Title of Case:

Persistent staphylococcal bacteremia affecting multiple systems in a boy with surgically corrected congenital heart disease

Background:

Management of persistent bacteremia in children with surgically corrected congenital cardiopathy remains challenging. The presence of vascular grafts may adversely affect outcome.

Case Presentation Summary:

A 9.5-year-old boy, with surgically corrected type-I-truncus arteriosus(and a pulmonary artery graft in place),was referred to our Department with a 3-day-fever(>38^οC),limp, elevated inflammatory markers, anemia, thrombocytopenia. He was empirically started on IV ceftriaxone, subsequently changed to IV cloxacillin-gentamicin, as for infective endocarditis, due to isolation of methicillin-sensitive St.aureus(MSSA) from blood. IV vancomycin was added on day-5, due to patient’s lack of clinical improvement and persistently positive blood cultures.

During hospitalization the patient developed:

Left-knee septic arthritis(ultrasound/MRI-confirmed), with MSSA isolation from synovial fluid.

Lung abscesses(HRCT-confirmed)

Acute glomerulonephritis(renal function decline, microscopic hematuria, nephrotic-range proteinuria). The condition was initially attributed to drug toxicity. Thus, cloxacillin-gentamicin were discontinued and vancomycin was switched to daptomycin. Due to persistence of inflammation, IV clindamycin and ceftaroline were added on day-11 and day-17 respectively. Renal involvement was ultimately attributed to immune-mediated damage and IV methylprednisolone(2mg/kg/d) was initiated, with gradual resolution of proteinuria and dose tapering.

Although the patient fulfilled Duke’s criteria for infective endocarditis, endocardial/graft involvement-vegetation was not confirmed by MRI/ultrasound. The patient remained on IV antibiotics for 42 days with slow recovery, and was discharged home on oral cefuroxime for 14 days. Five months afterwards, there are no clinical/laboratory signs of relapse.

Learning Points/Discussion:

S.aureus bacteremia in children with surgically treated congenital cardiopathy may be complicated by multisystem involvement, requiring a multidisciplinary approach. Immune-mediated nephritis is not unlikely. In the presence of vascular grafts, it may be prudent to follow an endocarditis treatment regimen, even when not confirmed by imaging techniques.