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Saudi Journal of Kidney Diseases and Transplantation
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LETTER TO EDITOR Table of Contents   
Year : 2001  |  Volume : 12  |  Issue : 1  |  Page : 55-56
Infective Endocarditis and Immunosuppression


Central Hospital North Zone, Arar, Saudi Arabia

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How to cite this article:
Bhat AW. Infective Endocarditis and Immunosuppression. Saudi J Kidney Dis Transpl 2001;12:55-6

How to cite this URL:
Bhat AW. Infective Endocarditis and Immunosuppression. Saudi J Kidney Dis Transpl [serial online] 2001 [cited 2020 Dec 5];12:55-6. Available from: https://www.sjkdt.org/text.asp?2001/12/1/55/33888
To the Editor:

Severe infection in immunosuppressed hosts is well known [1] and infective endo­carditis has been reported in patients with inflammatory bowel disease on immuno­suppressive therapy. [2],[3] However, to the best of our knowledge, infective endocarditis in patients with nephrotic syndrome on immuno­suppressive therapy has not been reported till date.

We herewith report a 12-year old boy who was previously admitted to the Nephrology Unit of Arar Central Hospital, Arar, Saudi Arabia in December, 1990 when he was diagnosed to have minimal change glome­rulonephritis (biopsy proved). He was managed initially with prednisolone 40 mg daily. However, he became steroid dependent and in July, 1993 oral cyclophosphamide 50 mg daily was added to the prednisolone, which he took for two months without showing any improvement. While on these drugs, the patient developed a tooth abscess, which was treated with drainage of pus and oral antibiotics by a local dental surgeon. Twenty days after his dental treatment, he presented with high grade fever (104°F), malaise and anasarca. On examination, he had cushingoid facies, pallor and the blood pressure was 130/86. He was tachypneic and had splenomegaly, while the cardiac and respiratory examinations were unrevealing. Investigations revealed moderate normocytic normocromic anemia, persistent proteinuria with mild hematuria, blood urea 13.1 mmol/L (75 mg/dl), serum creatinine 177 umol/L (2 mg/dl), sodium 135 mmol/L and potassium 5.1 mmol/L. Blood and urine cultures performed repeatedly were sterile and the x-ray chest was normal. On the fourth day of hospitalization, the patient developed a pansystolic murmur over the precordium which prompted us to think of infective endocarditis. Echocardiography was performed which was consistent with mitral regurgitation with vegetations on the anterior mitral leaflet. The patient was started on injection crystalline penicillin in a dose of 2 million units intravenous (i.v.) four hourly, and gentamycin 40 mg i.v. eight hourly. On the third day of therapy, the patient developed signs of aortic regurgitation and left ventricular failure. Unfortunately, he died of heart failure resistant to medical therapy. Suppression of cellular immunity is an accepted co-factor in the pathogenesis of bacterial endocarditis. [4],[5],[6] Bacteremia has been reported in patients with inflammatory bowel disease on immunosuppressants, as well as patients with liver disease, diver­ticulitis and malignancy. " In our patient, it is likely that the tooth infection led to a constant bacteremia which resulted in infection of normal mitral and aortic valves possibly as a direct sequel of suppression of the patients native immune response by prednisolone and cyclophosphamide.

 
   References Top

1.Meyers JD. Infection in bone marrow transplant recipients. Am J Med 1986;81: 27-38.  Back to cited text no. 1  [PUBMED]  
2.Kreuzpaintner G, Horstkotte D, Hey 11 A, Losse B, Strohmeyer G. Increased risk of bacterial endocarditis in inflammatory bowel disease. Am J Med 1992;92:391-5.  Back to cited text no. 2    
3.Wong JS. Infective endocarditis in Crohn's disease. Br Heart J 1989;62:163-4.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Bayliss R, Clarke C, Oakley CM, Sumerville W, Whitefield AG, Young SE. The bowel, the genitourinary tract and infective endocarditis. Br Heart J 1984;51: 339-45.  Back to cited text no. 4    
5.Oakley CM. Infective endocarditis. BrJ Hosp Med 1980;24:232,234,239-43.  Back to cited text no. 5    
6.Skehan JD, Murray M, Mills PG. Infective endocarditis: incidence and mortality in North East Thames Region. Br Heart J 1988;59:62-8.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]

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Correspondence Address:
Abdul Wahid Bhat
Central Hospital North Zone, Arar
Saudi Arabia
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PMID: 18209363

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