==== Front Ann Saudi MedAnn Saudi MedAnnals of Saudi Medicine0256-49470975-4466King Faisal Specialist Hospital and Research Centre 1676145510.5144/0256-4947.2006.147asm-2-147Case ReportEndocarditis caused by Pasteurella multocida Al Ghonaim Mohammed A. *Abba Abdullah A. †Al Nozha Mansour † * Department Of Medicine, College of Medicine and King Khalid University Hospital, Riyadh, Saudi Arabia † King Saud University, Riyadh, Saudi ArabiaCorrespondence and reprint requests: Mohammed A. Al Ghonaim, MD, MBBS, Medical Resident, 14844 64th Avenue, Edmonton, Alberta, T6H 4Y4, Canada, Tel: +1-780-434 2023, Fax: +1-780-434 2023, mohdgm@hotmail.comMar-Apr 2006 26 2 147 149 01 2 2005 Copyright © 2006, Annals of Saudi Medicine2006This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. ==== Body Pasturella multocida, a small gram-negative coccobacillus, is primarily a pathogen in animals, but can cause a variety of infections in humans.1 Infection usually follows a bite or contact with secretions from felines such as dogs or cats. Infection is usually followed by cellulitis, but the organism has been implicated in pneumonia, meningitis, liver abscess and osteomyelitis. Systemic infection is rare; only eleven cases of P. multicoda endocarditis have been reported in the English literature. We report a case of P. multocida endocarditis in a Saudi patient who had frequent contact with sheep, but in whom there was no clear portal of entry of the organism. In addition, the patient had no co-morbid conditions and was not immunosuppressed. To our knowledge, this is the twelfth reported case of endocarditis by this unusual organism in the English literature. We review the previously reported eleven cases. Case A 50-year-old Saudi presented with a 3-week history of dyspnea, orthopnea, proxysmal nocturnal dyspnea, cough and scanty white sputum. There was no fever or other constitutional features, or other symptoms referable to other systems. The patient was a truck driver and had frequent contact with sheep, but could not recollect a bite or a skin lesion prior to presentation. He had no significant current or past medical history. On physical examination, he was in respiratory distress with the following vital signs: respiratory rate of 23/min, pulse rate 100/min, blood pressure 120/60 mm Hg and a temperature of 38.9°C. He had splinter haemorrhages but no other peripheral signs of endocarditis. He was in sinus rhythm and the pulse was collapsing in character. The jugular venous pressure was elevated at 4 cm and he had signs of mitral and aortic regurgitation. Examination of the respiratory system revealed bilateral basal inspiratory crepitations. Examination of the abdomen, fundi and the central nervous system was unremarkable. There were no obvious skin lesions to suggest a recent or remote animal bite. He was not on any medications. Investigations revealed mild leucocytosis at 12.0 x 103/μL, normal haemoglobin, and normal renal and hepatic function. A chest radiograph showed cardiomegaly with pulmonary oedema and the electrocardiogram showed sinus rhythm, left axis deviation and left ventricular hypertrophy. An echocardiogram showed dilated left ventricle and atrium. A large vegetation, noted at the non-coronary cusp, was freely moving in the left ventricular outflow tract. There was severe aortic regurgitation with aortic root abscess and mild mitral regurgitation. Blood culture grew P. multocida on four occasions. The organism was oxidase, catalase and indole positive and identification was confirmed by using API 20E (Bio Merieux, France). Screening was negative for the human immunodeficiency virus (HIV). The patient was treated with penicillin, gentamicin and anti-failure measures. He underwent aortic valve replacement after four days of medical treatment. The histology of the diseased valve confirmed endocarditis although the culture was negative. He made an uneventful recovery and remains well after a two-year follow up. Discussion The case satisfied Duke’s criteria for the diagnosis of endocarditis in having two of the major criteria and one minor criterion. Although P. multocida can be easily misidentified, the methods we used distinguished it from organisms such as Haemophilus aphrophilus and Haemophilus parainfluenzae. To our knowledge, this is the twelfth reported case of P. multocida endocarditis in the English literature.2–12 Table 1 gives the details of the previously reported cases. The organism is usually recovered from the nasopharnynx or gastrointestinal tract of felines and is a component of oral flora in most mammals. Infection in man follows animal bite or contact with secretions. The most common sequel are