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Publication Date
4-30-2025
Keywords
gme, oaa, ppmc gme
Disciplines
Cardiology | Internal Medicine
Abstract
Introduction Infective endocarditis (IE) is a relatively uncommon disease with an annual incidence of 5 per 100,000 people in the U.S.. Dental procedures are an exceptionally rare cause of IE. Amidst a global emphasis on antibiotic stewardship, U.S. and European guidelines only recommend antibiotic prophylaxis for dental procedures in high-risk groups. Having a bicuspid aortic valve (BAV) confers an 11-fold risk of endocarditis compared to the general public, and yet, is not classified as high-risk per AHA/IDSA guidelines. We present a patient with BAV who developed IE following a noninvasive dental procedure and review whether patients with BAV are under-classified and warrant antibiotic prophylaxis. Case presentation A 58-year-old previously healthy male presented to the ED with a 4-6-week history of fatigue, progressive dyspnea, and intermittent fevers. Two weeks prior to onset of symptoms, he underwent a routine dental cleaning. Examination revealed decreased bibasilar breath sounds, pitting edema to the mid-shins, a new diastolic murmur, and bounding carotid pulses. Work-up revealed leukocytosis, elevated procalcitonin, and small bilateral pleural effusions. Cefepime was started for presumed sepsis. Admission blood cultures grew Aggregatibacter aphrophilus, a HACEK organism. Transthoracic echocardiogram demonstrated a focal vegetation of the aortic valve, confirming bacterial endocarditis. There was moderate-to-severe aortic insufficiency (AI), though concomitant severe left ventricular enlargement suggested a degree of chronic AI. Urgent bioprosthetic aortic valve replacement was performed on hospital day 7. Pathology of the excised aortic valve demonstrated bicuspid morphology with Sievers type 2 anatomy. The patient recovered well after 6 weeks of ceftriaxone therapy. Discussion The patient’s HACEK bacteremia and endocarditis were attributed to his recent noninvasive dental cleaning. The diagnosis raised concern for underlying valvular pathology, and the patient was found to have BAV, which is the most common congenital cardiac abnormality and present in approximately 2% of the population. Native valve endocarditis following dental procedures is rare, with an estimated incidence of 1 case per 14 million procedures. The American Heart Association Prevention of Endocarditis guidelines only recommend antibiotic prophylaxis for odontologic procedures in high-risk cardiac conditions. This currently excludes BAV, though newer retrospective studies suggest that patients with BAV may be at higher risk of IE than previously thought. For example, a study by Zegri-Reiriz et al. showed that patients with BAV had a higher incidence of viridans group streptococcus IE and IE from suspected odontologic origin compared to traditionally high-risk groups (14.8% vs. 5.8%; p< 0.01). Additionally, BAV-related IE often leads to perivalvular abscesses, requiring earlier surgery in nearly 75% of cases. Both this case and recent studies question whether BAV warrants reclassification as a high-risk condition for IE. Additional studies are required to further explore the benefit of antibiotic prophylaxis in this group.
Area of Special Interest
Cardiovascular (Heart)
Specialty/Research Institute
Cardiology
Specialty/Research Institute
Graduate Medical Education
Specialty/Research Institute
Internal Medicine
