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  • Case report
  • Open Access
  • Open Peer Review

Lactococcus garvieae, an unusual pathogen in infective endocarditis: case report and review of the literature

  • 1,
  • 2,
  • 3,
  • 1 and
  • 1, 4, 5, 6, 7Email author
Contributed equally
BMC Infectious Diseases201919:301

https://doi.org/10.1186/s12879-019-3912-8

  • Received: 23 November 2018
  • Accepted: 17 March 2019
  • Published:
Open Peer Review reports

Abstract

Background

Lactococcus garvieae is an unusual cause of infective endocarditis (IE). No current diagnostic and therapeutic guidelines are available to treat IE caused by these organisms. Based on a case report, we provide a review of the literature of IE caused by L. garvieae and highlight diagnostic and treatment challenges of these infections and implications for management.

Case presentation

A 50-year-old Asian male with mitral prosthetic valve presented to the hospital with intracranial haemorrhage, which was successfully treated. Three weeks later, he complained of generalized malaise. Further work up revealed blood cultures positive for Gram-positive cocci identified as L. garvieae by MALDI-TOF. An echocardiogram confirmed the diagnosis of IE. Susceptibility testing showed resistance only to clindamycin. Vancomycin plus gentamicin were started as empirical therapy and, subsequently, the combination of ceftriaxone plus gentamicin was used after susceptibility studies were available. After two weeks of combination therapy, ceftriaxone was continued as monotherapy for six additional weeks with good outcome.

Conclusions

Twenty-five cases of IE by Lactococcus garvieae have been reported in the literature. Compared to other Gram-positive cocci, L. garvieae affects more frequently patients with prosthetic valves. IE presents in a subacute manner and the case fatality rate can be as high as 16%, comparable to that of streptococcal IE (15.7%). Reliable methods for identification of L. garvieae include MALDI-TOF, 16S RNA PCR, API 32 strep kit and BD Automated Phoenix System. Recommended antimicrobials for L. garvieae IE are ampicillin, amoxicillin, ceftriaxone or vancomycin in monotherapy or in combination with gentamicin.

Keywords

  • Lactococcus
  • Case report
  • Gram positive cocci
  • Infective endocarditis
  • Diagnosis
  • Treatment
  • Risk factors

Background

Lactococcus garvieae are Gram-positive cocci previously considered part of the genus Streptococcus. In 1985, these organisms were classified within the genus lactococci due to DNA-DNA hybridization studies and fatty acid profiles [13]. Currently, the genus Lactococcus contains 11 species [4]. L. garvieae is associated with fish infections in warm water causing outbreaks of haemorrhagic sepsis in rainbow trout [2, 5]. These organisms have also been isolated from raw cow milk, goat cheese, fish, beef meat, poultry and pork meat [6]. Human infections caused by L. garvieae have been reported in different countries and have been associated to ingestion of raw seafood. Indeed, a study by Wang et al. found that among four patients with invasive L. garvieae infection, three had ingested sea food contaminated by these organisms [7]. Infective endocarditis (IE) is a known disease caused by L. garvieae, however, the true incidence of disease is difficult to assess since misidentification with other Gram-positive cocci like Enterococcus spp. and streptococci (employing different automatized diagnostic tools) has commonly been reported [8, 9]. Here, we report a case of L. garvieae IE and describe the risk factors associated with this disease, the diagnostic challenges to identify these organisms and therapeutic approaches used to treat these infections. We seek to provide clinicians with relevant and updated information on the diagnosis and management of IE caused by the genus L. garvieae.

We searched MEDLINE, EMBASE and LILACS using the following MeSH, major and free terms: “endocarditis”, “endocarditis, bacterial”, “endocarditis, subacute bacterial”, “endocarditis bacteriana”, “endocarditis bacteriana subaguda” and “lactococo”, “lactococcus”, “lactococcus lactis”, “lactococcus garvieae”, “lactococcus garvieae endocarditis”. We selected all the articles in Spanish, English and French published before March 2018 that included case reports of endocarditis and Lactococcus in the titles.

