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 Table of Contents  
Year : 2022  |  Volume : 8  |  Issue : 1  |  Page : 42-44

Escherichia coli urosepsis leading to native valve endocarditis

1 Department of Cardiology, Topiwala National Medical College and B.Y.L Nair Charitable Hospital, Mumbai, Maharashtra, India
2 Department of General Medicine, Jawaharlal Nehru Medical College and Acharya Vinoba Bhave Rural Hospital, Wardha, Maharashtra, India
3 Department of Pediatrics, Jawaharlal Nehru Medical College and Acharya Vinoba Bhave Rural Hospital, Wardha, Maharashtra, India
4 Department of Pathology, Jawaharlal Nehru Medical College and Acharya Vinoba Bhave Rural Hospital, Wardha, Maharashtra, India

Date of Submission05-Feb-2022
Date of Decision15-Mar-2022
Date of Acceptance19-Mar-2022
Date of Web Publication26-Apr-2022

Correspondence Address:
V V. S.S. Sagar
Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (DU), Wardha, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpcs.jpcs_7_22

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Escherichia coli, a Gram-negative facultative anaerobe, is the common causative organism leading to urinary tract infection. However, the involvement of endocardium by E. coli has been reported to be very rare in spite of the septicemia caused by this organism. However, the mortality rate due to infective endocarditis caused by E. coli was reported to be higher than due to other organisms like HACEK group of organisms. Conventional risk factors leading to infective endocarditis include cirrhosis of the liver, prosthetic heart valves, and other sources of infection like urosepsis. Here, we report the case of a 60-year-old diabetic male who presented with obstructive uropathy-induced urinary tract infection leading to infective endocarditis.

Keywords: Escherichia coli, Gram-negative bacteria, infective endocarditis, urinary tract infection

How to cite this article:
Kamat S, Sagar V V, Akhil CV, Acharya S, Shukla S, Kumar S. Escherichia coli urosepsis leading to native valve endocarditis. J Pract Cardiovasc Sci 2022;8:42-4

How to cite this URL:
Kamat S, Sagar V V, Akhil CV, Acharya S, Shukla S, Kumar S. Escherichia coli urosepsis leading to native valve endocarditis. J Pract Cardiovasc Sci [serial online] 2022 [cited 2023 Mar 25];8:42-4. Available from: https://www.j-pcs.org/text.asp?2022/8/1/42/344138

  Introduction Top

Infectious endocarditis (IE) due to  Escherichia More Details coli (E. coli) is rare, although it is a common organism leading to septicemia. The incidence of 0.51% was reported in endocarditis due to E. coli. Increased incidence has been reported in >70-year-old patients, particularly in older women.[1] However, studies reported the incidence in younger patients also. Several risk factors can be attributed to the occurrence of infective endocarditis like hepatic cirrhosis, prosthetic cardiac valves, and any focus of infection like bacteremia, urosepsis. In addition to these risk factors, other comorbidities such as diabetes, excessive intake of alcohol, malignancy can be predisposing factors for the E. coli-induced infective endocarditis.[2] Mitral valve has been reported more commonly affected in such cases. The low incidence of E. coli IE can be explained by the inability of E. coli to adhere to endocardium and circulating antibodies in the serum.[3] There is an increased incidence of in-hospital mortality due to infective endocarditis caused by non-HACEK organisms, particularly E. coli. Hence, close attention is needed in E. coli IE during the hospital stay. Notably, the incidence of E. coli infective endocarditis has been recently increased both in immunocompetent and immunocompromised hosts leading to increased morbidity and mortality.

  Case Report Top

A 60-year-old diabetic female came with complaints of left loin pain radiating to groin, lower abdominal pain, multiple episodes of high-grade fever associated with chills, burning micturition, increased frequency and urgency of urination, nausea, vomiting of three episodes, fatigue, and breathlessness which was of New York Heart Association grade 3 for 5 days.

On admission, the patient was febrile having pulse rate of 116/min, blood pressure of 130/80mm Hg, SpO2 on ambient air was 90%; hence, started on 2 L oxygen therapy with nasal mask after which saturation improved to 96%. On auscultation, bilateral basal crepitations and grade 2 pansystolic murmur best heard in mitral and tricuspid areas radiating to axilla during expiration. Per abdomen on examination revealed left loin tenderness.

