Introduction: Raoultella ornithinolytica, an encapsulated gram-negative bacillus of the enterobacteriaceae family, is primarily an aquatic-commensal but has also emerged as a nosocomial pathogen post-invasive procedures. It has infrequently been implicated in gastrointestinal, skin, and genitourinary tract infections. Heart transplantation (HT) is seldom done in patients with infective endocarditis (IE) and is typically a salvage treatment for intractable IE.
Description: A 62-year-old male presented with insidious onset sporadic fevers associated with chills and dyspnea for the last several weeks. His medical history was notable for severe calcific aortic stenosis status post-surgical mechanical aortic valve replacement (AVR) three months ago and chronic kidney disease stage III. His hospital course immediately after his AVR was complicated by R. Ornithinolytica UTI and sepsis, followed by six weeks of intravenous antibiotics. He did well after discharge from rehab. Post-admission, this time, his urine and blood cultures were again positive for R. ornithinolytica. Inflammatory markers were elevated. A transthoracic echocardiogram showed a normal prosthetic valve gradient and an echo-dense space in the mitral-aortic intervalvular fibrosa area associated with perivalvular aortic regurgitation, concerning for IE with perivalvular abscess. Subsequent urgent transfer to a higher center for further management culminated in a successful orthotopic heart transplant due to refractory complications [end-stage heart failure].
Discussion: This case represents the first documented instance of R. ornithinolytica IE necessitating HT. A literature review indicates the median age for HT in IE cases (from any cause) is typically 44 years (23-64 years), predominantly done in males (84%), with aortic valve involvement in 64% of cases and a median interval of 75 days (23-840 days) from diagnosis of IE to HT. Current evidence is sparse regarding HT as a definitive treatment for IE. Literature also suggests that with effective antibiotic therapy in the post-transplantation period, HT may be regarded as a "last ditch" resort in younger patients, without significant comorbidities and persistently negative blood cultures at the time of HT, and without major embolization.