Case presentation

A 50-year-old Asian man with history of rheumatic heart disease (without hypertension) and mechanical prosthetic mitral valve replacement 5 years before admission, dyslipidaemia and reflux esophagitis presented to the emergency room with severe bilateral occipital headache. He was diagnosed with an intracranial haemorrhage confirmed by CT brain. At the time of admission, his INR was within therapeutic range (2.35). After initial work up, the patient was hospitalized for 10 days and discharged without any residual neurologic sequelae. Atorvastatin was prescribed. No fever or elevation of the C reactive protein (CRP) or erythrocyte sedimentation rate (ESR) were identified during the admission. He worked as an accountant and had been living in the US for the past 30 years with no recent travel outside the US. Three weeks later, he complained of flu-like symptoms and oseltamivir was prescribed. A week later, the patient returned to the hospital with epistaxis, haematuria, and malaise without fever. Physical examination was unremarkable with normal neurologic exam, except for a pansystolic heart murmur. Blood tests showed elevated white blood count (14.5 × 109/L) and serum creatinine of 1.54 mg/dl (Normal value: 0.8–1.2 mg/dl). CRP and ESR were also elevated (34.5 mg/dl and 75 mm/h, respectively). A Chest X ray was found without acute abnormalities and the urine analysis showed no abnormalities. Three days after admission, blood cultures were positive for Gram-positive cocci in chains in 4 out of 4 bottles. Transthoracic echocardiography was inconclusive, but a transoesophageal echocardiography (TEE) revealed a 0.8 cm vegetation on the ventricular side of the native aortic valve without valve dysfunction, confirming the diagnosis of IE. Empirical intravenous antibiotic therapy was started with vancomycin 30 mg/kg/day in divided doses and gentamicin 3 mg/kg/day. The organism was recovered on blood agar and was identified by MALDI-TOF as Lactococcus garvieae. Susceptibility testing showed resistance to clindamycin, whereas it was susceptible to penicillin (MIC 0.25 μg/ml), ceftriaxone (MIC 0.25 μg/ml), vancomycin (MIC 1.5 μg/ml) and levofloxacin (MIC 2 μg/ml). With these results, vancomycin was switched to ceftriaxone 2 g IV twice daily plus gentamicin as combination therapy for the first 2 weeks. This regimen was chosen based on previous cases since no specific guidelines exist on how to treat these organisms. Gentamicin was stopped after two weeks and ceftriaxone was continued for 4 additional weeks pending a surgical decision. In the setting of intracranial bleed and IE, rupture of a mycotic aneurysm was highly suspected and the patient was considered a possible surgical candidate for aortic valve replacement. CT angiography of the brain (5 weeks after the initial episode of intracranial bleed) showed encephalomalacia in the left parietal and occipital lobes with subacute to chronic haemorrhage, with no mycotic aneurysms. After several discussions, the stroke team agreed on resuming anticoagulation with heparin IV drip (considering that the patient had a “chronic” bleed without active haemorrhage and that the risk of embolism was high due to the presence of a mechanical heart valve and IE). It was also suggested postponing aortic valve replacement for at least 4 weeks after effective antimicrobial therapy. After 4 weeks of therapy, decrease of inflammatory markers (CRP to 8.5 mg/dl and ESR to 40 mm/h) was observed and repeat blood cultures were negative.

Upon further questioning, the patient admitted that his diet was rich in grilled fish. Additionally, he reported a long history of chronic epigastric pain for 5 years, for which he had been taking over the counter medicines. An esophagogastroduodenoscopy showed severe gastritis and reflux esophagitis. After 6 weeks of treatment for IE, the patient had clinical improvement with no recurrence of infection but repeat TEE revealed severe aortic valve insufficiency. He underwent mechanical aortic valve replacement without complications and cultures from the excised valve were sterile.

Discussion and conclusion

Different clinical presentations of subacute IE make it challenging to make an early diagnosis of infection and can cause delays in appropriate treatment. In our case, treatment of IE was delayed due to low suspicion of the disease at presentation and the occurrence of the intracranial haemorrhage. Importantly, collection of blood cultures as soon as infection was suspected, led to isolation of L. garvieae and identification using MALDI-TOF.

A total of 25 cases of IE caused by L. garvieae were identified in the literature review [830]. Among the 25 cases of IE caused by L. garvieae (Table 1), 58% were reported in men and the median age of presentation was 68 years. Median duration of symptoms before consulting was 14 days (IQR = 6.2–21). The most common reported symptoms were fever (68%) and chills (28%). Presence of heart murmurs was the most common finding in the physical examination (72%). Laboratory tests usually showed leucocytosis, elevated CRP and ESR. Echocardiogram was reported in 24 out of 25 cases and vegetations were identified in 83.3%. The mitral valve was the most frequently involved valve. Colonoscopy was performed in 5 cases, all of which reported colonic polyps. The median duration of antimicrobial therapy was 42 days (IQR 41–45.5).
Table 1

Clinical, microbiological and management characteristics of IE by L. garvieae

Reference

Country

Age

Sex

Associated factors for IE by L. garvieae and comorbidities

Symptoms and duration (days)

Physical examination

Laboratories and Echocardiography (Vegetation size)

Identification

Susceptibility

Therapy and days of treatment

Complications and Outcome

Clavero et al. 2017

Chile

72

F

AV fistulas, Diverticulosis, CKD, DM 2 and HTN, colonic polyps

Chills, fever (1)

Fever, systolic murmur, pulmonary crackles

TEE: mitral vegetation (4 mm) Labs: Leucocytosis elevated CRP Colonoscopy: Colonic polyps

LG: Vitek 2¥, MS and 16S rRNA PCR.

MIC: VAN: 2 μg/ml, CTX 0.25 µg/ml PEN: 0.5 µg/ml. Kirby Bauer: Sensitive: ERY, CIP, SXT, AMC Resistant: CLI. Applying the criteria for B-haemolytic streptococci

Empiric: CLO + AMK Directed: VAN + GEN µg (NI)

Shock, respiratory failure (Died)

Lim and Jenkins 2017

UK

57

M

Cooked fish, gallstones, renal stones, Colonic polyps

Fever weight loss (60)

Pansystolic murmur

TEE: mitral valve vegetation (NI) and regurgitation. Colonoscopy: Duodenal polyps

LG: MS

PEN MIC: 1 mg/L

Etest BioMérieux, S: GEN 200 µg Oxoid by diffusion disc testing.

AMX + GEN (42d) Valve replacement

No complications, (Alive)

Landeloos et al. 2017

Belgium

82

F

Prosthetic mitral valve, previous endocarditis, Cooked fish, colonic polyps, FA, HTN, Osteoporosis.

Fever, hyporexia, dyspnoea (14)

Bradycardia, Basal lung crepitations, reinforce caused S2

TEE: mitral vegetation (10x5mm) Labs: Elevated CRP no leucocytosis. Colonoscopy: Colonic polyps.

LG: MS, 16S rRNA PCR.

