Cardiol Res

Cardiology Research, ISSN 1923-2829 print, 1923-2837 online, Open Access

Article copyright, the authors; Journal compilation copyright, Cardiol Res and Elmer Press Inc

Journal website https://www.cardiologyres.org

Case Report

Volume 8, Number 5, October 2017, pages 236-240

A Case of Early Prosthetic Valve Endocarditis Caused by Staphylococcus warneri in a Patient Presenting With Congestive Heart Failure

Figure 1. The 12-lead electrocardiogram showing atrial fibrillation with rapid ventricular response and heart rate of 131 beats per minute.

Figure 2. Portable chest X-ray on admission, with opacification of the left lung base (pleural effusion vs. consolidation), scattered density in the right lung base, and pulmonary venous congestion.

Figure 3. Transesophageal echocardiogram showed severe intravalvular aortic regurgitation (thin arrow) due to an avulsed and prolapsed non-coronary aortic cusp seen here prolapsing into the aortic annulus during systole with the regurgitant jet of intravalvular aortic regurgitation. LA: left atrium. LVOT: left ventricular outflow tract. AVR: aortic valve replacement.

Figure 4. Transesophageal echocardiogram showed an avulsed and prolapsed non-coronary aortic cusp (thin arrow) seen here prolapsing into the LVOT during diastole with the severe intravalvular aortic regurgitation jet. LA: left atrium. LVOT: left ventricular outflow tract. AVR: aortic valve replacement.

**Table 1.** Laboratory Values on Hospital Admission
Complete blood count
White blood cells	5,500/mm³. Differential: neutrophils 51.9%, lymphocytes 26.7%, monocytes 13.3%, eosinophils 7.1%, basophils 1%.
Hemoglobin	11.3 g/dL
Hematocrit	34.5%
Platelets	221,000/mm³
Coagulation profile
Prothrombin time (PT)	14.2 s
Partial thromboplastin time (PTT)	26.3 s
International normalized ratio (INR)	1.11
Comprehensive metabolic panel
Sodium	141 mmol/L
Potassium	3.4 mmol/L
Chloride	106 mmol/L
Bicarbonate	26 mmol/L
Blood urea nitrogen	16 mg/dL
Creatinine	1.06 mg/dL
Glucose	101 mg/dL
Albumin	3.5 g/dL
Total protein	6.1 g/dL
Alkaline phosphatase	82 U/L
Alanine amino transferase (ALT)	12 U/L
Aspartate amino transferase (AST)	18 U/L
Total bilirubin	0.7 mg/dL
Direct bilirubin	0.1 mg/dL
Troponin	0.058 mg/mL (reference ranges: normal ≤ 0.028; acute myocardial infarction ≥ 0.3)

Table 1. Laboratory Values on Hospital Admission

Complete blood count

White blood cells

5,500/mm³. Differential: neutrophils 51.9%, lymphocytes 26.7%, monocytes 13.3%, eosinophils 7.1%, basophils 1%.

Hemoglobin

11.3 g/dL

Hematocrit

34.5%

Platelets

221,000/mm³

Coagulation profile

Prothrombin time (PT)

14.2 s

Partial thromboplastin time (PTT)

26.3 s

International normalized ratio (INR)

1.11

Comprehensive metabolic panel

Sodium

141 mmol/L

Potassium

3.4 mmol/L

Chloride

106 mmol/L

Bicarbonate

26 mmol/L

Blood urea nitrogen

16 mg/dL

Creatinine

1.06 mg/dL

Glucose

101 mg/dL

Albumin

3.5 g/dL

Total protein

6.1 g/dL

Alkaline phosphatase

82 U/L

Alanine amino transferase (ALT)

12 U/L

Aspartate amino transferase (AST)

18 U/L

Total bilirubin

0.7 mg/dL

Direct bilirubin

0.1 mg/dL

Troponin

0.058 mg/mL (reference ranges: normal ≤ 0.028; acute myocardial infarction ≥ 0.3)