Laboratory parameters- urine examination was found albumin trace, 30-40 pus cells and RBCs, haemoglobin 12g/dl, elevated Total leukocyte count 21,532 cells/cumm, platelet count 1.8lakh/cumm, raised serum creatinine 2.1mg/dl and serum urea 96mg/dl, reduced serum albumin 2.3g/dl. Urine culture was showed pink lactose fermenting translucent colonies of E. coli seen on MacConkey agar as shown in [Figure 1]. Ultrasound (USG) abdomen revealed left renal calculi with hydroureteronephrosis. Repeat blood investigations were suggestive of persistent leukocytosis. Repeat USG abdomen and pelvis have been done to rule out any focal renal and prostatic abscess which was normal. X-ray chest revealed opacities in bilateral perihilar and parenchymal lung fields with mild pleural effusion and a wedge-shaped peripheral opacity in the right lung field. Two-dimensional echocardiography revealed a small echogenic mass on anterior leaflets of mitral and tricuspid valves with prolapse causing moderate mitral and tricuspid regurgitation most likely vegetations, left ventricular ejection fraction 60% as shown in [Figure 2] and Video 1.
Figure 1: Urine sample showing pink lactose fermenting translucent colonies of Escherichia coli seen on MacConkey agar

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Figure 2: (a and b) Small echogenic mass on anterior leaflets of mitral and tricuspid valves with prolapse causing mitral and tricuspid regurgitation most likely vegetations

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Suspecting infective endocarditis, three blood cultures were drawn from three different sites 2 h apart revealed E. coli, inflammatory markers such as erythrocyte sedimentation rate 80mm/h, C-reactive protein 20mg/dl were grossly elevated. Antibiotic sensitivity testing was done on Mueller‒Hinton agar using disc diffusion method and found to be sensitive to nitrofurantoin, ceftriaxone, amikacin, gentamicin, and cotrimoxazole.

She was started initially on piperacillin-tazobactam 2.25g intravenous (IV) thrice a day, levofloxacin 500mg alternate day in renal doses, phenazopyridine 200mg twice a day, syrup disodium hydrogen citrate 15ml in 100ml water thrice a day, paracetamol 650mg thrice a day, and perinorm 10mg thrice a day. Insulin in divided doses was given to control hyperglycemia. Double J stenting was done on the left kidney.

Later, after getting the antibiotic sensitivity report, the patient was shifted to ceftriaxone 2gm IV twice a day, amikacin 500mg alternate day, lasix 40 mg twice a day, and carvedilol 3.125 mg half dose twice a day. After 4 weeks of treatment, the patient gradually improved symptomatically and two-dimensional echocardiography revealed no vegetations.

  Discussion Top

Native valve endocarditis due to E. coli was reported to be extremely rare. Very few studies revealed the occurrence of infective endocarditis following urosepsis, especially in diabetics, immunocompromised hosts, and females. Noureddine et al. had reported increased affection of Gram-negative bacteria in people with comorbidities compared to other organisms.[4] Infective endocarditis following urinary tract infection can be attributable to consequences of immunologic and embolic phenomena. Low incidence of endocarditis due to E. coli was due to the fact that poor adherence to endocardium and lack of surface proteins that help in binding to host matrix molecules but possess extraintestinal virulence factors such as toxins adhesins, host defense avoidance systems, and iron acquisition systems which make them potentially pathogenic in extraintestinal sites.[5]

Gram-negative infective endocarditis leads to increased morbidity and mortality necessitating aggressive management. IE complications caused by Gram-negative organisms are renal failure, central nervous system involvement, and cardiac dysfunction.[6] Pseudomonas infection superadded with E. coli frequently leads to annular abscesses, systemic embolization, and heart failure.