NI

Empiric: CRO Directed: MXF Changed: PEN + GEN Ambulatory: AMX monotherapy (42d) No valve replacement

No complications (Alive)

Bazemore et al. 2016

USA

45

M

Multiple substance abuse. Repair of aortic root aneurysm, Hepatitis C and cirrhosis

Malaise, weakness (60)

Fever, systolic murmur

No Echo reported.

Leucocytosis, Elevated CRP and ESR.

LG: MS

E-test: sensitive to CRO and VAN Cut-off values for S. bovis

Empiric: TZP + VAN

Directed: CRO + GEN (NI) + Valve repair

Aortic valve dehiscence (Alive)

Suh et al. 2016

South Korea

75

F

Mitral valve prosthesis, eats sea fresh food.

Dyspnoea (3)

Holosystolic murmur

TTE: mitral vegetation (16 mm) Labs: leucocytosis, Elevated CRP

LG: Vitek 2¥, 16S rRNA PCR.

MicroScan MICroSTREP plus panel: PEN 0.12 µg/ml, AMC: 0.5/0.25 µg/ml, CRO 0.25 µg/ml, CTX 0.25 µg/ml, MEM 0.06 µg/ml, VAN 1 µg/ml, LVX 1 µg/ml, CLI > 0.5 mcg/ml (only R to CLI). E test (bioMérieux, Marcy lEtoile, France)

PEN 0.75 mg/L, CRO 0.38 mg/L,

TEC 0.125 mg/L. Susceptibility CLSI for viridans streptococci.

Empiric: CRO + GEN + RIF Directed: TEC

Changed: CRO monotherapy (40d)

Aortic and mitral replacement

Heart failure (Alive)

Heras Cañas et al. 2015

Spain

68

M

Prosthetic aortic valve, HTN, dyslipidaemia, Hodgkin lymphoma in remission, AV block.

Fever, Dyspnoea (10)

NI

TTE: mitral vegetations (NI).

Laboratories: Leucocytosis, elevate CRP.

LG: MS and 16S rRNA PCR

Streptococci breakpoints:

S: CTX: 0.38 µg/ml, ERY: 0.25 mg/dl, VAN 1 µg/ml, LVX 1.5 µg/ml, VAN, AMP, CTX, OXA.

I: PEN-I MIC 0.75 µg/ml,

R: CLI 1 µg/ml.

Empiric: DAP + AMP + CRO Directed: DAP+AMP + CRO + GEN (NI) + Valve replacement

AKI, Aortic valve dehiscence (Alive)

Igneri et al. 2015

USA

83

M

Prosthetic aortic valve, Recent dental intervention, CHF, CLL, Prostate cancer, Coarctation of aorta, CABG

Malaise, fever, vomit, headache, cough, myalgia, diaphoresis (7)

NI

TTE: Could not exclude vegetations,

Labs: Leucocytosis, Elevated CRP

NI

NI

Empiric: AMP + GEN

Directed: CTX + GEN (42d)

Valve surgery

No complication, (Alive)

Ortiz et al. 2014

Spain

70

F

No risk factors or comorbidities

Dyspnoea (NI)

Holosystolic murmur, fever

TTE: mitral vegetation (NI) Labs: Leucocytosis and elevated CRP

NI

S: CTX, CIP, ERY, DAP, VAN.

Empiric: AMC + GEN Directed: VAN monotherapy (42d)

valve surgery

No complications (Alive)

 

Spain

77

F

Colorectal cancer, HTN, CLL

Back pain, fever (2)

Purpuric lesions in extremities, fever

TEE: mitral and aortic vegetation (NI) Labs: NI

NI

S: PEN, AMC, CIP, VAN.

AMP + GEN (NI)

No valve surgery

AKI, Heart failure (Died)

Tsur et al. 2014

Israel

76

M

Raw fish, Prosthetic aortic valve, CHF, AF, DM 2, HTN, Oesophageal carcinoma.

Constipation, fever (NI)

Fever, Tachycardia, Systolic murmur.

TEE: Vegetation biologic prosthetic valve (NI)

Labs: Leucocytosis

Lactococcus: API 32 strep kita, 16S rRNA PCR

S: CRO and GEN.

I: PEN

R: CLI

Empiric: CRO

Directed: CRO+ GEN (NI)

No valve replacement

No complications (Alive)

Rasmussen et al. 2014

Sweden

81

M

Prosthetic aortic valve, rectal diverticulosis, CAD, CABG, AF

Malaise, headache, dysphasia (NI)

Fever, systolic murmur.

TEE: vegetations mitral valve and prosthetic valve (NI)

Labs: Elevated CRP

LG: Vitek 2¥, 16S rRNA PCR

PEN: 0.5 mg/L, TOB: 2 mg/L.

PEN + TOB (28d)

No valve replacement

Subdural hematoma (Alive)

Navas et al. 2013

USA

64

M

Previous mitral valve repair, Dental intervention, CAD, Cardiac defibrillator, DM2, COPD

Fatigue, weight loss, hyporexia, weakness, fever (NI)

NI

Echo not specified: Aortic vegetations

LG: Vitek 2¥, 16S rRNA PCR and MS

Wrong ID: Microscanb

Streptococcus breakpoints:

I: PEN and AMP

R: CLI

VAN monotherapy (42d)

Aortic valve replacement. Removal of pacemaker

Intracardiac device infection (Alive)

Fleming et al. 2012

USA

68

M

Prosthetic aortic valve, NHL in remission. Colonic polyps

Migratory arthralgias, dyspnoea, hyporexia, fatigue, weight loss, fever (21)

Systolic ejection murmur. Splinter haemorrhage in nails of left hand

Echo not specified: Vegetation mitral valve. (NI)

Labs: Elevated CRP and ESR Colonoscopy: Colonic polyps

LG: Vitek 2¥, 16S rRNA PCR

Breakpoints for VGS:

S: VAN, SAM, CRO, TZP

R: AMP, GEN, CLI.