**Table 2.** Review of Previously Published Cases of *Staphylococcus warneri* Endocarditis
Reference	Presenting signs and symptoms	Valve(s) involved (native vs. prosthetic valve)	Presence of vegetation and/or intracardiac abscess on echo or surgical examination
Dan et al (1984) [1]	32-year-old male with fatigue, anorexia, CP, fever, tachycardia, new diastolic murmur and systolic crescendo-decrescendo murmur	Aortic (native valve)	Vegetation present
Wood et al (1989) [2]	66-year-old male with worsening low back pain, became febrile, XR with vertebral disc prosthesis, disk space narrowing, and end plate destruction of L2-3	Aortic and Mitral (native valves)	Vegetations on both valves and aortic valve ring abscess
Kamath et al (1992) [3]	64-year-old male with fevers, subconjunctival hemorrhage, slinter hemorrhages, systolic murmur, and diastolic murmur	Mitral, aortic, and pulmonary valves	Vegetations on all 3 valves
Abgrall et al (2001) [8]	71-year-old male s/p aortic valve replacement 5 days prior, afebrile, no leukocytosis. Blood cultures negative; culture of vegetation tags with S. warneri	Aortic (prosthetic valve)	Vegetation present with suspected aortic valve ring abscess
Stollberger et al (2006) [4]	48-year-old male s/p L4-5 disk prosthesis implantation, with recurrent fevers, night sweats every 3 - 4 months	Aortic (native)	Vegetation present
Kini et al (2010) [5]	78-year-old female with cough, pleural effusions, and bilateral lower extremity edema with clear serous discharge	Mitral (native valve)	Vegetation present
Arslan et al (2011) [6]	43-year-old female with aortic valve replacement 3 years prior with recent prosthetic valve endocarditis due to S. warneri 3 months prior, presented with 20 days of fevers, night sweats	Aortic valve (prosthetic valve)	Vegetation present
Bhardwaj et al (2016) [7]	59-year-old male with history of scalp laceration 2 weeks prior presenting with 3 days of lethargy, abdominal pain, acute kidney injury, and hypotensive, pansystolic murmur	Mitral (native valve)	Vegetations present (two in total)
Current case (2017)	67-year-old male with valve replacement 7 months prior, presenting with chest pain, constitutional symptoms, no documented fever	Aortic (prosthetic valve)	No vegetations or Aortic valve ring abscess

Table 2. Review of Previously Published Cases of Staphylococcus warneri Endocarditis

Reference

Presenting signs and symptoms

Valve(s) involved (native vs. prosthetic valve)

Presence of vegetation and/or intracardiac abscess on echo or surgical examination

Dan et al (1984) [1]

32-year-old male with fatigue, anorexia, CP, fever, tachycardia, new diastolic murmur and systolic crescendo-decrescendo murmur

Aortic (native valve)

Vegetation present

Wood et al (1989) [2]

66-year-old male with worsening low back pain, became febrile, XR with vertebral disc prosthesis, disk space narrowing, and end plate destruction of L2-3

Aortic and Mitral
(native valves)

Vegetations on both valves and aortic valve ring abscess

Kamath et al (1992) [3]

64-year-old male with fevers, subconjunctival hemorrhage, slinter hemorrhages, systolic murmur, and diastolic murmur

Mitral, aortic, and pulmonary valves

Vegetations on all 3 valves

Abgrall et al (2001) [8]

71-year-old male s/p aortic valve replacement 5 days prior, afebrile, no leukocytosis. Blood cultures negative; culture of vegetation tags with S. warneri

Aortic (prosthetic valve)

Vegetation present with suspected aortic valve ring abscess

Stollberger et al (2006) [4]

48-year-old male s/p L4-5 disk prosthesis implantation, with recurrent fevers, night sweats every 3 - 4 months

Aortic (native)

Vegetation present

Kini et al (2010) [5]

78-year-old female with cough, pleural effusions, and bilateral lower extremity edema with clear serous discharge

Mitral (native valve)

Vegetation present

Arslan et al (2011) [6]

43-year-old female with aortic valve replacement 3 years prior with recent prosthetic valve endocarditis due to S. warneri 3 months prior, presented with 20 days of fevers, night sweats

Aortic valve (prosthetic valve)

Vegetation present

Bhardwaj et al (2016) [7]

59-year-old male with history of scalp laceration 2 weeks prior presenting with 3 days of lethargy, abdominal pain, acute kidney injury, and hypotensive, pansystolic murmur

Mitral (native valve)

Vegetations present (two in total)

Current case (2017)

67-year-old male with valve replacement 7 months prior, presenting with chest pain, constitutional symptoms, no documented fever

Aortic (prosthetic valve)

No vegetations or Aortic valve ring abscess