Published: 2021-05-27

Atypical symptoms with typical signs in a patient with Propionibacterium acnes related mitral valve endocarditis

Rashid Hameed, Noshine Irrum, Pankaj Saxena, Muntaser D. Musameh


Infective endocarditis (IE) is a serious medical condition associated with an increase in morbidity and mortality if not treated promptly and adequately. The clinical outcome depends on the early diagnosis and aggressiveness of the causative organism. Patients usually present with typical features suggestive of Infective endocarditis but in some circumstances the presentations are atypical, and if not diagnosed and treated, may lead to serious consequences. We present a case of atypical presentations of infective endocarditis caused by Propionibacterium acnes organism with no classical features of endocarditis and had symptoms suggestive of urinary tract infection. The diagnosis of IE can be very difficult in patients with atypical clinical presentation, particularly caused by low-pathogenicity organisms. Appropriate clinical assessment and high level of suspicious especially in the patients with previous history of infective endocarditis or having prosthetic valves in situ is crucial.


Infective endocarditis, Propionibacterium acnes, Splinter haemorrhage

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Dickerman SA, Abrutyn E, Barsic B, Bouza E, Cecchi E, Moreno A, et al. The relationship between the initiation of antimicrobial therapy and the incidence of stroke in infective endocarditis: an analysis from the ICE Prospective Cohort Study (ICE-PCS). Am Heart J. 2007;154(6):1086-94.

Nihoyannopoulos P, Oakley CM, Exadactylos N, Ribeiro P, Westaby S, Foale RA. Duration of symptoms and the effects of a more aggressive surgical policy: two factors affecting prognosis of infective endocarditis. Eur Heart J. 1985;6(5):380-90.

Lodise TP, Kinnon PS, Swiderski L, Rybak MJ. Outcomes analysis of delayed antibiotic treatment for hospital-acquired Staphylococcus aureus bacteremia. Clin Infect Dis. 2003;36(11):1418-23.

Grice EA, Segre JA. The skin microbiome. Nat Rev Microbiol. 2011;9(4):244-53.

Jakab E, Zbinden R, Gubler J, Ruef C, Graevenitz A, Krause M. Severe infections caused by Propionibacterium acnes: an underestimated pathogen in late postoperative infections. Yale J Biol Med. 1996;69(6):477-82.

Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. J Am Dent Assoc. 2007;138(6):739-45.

Piggott DA, Higgins YM, Melia MT, Ellis B, Carroll KC, Farland EG, et al. Characteristics and Treatment Outcomes of Propionibacterium acnes Prosthetic Shoulder Infections in Adults. Open Forum Infect Dis. 2015;3(1):191.

Cooper ME, Trivedi NN, Sivasundaram L, Karns MR, Voos JE, Gillespie RJ. Diagnosis and Management of Periprosthetic Joint Infection After Shoulder Arthroplasty. JBJS Rev. 2019;7(7):3.

Achermann Y, Goldstein EJ, Coenye T, Shirtliff ME. Propionibacterium acnes: from commensal to opportunistic biofilm-associated implant pathogen. Clin Microbiol Rev. 2014;27(3):419-40.

Noel W, Hammoudi N, Wegorowska E, Alessandro C, Steichen O. Pacemaker endocarditis caused by Propionibacterium acnes: a case report. Heart Lung. 2012;41(6):21-3.

Lalani T, Person AK, Hedayati SS, Moore L, Murdoch DR, Hoen B, et al. Propionibacterium endocarditis: a case series from the International Collaboration on Endocarditis Merged Database and Prospective Cohort Study. Scand J Infect Dis. 2007;39(10):840-8.

Sohail MR, Gray AL, Baddour LM, Tleyjeh IM, Virk A. Infective endocarditis due to Propionibacterium species. Clin Microbiol Infect. 2009;15(4):387-94.

Weinstein MP. Blood culture contamination: persisting problems and partial progress. J Clin Microbiol. 2003;41(6):2275-8.

Clayton JJ, Baig W, Reynolds GW, Sandoe JAT. Endocarditis caused by Propionibacterium species: a report of three cases and a review of clinical features and diagnostic difficulties. J Med Microbiol. 2006;55(8):981-7.

Olsson J, Davidsson S, Unemo M, Molling P, Andersson SO, Andren O, Soderquist B, et al. Antibiotic susceptibility in prostate-derived Propionibacterium acnes isolates. APMIS. 2012;120(10):778-85.

Khassebaf J, Hellmark B, Davidsson S, Unemo M, Nilsdotter AA, Soderquist B. Antibiotic susceptibility of Propionibacterium acnes isolated from orthopaedic implant-associated infections. Anaerobe. 2015;32:57-62.

Murdoch DR, Corey GR, Hoen B, Miro JM, Fowler VG, Bayer AS, et al. Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century: the International Collaboration on Endocarditis-Prospective Cohort Study. Arch Intern Med. 2009;169(5):463-73.

Delahaye F, Fol S, Celard M, Vandenesch F, Beaune J, Bozio A, Gevigney G. Endocardites infectieuses a Propionibacterium acnes. Arch Mal Coeur Vaiss. 2005;98(12):1212-8.

Park HJ, Na S, Park SY, Moon SM, Cho OH, Park KH, et al. Clinical significance of Propionibacterium acnes recovered from blood cultures: analysis of 524 episodes. J Clin Microbiol. 2011;49(4):1598-601.

Del PJL, Patel R. Clinical practice. Infection associated with prosthetic joints. N Engl J Med. 2009;361(8):787-94.