Empiric: AMP + GEN

Directed: VAN monotherapy (42d)

No valve replacement

No information of complications (Died)

Russo et al. 2012

Italy

63

M

Ascending aorta and aortic valve replacement, previous endocarditis, HTN.

Fever, chills, Pharyngodini, weakness. (7)

Systolic murmur, hepatomegaly

TEE: mitral vegetation (NI)

Labs: Elevated CRP

LG: API 32b, Vitek 2¥, 16S rRNA PCR

EUCAST Streptococci breakpoint:

S: ERY/S: 0.125 μg/ml, CTX 0.5 μg/ml LVX: 0.5 μg/ml, AMP: 0.25 μg/ml, AMC: 0.5 μg/ml, CIP: 0.75 μg/ml, DAP: 0.125 μg/ml, GEN: 2 μg/ml VAN: 2 μg/ml TEC: 0.5 μg/ml

I: PEN: 2 μg/ml

R: CLI: > 64 μg/ml, RIF > 64 µg/ml

Empiric: VAN + GEN

Directed: AMP monotherapy (14d)

No valve replacement

No complications (Alive)

Watanabe et al. 2011

Japan

55

F

No risk factors or comorbidities

Malaise, myalgia, fever (60)

Systolic murmur, painful black induration in finger.

TEE: Mitral vegetation (10 mm) Labs: No leucocytosis Elevated CRP

LG: Rapid ID32 Strep. a, 16S rRNA

E test: (AB Biodisk, Dalvagen, Solna, Sweden): ERY 0.25 mg/L, CLI: > 256, VAN: 0.38 mg/L, LZD: 2 mg/L, PEN 0.5 mg/L, CRO 0.38 1mg/L, GEN: 1.5 mg/L, STR: 64 mg/L

Empiric: PEN + GEN. Directed: CRO + GEN (63d) No valve surgery

Septic embolism, stroke, aspirative pneumonia (Alive)

Zuily et al. 2011

France

64

F

Mitral valve prosthesis, fresh seafood, Pacemaker, Hepatitis C cirrhosis,

Fever (NI)

Fever, Murmur.

TEE: Mitral vegetations (NI) Labs: Elevated CRP and ESR. Leucocytosis

LG: PCR

NI

AMX + GEN (42d)

no surgery

No complications (Alive)

Wilbring et al. 2011

Germany

55

M

Fish farmer, mechanical tricuspid valve prosthesis, periodontitis

Chills, fever, dyspnoea (14)

Murmur

TEE: Mechanical prosthetic valve vegetation (7x9mm)

Labs: Leucocytosis and elevated CRP

NI

NI

Inpatient: GEN + VAN + RIF ambulatory: LVX + AMC (56d)

No valve replacement

No complications (Alive)

Hirakawa et al. 2011

Brazil

58

F

Mitral prosthetic valve, fish and cheese often. Dental prosthesis and recent gingival perforation. DM 2, HTN, Dyslipidaemia

Fever, chills, diaphoresis, erythematous nodules in hands and legs, myalgia, weakness. (6)

Fever, Osler nodes on left hand and legs.

TEE: No vegetations Labs: Elevated CRP and ESR no leucocytosis.

LG: Not specified biochemical tests. PCR.

S: PEN, GEN, VAN.

R CLI

VAN monotherapy (28d)

No valve surgery

No complications (Alive)

Li et al. 2008

Taiwan

41

M

No risk factors or comorbidities

Slurred speech (1)

Right hemiplegia loss of right body sensation, right positive Babinski sign, murmur, fever

TEE: Mitral vegetation and rupture of chordae tendineae (NI)

Labs: Leucocytosis and elevated CRP

LG: Vitek 2¥, Automated Pheonixc, 16S rRNA PCRe

I: PEN: 0.75 µg/ml.

PEN + GEN (30d)

Valve replacement

Septic emboli, stroke, shock (Alive)

Yiu et al. 2007

China

67

M

Heart rheumatic disease, previous endocarditis, eats fresh fish, AF

Chills, fever (21)

Fever, mitral regurgitation murmur

TEE: Mitral vegetation (10x1mm) Labs: Elevated ESR Neutrophilia

NI

NI

AMP monotherapy (42d)

Valve replacement

Partial rupture of mitral valve (Alive)

Wang et al. 2006

Taiwan

72

M

Kidney stones, mitral valve prolapse. Raw fish consumption, gastric ulcer

Fever, purpuric leg lesions (14)

Systolic murmur.

Echo not specified: Severe mitral regurgitation, prolapse of posterior mitral valve, echogenic mass on the posterior mitral valve Labs: No leucocytosis. Endoscopy: Gastric ulcer

LG: ID32 STREP; BioMérieux, Hazelwood, MO, USA, 16S rRNA PCR

NI

PEN + GEN (42d)

No complications (Alive)

Vinh et al. 2006

Canada

80

M

DM2, Hyperlipidaemia, CAD, CHF

Dyspnoea, epigastric discomfort. (NI)

Midsystolic murmur

TEE: Aortic vegetations (24 mm) Labs: NI

Wrong ID: API 20d (L. lactis), Vitek 2¥(Enterococcus), 16S rRNA PCR

CLSI Enterococcus spp. breakpoints:

S: PEN, CIP, OFX, LVX, TET, VAN.

