => "<p id="par0035" class="elsevierStylePara elsevierViewall">intensive care unit</p>" ] 7 => array:2 [ "termino" => "IDUs" "descripcion" => "<p id="par0040" class="elsevierStylePara elsevierViewall">intravenous drug users</p>" ] 8 => array:2 [ "termino" => "IE" "descripcion" => "<p id="par0045" class="elsevierStylePara elsevierViewall">infective endocarditis</p>" ] 9 => array:2 [ "termino" => "LV" "descripcion" => "<p id="par0050" class="elsevierStylePara elsevierViewall">left ventricle/left ventricular</p>" ] 10 => array:2 [ "termino" => "MRSA" "descripcion" => "<p id="par0055" class="elsevierStylePara elsevierViewall">methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span></p>" ] 11 => array:2 [ "termino" => "MV" "descripcion" => "<p id="par0060" class="elsevierStylePara elsevierViewall">mitral valve</p>" ] 12 => array:2 [ "termino" => "RBC" "descripcion" => "<p id="par0065" class="elsevierStylePara elsevierViewall">red blood cells</p>" ] 13 => array:2 [ "termino" => "RC" "descripcion" => "<p id="par0070" class="elsevierStylePara elsevierViewall">right coronary</p>" ] 14 => array:2 [ "termino" => "RV" "descripcion" => "<p id="par0075" class="elsevierStylePara elsevierViewall">right ventricle/right ventricular</p>" ] 15 => array:2 [ "termino" => "TV" "descripcion" => "<p id="par0080" class="elsevierStylePara elsevierViewall">tricuspid valve</p>" ] ] ] ] ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">AoV: aortic valve; EF: ejection fraction; IS: interventricular septum; LV: left ventricle/left ventricular; LVESD: left ventricular end-systolic diameter; LVPW: left ventricular posterior wall; MMI: myocardial mass index; MV: mitral valve; PV: pulmonary valve; RA: right atrial; RC: right coronary; RV: right ventricle/right ventricular; TV: tricuspid valve.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Before antibiotic therapy(day 8) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">After treatment with ampicillin + ceftriaxone (day 11)</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">After treatment with oxacillin + gentamicin(day 20) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">After treatment with vancomycin(day 48) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">EF 27% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">EF 45% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">EF 20% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">EF 10% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">EF 50% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vegetations on TV and right atrium \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Large florid vegetations on TV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Vegetations on TV leaflets (largest 29 mm), vegetations on AoV and RC leaflet (up to 6-7 mm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Vegetations on AoV and MV not visible \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Regurgitation: grade 3–4 TV, grade 1 MV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade 4 TV regurgitation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Regurgitation: grade 2 PV, grade 1 MV, grade 4 TV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pericardial effusion: 12.6 mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pericardial effusion: 16 mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pericardial effusion: 12–14 mm (no tamponade) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pericardial effusion: 5 mm \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Grade 4 TV leakage \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade 4 TV leakage \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade 4 TV leakage, grade 1 AoV leakage, grade 1 MV leakage \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ascending aorta:28 mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ascending aorta:22 mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Significant RV and RA volume overload, RV dilatation, dyskinetic IS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">LV concentric hypertrophy, dilatation of right heart chambers dominant; LVESD: 35 mm; IS: 15 mm; LVPW: 14 mm; MMI: 132 g/m<span class="elsevierStyleSup">2</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">LV non-dilated, poor systolic function; RV poor systolic function; MV leaflets fibrosed; LVESD: 39 mm, IS: 9 mm, LVPW: 11 mm, MMI: 69 g/m<span class="elsevierStyleSup">2</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Recovery of LV systolic function \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab934118.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Evolution of echocardiographic changes according to antibiotic therapy.</p>" ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">iv: intravenous.