cellulitis, subcutaneous abscesses, and skin ulcers. Other less commonly affected organs include the bones and joints, and the oral and respiratory tract. Bacteremia is uncommon and endocarditis rarely results from such bacteremia. In a series of thirteen cases with bacteremia, Raffi and his associates13 reported none with endocarditis. Culture of the excised valve in our case did not grow the organism. This is similar to the case reported by Lehmann et al3 and may be the result of the antibiotics the patient received earlier. Patients with P. multocida infections often have other co-morbid conditions such a chronic obstructive lung disease, bronchiectasis, chronic liver disease or immunosuppression. Our patient had no prior co-morbid state. In addition, he was not on any immunosuppressants nor was he positive for the HIV virus. The organism is highly susceptible to numerous antibiotics including penicillins, cephalosporins, tetracyclines, and chloramphenicol. Penicillin is the drug of choice.14 Despite susceptibility to, and treatment with these readily available antibiotics, about half of the reported cases of endocarditis died and valve replacement was required in another one third. The outcome is probably related to the duration of illness and the rapidity with which diagnosis is made and treatment commenced. P. multocida is a recognized but rare cause of endocarditis, and although the organism is susceptible to many antibiotics, it can run a fatal cause if not recognized early. Table 1 Endocarditis due to P. multocida: summary of cases described in English medical literature. Case No. Year of Publication Age (year) & Sex Animal Exposure Valvular vegetation Co-morbid condition Outcome 1 19702 10 / F No NR NR Recovered but died soon of uncertain cause 2 19773 51 / M - AV NR Survived, required AVR 3 19834 50 / M Dog /sheep NR NR Died 4 19895 63 / F Dog AV Glomerulonephritis Recovered, required AVR* 5 19906 17 / M No MV Renal insufficiency Died of intra cerebral hemorrhage 6 19927 61 / M Dog AV Polycystic kidneys Died* 7 19968 72 / F Cat AV Prosthesis Liver cirrhosis Survived 8 19979 65 / M Dog AV Prosthetic valve Died* 9 199810 65 / M Dog NR Liver cirrhosis Died 10 200211 48 / M Dog MV Pre-existing MV stenosis Survived. Required MVR 11 200312 48 / F Dog AV Liver cirrhosis Survived, recurrent endocairditis after AVR 12 2005 (PR) 50 / M Sheep AV No known co-morbid condition Survived, required AVR F=Female, M=Male, NR=No record, AV=Aortic valve, MV=Mitral valve, AVR=Aortic valve replacement, MVR=Mitral valve replacement, AVR = Aortic valve replacement, PR =Present report. ==== Refs References 1 Weber DJ Wolfson JS Swartz MN Hooper DC Pasteurella multocida infections: Report of 34 cases and review of literature Medicine 1984 63 2 133 154 6371440 2 Phillips I Midgley J Lapage SP Endocarditis due to a Pusteurella-like organism East Afr Med J 1970 47 8 440 4 5479793 3 Lehmann V Knotsen SB Ragnhildstveit F Skagseth E Solberg C Endocarditis caused by P. multocida Scand J Infec Dis 1977 9 247 8 905786 4 Singh CP Spurrell JR Pasteurella multocida endocarditis Br Med J (Clin Res Ed) 1983 286 6381 1862 3 5 Salmon D Fantin B Bricaire F Vilde JL Pangon B Ferand D Endocarditis due to Pasteurella multocida with glomerulitis Am J Med 1989 86 4 493 6 Thamlikitkul V Sangruchi T Pasteurella multocida infective endocarditis: a case report J Med Assoc Thai 1990 73 12 704 6 2086720 7 Hombal SM Dincsoy HP Pasteurella multocida endocarditis Am J Clin Pathol 1992 98 6 565 8 1462953 8 Genne D Siegrist HH Monnier P Nobel M Humair L de Torrente A Pasteurella multocida endocarditis: report of a case and review of the literature Scand J Infect Dis 1996 28 1 95 7 9122643 9 Nettles RE Sexton DJ Pateurella multocida Prosthetic Valve Endocarditis: Case report and Review Clin Infect Dis 1997 25 920 1 9356811 10 Vasquez JE Ferguson DA Bin-Sagheer S Myers JW Ramsak A Wilson MA Sarubbi FA Pasteurella multocida Endocarditis: A molecular epidemiological study Clin Infect Dis 1998 26 518 20 9502493 11 Fukumoto Y Moriyama Y Iguro Y Toda R Taira A Pasteurella multocida: report of a case Surg Today 2002 32 6 513 5 12107776 12 Fayad G Modine T Mokhtari S Legout L Decoene C Azzaoui R Pasteuerella multocida aortic valve endocarditis: case report and literature review J Heart Valve Dis 2003 12 2 261 3 12701800 13 Raffi F Barrier J Barou D Drugeon H Nicolas F Pusteurella multocida bacteremia: Report of thirteen cases over twelve years and review of the literature Scand J Infec Dis 1987 19 385 393 3313679 14 Mortensen JE Giger D Rodgers GL In vitro activity of oral anti microbial agents against clinical isolates of Pasteurella multocida Diagn Microbiol Infect Dis 1998 30 99 9554176