CLSI Streptococcus spp. breakpoints:

S: AMP, VAN, GEN

I: PEN

R: CLI

Empiric inpatient: AMP

Ambulatory: PEN and then switched to AMP again. Monotherapy (56d)

Valve replacement

No complications (Alive)

Fihman et al. 2005

France

86

M

Prosthetic aortic valve, Cholecystectomy.

Fever, right hip pain (21)

Fever, respiratory distress

TEE: Aortic vegetation (10 mm) Labs: Leucocytosis and elevated CRP.

LG: API 32a, 16S rRNA PCR

E test: MIC: PEN: 0.75 μg/ml, AMX: 0.5 μg/ml CTX: 0.38 μg/ml, VAN: 1.5 μg/ml, TEC: 0.38 μg/ml, CLI >8 µg/ml

Inpatient: AMX + GEN Ambulatory: AMX monotherapy (49d)

Valve repair

No complications (Alive)

James et al. 2000

UK

56

F

Aortic valve prosthesis

Low back pain, chills, night sweat, weight loss, hyporexia (63)

Low back tenderness, splinter haemorrhages In nails, murmur

TTE: No vegetations Labs: Elevated ESR and CRP. No leucocytosis

LG: API Strep f

With streptococci reference laboratory (Respiratory and systemic reference laboratory London UK).

Empiric: VAN Directed: TEC monotherapy (56d)

Osteomyelitis (Alive)

Fefer et al. 1998

USA

84

F

Pacemaker for heart block, Aortic valve prosthesis, omeprazole, hypertrophic cardiomyopathy, ITP, hypothyroidism.

Hyporexia, weakness, dyspnoea (NI)

Holosystolic murmur, bilateral pulmonary rales

TEE: Ruptured chordae tendineae. Labs: Leucocytosis. Negative colonoscopy.

LG: Biochemical tests.

NCCLS Staphylococcus spp. breakpoints:

S: VAN, AMP, CRO

Empiric: AMP + GEN Directed: CRO monotherapy (NI)

Intracranial haemorrhage, Rupture of chordae tendineae (Died)

NI No information, AMK amikacin, AMX amoxicillin, AMC amoxicillin-clavulanic acid, AMP ampicillin, CFZ cefazolin, CDN cefditoren, CTX cefotaxime, CRO ceftriaxone, CEF cephalothin, CHL chloramphenicol, CIP ciprofloxacin, CLR clarithromycin, CLI clindamycin, DAP daptomycin, ERY erythromycin, GEN gentamicin, LVX levofloxacin, LZD linezolid, MEM meropenem, MXF moxifloxacin, OFX ofloxacin, PEN penicillin, TZP piperacillin-tazobactam, RIF rifampin, STR streptomycin, TEC teicoplanin, TET tetracycline, TOB tobramycin, SXT trimethoprim-sulfamethoxazole, VAN vancomycin, MIC Minimal inhibitory concentration, S Sensitive, I Intermediate, R resistant, VGS Viridans Group Streptococci, CKD Chronic kidney disease, AKI Acute kidney injury, DM2 Diabetes mellitus type 2, AF Atrial fibrillation, CHF Cardiac heart failure, NHL Non-Hodgkin Lymphoma, COPD Chronic obstructive pulmonary disease, CLL Chronic lymphocytic leukaemia, CAD Coronary artery disease, CABG Coronary artery bypass graft, LG Lactococcus garvieae a Manual API 32 strep kit, automated Vitek 2 kit with GP identification card (BioMérieux Marcy l’etoile, france), b Microscan walk away system (dade behring, inc., Sacramento, CA), c:Automated Phoenix system (Becton Dickinson Diagnostic systems, Franklin Lakes, NJ), d: API 20strep kit (BioMérieux), e: 500 16S ribosomal rRNA bacterial sequencing kit (PE applied Biosystems, Foster city, CA, USA) ABI PRISM 310 Genetic Analyzer (PE applied biosystems), f: API Strep (BioMérieux, Basngstoke, Hants, UK)

When compared to other Gram-positive microorganisms, L. garvieae seems to affect more frequently patients with prosthetic valves. In our review, 52% (n = 13) patients with L garvieae IE had prosthetic valves, while large cohorts of endocarditis caused by Enterococcus spp., Streptococcus spp., Coagulase negative Staphylococci (CoNS) and S. aureus, report prosthetic valve involvement in 15.3–35%, 16.3–17.2%, 28–32.2% and 15.3–16% of cases, respectively [3133]. Complications of IE such as valve dehiscence or rupture, septic emboli, renal failure, shock, stroke and heart failure were reported in 50% (n = 12) of cases. Surgery for valve repair or replacement was performed in 48% of cases. The case fatality rate of L. garvieae IE was 16% (n: 4), which is low compared to that of other GPC such as S. aureus (44.4%), Enterococcus spp. (23%) and CoNS (33.4%), but comparable to that of streptococci IE (15.7%) [32].

The ingestion of raw sea food or exposure to fish, the presence of colonic polyps and the repeated exposure to dairy products have been postulated to be risk factors for infection by L. garvieae [7]. Less than half of patients with IE caused by L. garvieae reported ingestion of fish (including raw or cooked) [7, 15, 19, 23, 24, 2628, 30] or were diagnosed with a concomitant GI disorder [10, 13, 1921, 24, 2830]. Our patient reported both conditions. The most important predisposing factor in these patients appears to be the presence of previous valvular disease. Of note, colonoscopy may be considered in patients with L. garvieae IE to rule out colonic polyps.