Very few guidelines are available in treating Gram-negative causative infective endocarditis. A combination of parenteral cephalosporin and an aminoglycoside is sensitive.[7] However, extended spectrum beta lactamase ESBL-producing E. coli strains require carbapenem +/-aminoglycoside. Judicious antibiotic dosage after antibiotic sensitivity testing has been recommended with accurate monitoring of adverse drug reactions.[8]

A similar case was reported by Lauridsen et al in a 67 year old patient who developed infective endocarditis affecting mitral valve.[9] Rangarajan et al. had reported a case of an old individual with urinary infection and septicemia due to Gram-negative organisms who had later developed endocarditis affecting mitral valve with a preexisting coronary artery disease, contributing to declining left ventricular function and heart failure, finally, necessitating surgical intervention.[10]

In our case, one major (vegetation over anterior mitral and tricuspid leaflets and mitral valve regurgitation on 2D echo) and three minor (fever, vascular phenomena such as pulmonary infarct and blood culture revealed E. coli) criteria fulfilled for modified Duke Criteria. Here, the patient had primary urinary tract infection which later led to infective endocarditis even without known history of cardiac disease. The patient was managed with intravenous antibiotics with good response to treatment without the necessity of surgical intervention.

  Conclusion Top

Urosepsis has to be considered as an important risk factor for E. coli endocarditis that had no previous cardiac history. Prolonged fever in urinary tract infection in spite of appropriate antibiotic therapy should be evaluated further to rule out endocarditis that helps to reduce associated morbidity and mortality.

Ethics clearance

Appropriate consent was taken from the relatives of the patient before making the case report. As this is a case report the university's guideline does not require an ethical committee and/or Institutional Review Board (IRB) clearance for its scientific publication.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.


We thank microbiologists for providing pictures of E. coli on urine and blood cultures.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Rangarajan D, Ramakrishnan S, Patro KC, Devaraj S, Krishnamurthy V, Kothari Y, et al. Native valve Escherichia coli endocarditis following urosepsis. Indian J Nephrol 2013;23:232-4.  Back to cited text no. 1
[PUBMED]  [Full text]  
Benaissa E, Yasssine BL, Chadli M, Maleb A, Elouennass M. Infective endocarditis caused by Escherichia coli of a native mitral valve. IDCases 2021;24:e01119.  Back to cited text no. 2
Leonard MF, Rodriguez-Villalobos H, Boisen N, Scheutz F, Laterre PF, Hantson P. The causal relationship between O2:K7:H6 extra-intestinal pathogenic Escherichia coli (ExPEC) and native valve endocarditis: A case report. BMC Infect Dis 2021;21:370.  Back to cited text no. 3
Akuzawa N, Kurabayashi M. Native valve endocarditis due to Escherichia coli infection: A case report and review of the literature. BMC Cardiovasc Disord 2018;18:195.  Back to cited text no. 4
Kumar S, Diwan SK, Wanjari AK, Mahure C. Infective endocarditis due to internal jugular vein haemodialysis catheterJournal, Indian Academy of Clinical Medicine. JIACM 2013;14:266-7.   Back to cited text no. 5
Bhayani P, Rawekar R, Bawankule S, Kumar S, Acharya S, Gaidhane A, et al. Profile of urinary tract infection in a rural tertiary care hospital: Two-year cross-sectional study. J Datta Meghe Inst Med Sci Univ 2019;14:22-6.  Back to cited text no. 6
  [Full text]  
Naha S, Naha K, Acharya V, Hande HM, Vivek G. Community-acquired multidrug-resistant Gram-negative bacterial infective endocarditis. BMJ Case Rep 2014;2014:bcr2014204176.  Back to cited text no. 7
Watanakunakorn C, Kim J. Mitral valve endocarditis caused by a serum-resistant strain of Escherichia coli. Clin Infect Dis 1992;14:501-5.  Back to cited text no. 8
Lauridsen TK, Arpi M, Fritz-Hansen T, Frimodt-Møller N, Bruun NE. Infectious endocarditis caused by Escherichia coli. Scand J Infect Dis 2011;43:545-6.  Back to cited text no. 9
Rangarajan D, Ramakrishnan S, Patro KC, Devaraj S, Krishnamurthy V, Kothari Y, et al. Native valve Escherichia coli endocarditis following urosepsis. Indian J Nephrol 2013;23:232-4.  Back to cited text no. 10
[PUBMED]  [Full text]  


  [Figure 1], [Figure 2]

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