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Combination of antibiotics \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Daily dosage \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Duration (days) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total dose (g) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ampicillin, ceftriaxone iv on days 9-11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.0 g×41.0 g×2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">246 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ceftriaxone iv only on days 12–17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.0 g×2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Oxacillin iv; gentamicin iv on days 18–20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.0 g×40.160 g×1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">240.48 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vancomycin iv on days 21–48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 g×2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">27 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">54 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab934119.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Details of antimicrobial treatment.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0060" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Infective endocarditis in intravenous drug abusers: an update" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "C. Sousa" 1 => "C. Botelho" 2 => "D. Rodrigues" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Eur J Clin Microbiol Infect Dis" "fecha" => "2012" "volumen" => "9" "paginaInicial" => "2905" "paginaFinal" => "2910" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0065" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Treatment strategies for infective endocarditis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "T. Chopra" 1 => "G.W. 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| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 6 | 6 | 12 |
| 2024 Outubro | 54 | 25 | 79 |
| 2024 Setembro | 71 | 25 | 96 |
| 2024 Agosto | 57 | 30 | 87 |
| 2024 Julho | 49 | 28 | 77 |
| 2024 Junho | 46 | 19 | 65 |
| 2024 Maio | 53 | 25 | 78 |
| 2024 Abril | 35 | 32 | 67 |
| 2024 Maro | 48 | 23 | 71 |
| 2024 Fevereiro | 69 | 29 | 98 |
| 2024 Janeiro | 36 | 33 | 69 |
| 2023 Dezembro | 57 | 25 | 82 |
| 2023 Novembro | 35 | 21 | 56 |
| 2023 Outubro | 36 | 15 | 51 |
| 2023 Setembro | 42 | 19 | 61 |
| 2023 Agosto | 37 | 16 | 53 |
| 2023 Julho | 28 | 10 | 38 |
| 2023 Junho | 44 | 10 | 54 |
| 2023 Maio | 45 | 26 | 71 |
| 2023 Abril | 37 | 5 | 42 |
| 2023 Maro | 50 | 28 | 78 |
| 2023 Fevereiro | 49 | 28 | 77 |
| 2023 Janeiro | 25 | 10 | 35 |
| 2022 Dezembro | 33 | 22 | 55 |
| 2022 Novembro | 46 | 27 | 73 |
| 2022 Outubro | 42 | 18 | 60 |
| 2022 Setembro | 35 | 20 | 55 |
| 2022 Agosto | 43 | 37 | 80 |
| 2022 Julho | 52 | 28 | 80 |
| 2022 Junho | 30 | 18 | 48 |
| 2022 Maio | 46 | 31 | 77 |
| 2022 Abril | 48 | 20 | 68 |
| 2022 Maro | 43 | 24 | 67 |
| 2022 Fevereiro | 48 | 17 | 65 |
| 2022 Janeiro | 46 | 17 | 63 |
| 2021 Dezembro | 36 | 28 | 64 |
| 2021 Novembro | 44 | 41 | 85 |
| 2021 Outubro | 66 | 39 | 105 |
| 2021 Setembro | 34 | 26 | 60 |
| 2021 Agosto | 43 | 22 | 65 |
| 2021 Julho | 42 | 24 | 66 |
| 2021 Junho | 47 | 24 | 71 |
| 2021 Maio | 50 | 20 | 70 |
| 2021 Abril | 96 | 32 | 128 |
| 2021 Maro | 81 | 14 | 95 |
| 2021 Fevereiro | 83 | 15 | 98 |
| 2021 Janeiro | 62 | 12 | 74 |
| 2020 Dezembro | 48 | 14 | 62 |
| 2020 Novembro | 82 | 29 | 111 |
| 2020 Outubro | 82 | 17 | 99 |
| 2020 Setembro | 68 | 18 | 86 |
| 2020 Agosto | 39 | 14 | 53 |
| 2020 Julho | 70 | 13 | 83 |
| 2020 Junho | 56 | 10 | 66 |
| 2020 Maio | 57 | 9 | 66 |
| 2020 Abril | 58 | 14 | 72 |
| 2020 Maro | 72 | 24 | 96 |
| 2020 Fevereiro | 121 | 25 | 146 |
| 2020 Janeiro | 53 | 6 | 59 |
| 2019 Dezembro | 52 | 8 | 60 |
| 2019 Novembro | 44 | 6 | 50 |
| 2019 Outubro | 54 | 9 | 63 |
| 2019 Setembro | 12 | 13 | 25 |
| 2019 Agosto | 40 | 9 | 49 |
| 2019 Julho | 44 | 11 | 55 |
| 2019 Junho | 37 | 10 | 47 |
| 2019 Maio | 37 | 11 | 48 |
| 2019 Abril | 22 | 12 | 34 |
| 2019 Maro | 62 | 8 | 70 |
| 2019 Fevereiro | 49 | 15 | 64 |
| 2019 Janeiro | 42 | 7 | 49 |
| 2018 Dezembro | 59 | 14 | 73 |
| 2018 Novembro | 122 | 7 | 129 |
| 2018 Outubro | 238 | 17 | 255 |
| 2018 Setembro | 77 | 13 | 90 |
| 2018 Agosto | 40 | 11 | 51 |
| 2018 Julho | 41 | 6 | 47 |
| 2018 Junho | 67 | 7 | 74 |
| 2018 Maio | 100 | 33 | 133 |
| 2018 Abril | 143 | 1 | 144 |
| 2018 Maro | 121 | 11 | 132 |
| 2018 Fevereiro | 66 | 5 | 71 |
| 2018 Janeiro | 92 | 6 | 98 |
| 2017 Dezembro | 123 | 16 | 139 |
| 2017 Novembro | 56 | 7 | 63 |
| 2017 Outubro | 27 | 12 | 39 |
| 2017 Setembro | 37 | 13 | 50 |
| 2017 Agosto | 41 | 14 | 55 |
| 2017 Julho | 17 | 11 | 28 |
| 2017 Junho | 27 | 13 | 40 |
| 2017 Maio | 31 | 7 | 38 |
| 2017 Abril | 22 | 4 | 26 |
| 2017 Maro | 27 | 2 | 29 |
| 2017 Fevereiro | 27 | 10 | 37 |
| 2017 Janeiro | 20 | 11 | 31 |
| 2016 Dezembro | 25 | 3 | 28 |
| 2016 Novembro | 23 | 8 | 31 |
| 2016 Outubro | 20 | 5 | 25 |
| 2016 Setembro | 15 | 10 | 25 |
| 2016 Agosto | 17 | 1 | 18 |
| 2016 Julho | 3 | 3 | 6 |
| 2016 Junho | 15 | 15 | 30 |
| 2016 Maio | 6 | 0 | 6 |
| 2016 Abril | 17 | 3 | 20 |
| 2016 Maro | 24 | 14 | 38 |
| 2016 Fevereiro | 51 | 29 | 80 |
| 2016 Janeiro | 37 | 19 | 56 |
| 2015 Dezembro | 31 | 14 | 45 |
| 2015 Novembro | 91 | 43 | 134 |
| 2015 Outubro | 73 | 54 | 127 |
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