For species identification, MALDI-TOF, 16S RNA PCR, API 32 strep kit (BioMérieux, Marcy l’Etoile, France), Vitek 2 kit with GP identification card (BioMérieux) and BD Automated Phoenix System seem to be reliable techniques for the identification of L. garvieae in our series. However, the Vitek 2 reported misidentification of Enterococcus spp. as L. garvieae in one case [8]. In contrast, the API 20 Strep (BioMérieux, Marcy-l’Etoile, France) and Microscan walk away system (Dade Behring, inc., Sacramento, CA) often misidentified the genus L. garvieae [8, 9]. Since the therapeutic approach for enterococci may be different to that used for Lactococcus, confirmation of identification should be performed with a reliable method. As no breakpoints for antibiotic susceptibility have been determined for Lactococcus spp. by the CLSI or EUCAST, most authors used those for viridans-group streptococci (VGS), group B streptococci, Enterococcus spp. or Staphylococcus spp. With these breakpoints, most L. garvieae isolates show intermediate resistance to penicillin and resistance to clindamycin [8, 9, 13, 22].

In summary, IE caused by L. garvieae may be a life-threatening infection. The most important predisposing factor is previous valvular disease. An association with gastrointestinal disease and consumption of fish has been established. Reliable methods for identification of L. garvieae include MALDI-TOF, 16S RNA PCR, API 32 strep kit (BioMérieux, Marcy l’Etoile, France) and BD Automated Phoenix System. Based on prior case reports and our own patient case, the recommended antimicrobials for L. garvieae are ampicillin (2 g every 4 h), amoxicillin (200 mg/kg/day divided in 4–6 doses), ceftriaxone (2 g every 12–24 h) or vancomycin (30 mg/kg/day divided in 2–3 doses) as monotherapy or in combination with gentamicin (3 mg/kg/day). Doses were defined using the recommendations for the treatment of VGS and enterococcal IE published by the American Heart Association/Infectious Diseases Society of America (AHA-IDSA) and European Society of Cardiology guidelines [34, 35]. It is unclear if combination therapy is needed (in cases where aminoglycoside toxicity is an issue), given that 5 out of 25 patients with L. garvieae IE were treated with vancomycin [9, 15, 17], teicoplanin [17] or ampicillin [8] monotherapy with good outcomes. Further, the majority of patients in the L. garvieae group who died were treated at some point with monotherapy and combination therapy.

Notes

Abbreviations

AF: 

Atrial fibrillation

AKI: 

Acute kidney injury,

AMC: 

Amoxicillin-clavulanic acid

AMK: 

Amikacin

AMP: 

Ampicillin

AMX: 

Amoxicillin

BD: 

Becton Dickinson

CABG: 

Coronary artery bypass graft

CAD: 

Coronary artery disease

CDN: 

Cefditoren

CEF: 

Cephalothin

CFZ: 

Cefazolin

CHF: 

Cardiac heart failure

CHL: 

Chloramphenicol

CIP: 

Ciprofloxacin

CKD: 

Chronic kidney disease

CLI: 

Clindamycin

CLL: 

Chronic lymphocytic leukaemia

CLR: 

Clarithromycin

CLSI: 

Clinical and laboratory standards institute

CLSI: 

Clinical and Laboratory Standards Institute

CONS: 

Coagulase negative staphylococci

COPD: 

Chronic obstructive pulmonary disease

CRO: 

Ceftriaxone

CRP: 

C Reactive Protein

CT: 

Computed Tomography

CTX: 

Cefotaxime

DAP: 

Daptomycin

DM2: 

Diabetes mellitus type 2

DNA: 

Deoxyribonucleic acid

ERY: 

Erythromycin

ESR: 

Erythrocyte Sedimentation Rate

EUCAST: 

European Committee on Antimicrobial Susceptibility Testing

GEN: 

Gentamicin

GI: 

Gastrointestinal

GP: 

Gram positive

GPC: 

Gram positive cocci

I: 

Intermediate

IE: 

Infective Endocarditis

INR: 

International Normalized Ratio

IQR: 

Interquartile range

IV: 

Intravenous

LG: 

Lactococcus garvieae

LVX: 

Levofloxacin

LZD: 

Linezolid

MALDI-TOF: 

Matrix-Assisted Laser Desorption/Ionization Time of Flight

MEM: 

Meropenem

MIC: 

Minimum Inhibitory Concentration

MXF: 

Moxifloxacin

NHL: 

Non-Hodgkin Lymphoma

NI: 

No information

OFX: 

Ofloxacin

PCR: 

Polymerase Chain Reaction

PEN: 

Penicillin

R: 

Resistant

RIF: 

Rifampin

RNA: 

Ribonucleic acid

S: 

Sensitive

STR: 

Streptomycin

SXT: 

Trimethoprim-sulfamethoxazole

TEC: 

Teicoplanin

TEE: 

Transoesophageal Echocardiography

TET: 

Tetracyclin

TOB: 

Tobramycin

TZP: 

Piperacillin-tazobactam

VAN: 

Vancomycin

Declarations

Funding

This work supported by NIH-National Institute of Allergy and Infectious Diseases grant number K24-AI114818 to CAA. This grant serves for undertaking research performed in CAA lab and for publication.

The funders of the study had no role in the study design, data collection, data analysis, data interpretation, or writing of the manuscript.

Availability of data and materials

No data or materials are available.

Authors’ contributions

AM, AD and CAA wrote the manuscript and structured the literature review. CAA, AM, SG and CN took care of the patient and collected clinical data. All authors reviewed and approved the final version of the manuscript.

Ethics approval and consent to participate

Does not apply.

Consent for publication

Written informed consent was given by the patient to publish the information in this case report.

Competing interests

CAA has received grant support from Merck, Entasis and MeMed diagnostics. The other authors have no competing interests to declare.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Department of Internal Medicine, Division of Infectious Diseases, UTHealth - McGovern Medical School, Houston, TX, USA
(2)
Grupo de Investigación en Enfermedades Infecciosas, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá, Colombia
(3)
Universidad de Antioquia, School of Medicine, Medellin, Colombia
(4)
Center for Antimicrobial Resistance and Microbial Genomics (CARMiG), UTHealth - McGovern Medical School, Houston, TX, USA
(5)
Center for Infectious Diseases, UTHealth – School of Public Health, Houston, TX, USA
(6)
Molecular Genetics and Antimicrobial Resistance Unit and International Center for Microbial Genomics, Universidad El Bosque, Bogota, Colombia
(7)
University of Texas Health Science Center at Houston (UTHealth), 6431 Fannin St. MSB 2.112, Houston, TX 77030, USA

References

  1. Schleifer KH, Kraus J, Dvorak C, Kilpper-Bälz R, Collins MD, Fischer W. Transfer of Streptococcus lactis and related streptococci to the genus Lactococcus gen. Nov. Syst Appl Microbiol. 1985;6(2):183–95.View ArticleGoogle Scholar
  2. Vendrell D, Balcázar JL, Ruiz-Zarzuela I, de Blas I, Gironés O, Múzquiz JL. Lactococcus garvieae in fish: a review. Comp Immunol Microbiol Infect Dis. 2006 Jul;29(4):177–98.View ArticleGoogle Scholar
  3. Collins MD, Farrow JA, Phillips BA, Kandler O. Streptococcus garvieae sp. nov. and Streptococcus plantarum sp. nov. J Gen Microbiol. 1983;129(11):3427–31.PubMedGoogle Scholar
  4. Varsha KK, Nampoothiri KM. Lactococcus garvieae subsp. bovis subsp. nov., lactic acid bacteria isolated from wild gaur (Bos gaurus) dung, and description of Lactococcus garvieae subsp. garvieae subsp. nov. Int J Syst Evol Microbiol. 2016;66(10):3805–9.View ArticleGoogle Scholar
  5. Cavanagh D, Fitzgerald GF, McAuliffe O. From field to fermentation: the origins of Lactococcus lactis and its domestication to the dairy environment. Food Microbiol. 2015;47:45–61.View ArticleGoogle Scholar
  6. Gibello A, Galán-Sánchez F, Blanco MM, Rodríguez-Iglesias M, Domínguez L, Fernández-Garayzábal JF. The zoonotic potential of Lactococcus garvieae: an overview on microbiology, epidemiology, virulence factors and relationship with its presence in foods. Res Vet Sci. 2016;109:59–70.View ArticleGoogle Scholar
  7. Wang C-YC, Shie H-S, Chen S-C, Huang J-P, Hsieh I-C, Wen M-S, et al. Lactococcus garvieae infections in humans: possible association with aquaculture outbreaks: Lactococcus Garvieae infections in humans. Int J Clin Pract. 2006;61(1):68–73.View ArticleGoogle Scholar
  8. Vinh DC, Nichol KA, Rand F, Embil JM. Native-valve bacterial endocarditis caused by Lactococcus garvieae. Diagn Microbiol Infect Dis. 2006;56(1):91–4.View ArticleGoogle Scholar
  9. Navas ME, Hall G, El Bejjani D. A case of endocarditis caused by Lactococcus garvieae and suggested methods for identification. J Clin Microbiol. 2013;51(6):1990–2.View ArticleGoogle Scholar
  10. Clavero R, Escobar J, Ramos-Avasola S, Merello L, Álvarez F. Lactococcus garvieae endocarditis in a patient undergoing chronic hemodialysis. First case report in Chile and review of the literature. Rev Chil Infectol. 2017;34(4):397–403.View ArticleGoogle Scholar
  11. Fefer JJ, Ratzan KR, Sharp SE, Saiz E. Lactococcus garvieae endocarditis: report of a case and review of the literature. Diagn Microbiol Infect Dis. 1998;32(2):127–30.View ArticleGoogle Scholar
  12. Fihman V, Raskine L, Barrou Z, Kiffel C, Riahi J, Berçot B, et al. Lactococcus garvieae endocarditis: identification by 16S rRNA and sodA sequence analysis. J Inf Secur. 2006;52(1):e3–6.Google Scholar
  13. Fleming H, Fowler SV, Nguyen L, Hofinger DM. Lactococcus garvieae multi-valve infective endocarditis in a traveler returning from South Korea. Travel Med Infect Dis. 2012;10(2):101–4.View ArticleGoogle Scholar
  14. Heras Cañas V, Pérez Ramirez MD, Bermudez Jiménez F, Rojo Martin MD, Miranda Casas C, Marin Arriaza M, et al. Lactococcus garvieae endocarditis in a native valve identified by MALDI-TOF MS and PCR-based 16s rRNA in Spain: a case report. New Microbes New Infect. 2015;5:13–5.View ArticleGoogle Scholar
  15. Hirakawa TF, da Costa FAA, Vilela MC, Rigon M, Abensur H. Araújo MRE de. Lactococcus garvieae endocarditis: first case report in Latin America. Arq Bras Cardiol. 2011;97(5):e108–10.View ArticleGoogle Scholar
  16. Igneri L, Eltoukhy N, Shaffer A, Goren R. 1200: a rare case of lactococcus garvieae endocarditis in a critically ill patient. Crit Care Med. 2015;43:302.View ArticleGoogle Scholar
  17. James PR, Hardman SM, Patterson DL. Osteomyelitis and possible endocarditis secondary to Lactococcus garvieae: a first case report. Postgrad Med J. 2000;76(895):301–3.View ArticleGoogle Scholar
  18. Li W-K, Chen Y-S, Wann S-R, Liu Y-C, Tsai H-C. Lactococcus garvieae endocarditis with initial presentation of acute cerebral infarction in a healthy immunocompetent man. Intern Med Tokyo Jpn. 2008;47(12):1143–6.View ArticleGoogle Scholar
  19. Lim FH, Jenkins DR. Native valve endocarditis caused byLactococcus garvieae: an emerging human pathogen. BMJ Case Rep. 2017;22(2017):1–3.Google Scholar
  20. Ortiz C, López J, Del Amo E, Sevilla T, García PE, San Román JA. Lactococcus garvieae infective endocarditis: report of 2 cases and review of the literature. Rev Espanola Cardiol Engl Ed. 2014;67(9):776–8.View ArticleGoogle Scholar
  21. Rasmussen M, Björk Werner J, Dolk M, Christensson B. Lactococcus garvieae endocarditis presenting with subdural haematoma. BMC Cardiovasc Disord. 2014;1(14):13.View ArticleGoogle Scholar
  22. Russo G, Iannetta M, D’Abramo A, Mascellino MT, Pantosti A, Erario L, et al. Lactococcus garvieae endocarditis in a patient with colonic diverticulosis: first case report in Italy and review of the literature. New Microbiol. 2012;35(4):495–501.PubMedGoogle Scholar
  23. Suh Y, Ja Kim M, Seung Jung J, Pil Chong Y, Hwan Kim C, Kang Y, et al. Afebrile multi-valve infective endocarditis caused by Lactococcus garvieae: a case report and literature review. Intern Med Tokyo Jpn. 2016;55(8):1011–5.View ArticleGoogle Scholar
  24. Tsur A, Slutzki T, Flusser D. Lactococcus garvieae endocarditis on a prosthetic biological aortic valve. Zoonoses Public Health. 2015;62(6):435–7.View ArticleGoogle Scholar
  25. Watanabe Y, Naito T, Kikuchi K, Amari Y, Uehara Y, Isonuma H, et al. Infective endocarditis with Lactococcus garvieae in Japan: a case report. J Med Case Rep. 2011;5:356.View ArticleGoogle Scholar
  26. Wilbring M, Alexiou K, Reichenspurner H, Matschke K, Tugtekin SM. Lactococcus garvieae causing zoonotic prosthetic valve endocarditis. Clin Res Cardiol Off J Ger Card Soc. 2011;100(6):545–6.View ArticleGoogle Scholar
  27. Yiu K-H, Siu C-W, TO KK-W, Jim M-H, Lee KL-F, Lau C-P, et al. A rare cause of infective endocarditis; Lactococcus garvieae. Int J Cardiol. 2007;114(2):286–7.View ArticleGoogle Scholar
  28. Zuily S, Mami Z, Meune C. Lactococcus garvieae endocarditis. Arch Cardiovasc Dis. 2011;104(2):138–9.View ArticleGoogle Scholar
  29. Bazemore TC, Maskarinec SA, Zietlow K, Hendershot EF, Perfect JR. Familial adenomatous polyposis manifesting asLactococcusEndocarditis: a case report and review of the association ofLactococcuswith underlying gastrointestinal disease. Case Rep Infect Dis. 2016;2016:5805326.PubMedPubMed CentralGoogle Scholar
  30. Landeloos E, Van Camp G, De Beenhouwer H. Lactococcus garviae prosthetic mitral valve endocarditis: a case report and literature review. Clin Microbiol Newsl. 2017;39(16):130–1.View ArticleGoogle Scholar
  31. Murdoch DR, Corey GR, Hoen B, Miró JM, Fowler VG, Bayer AS, et al. Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century: the international collaboration on endocarditis-prospective cohort study. Arch Intern Med. 2009;169(5):463–73.View ArticleGoogle Scholar
  32. Muñoz P, Kestler M, De Alarcon A, Miro JM, Bermejo J, Rodríguez-Abella H, et al. Current epidemiology and outcome of infective endocarditis: a multicenter, prospective, cohort study. Medicine (Baltimore). 2015;94(43):e1816.View ArticleGoogle Scholar
  33. Chirouze C, Athan E, Alla F, Chu VH, Ralph Corey G, Selton-Suty C, et al. Enterococcal endocarditis in the beginning of the 21st century: analysis from the international collaboration on endocarditis-prospective cohort study. Clin Microbiol Infect. 2013;19(12):1140–7.View ArticleGoogle Scholar
  34. Baddour LM, Wilson WR, Bayer AS, Fowler VG, Tleyjeh IM, Rybak MJ, et al. Infective endocarditis in adults: diagnosis, antimicrobial therapy, and Management of Complications: a scientific statement for healthcare professionals from the American Heart Association. Circulation. 2015;132(15):1435–86.View ArticleGoogle Scholar
  35. Habib G, Lancellotti P, Antunes MJ, Bongiorni MG, Casalta J-P, Del Zotti F, et al. 2015 ESC guidelines for the management of infective endocarditis: the task force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC) endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J. 2015;36(44):3075–128.View ArticleGoogle Scholar

Copyright

© The Author(s). 2019

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