Watch out for the Saurkraut: Weissella confusa endocarditis in a liver transplant candidate

A 65yearold Caucasian male with alcohol associated cirrhosis, ChildPugh Classification C, a MELDsodium score of 18, and currently undergoing liver transplant evaluation, presented to the hospital with confusion, weakness, and weight loss. He reported a gallbladder stent placement 19 months ago for chronic cholecystitis, endoscopic resection of an ampullary adenoma 10 months ago, and a transjugular intrahepatic portosystemic shunt (TIPS) placement for refractory ascites 17 months ago. His initial temperature was 36.6 Celsius, blood pressure 109/65 mm Hg, respiratory rate 16 per minute, and regular heart rate of 60 beat per minute. Initial physical exam showed systolic murmur grade 3, abdominal exam with slightly distended abdomen, alert and oriented to person but not place or time, and presence of asterixis. He denied a history of recreational drug use, smoking, or recent alcohol intake. His home medications included furosemide 20 mg daily, spironolactone 25 mg daily, rifaximin 550 mg twice daily, lactulose 30 gram twice daily, zinc sulfate 50 mg twice daily, ursodiol 300 mg twice daily, and ropinirole 0.25 mg at bedtime. Pertinent admission laboratory findings included a white blood cell count (WBC) of 13.3 k/ml with a left shift and stable liver biochemistries with aspartate aminotransferase 40 U/L, alanine aminotransferase 17 U/L, alkaline phosphatase 133 U/L, total bilirubin 1.4 mg/dl, albumin 2.0 g/dl, sodium 132 mmol/L, platelet 133 K/μl, and international normalized ratio (INR) 1.4 (calculated MELD score 14). He had a negative chest xray and urinalysis (Table 1) but blood cultures grew grampositive rods in less than 24 hours that were speciated as Weissella confusa. Vancomycin was started following the blood culture results. However, repeat blood cultures the following day showed persistent Weissella confusa bacteremia. On further questioning, he reported eating saurkraut on a weekly basis for several years but had no unusual new food exposures, sick contacts, or recent travel. An infectious disease consultant recommended to switch from vancomycin to ampicillin 2 gram every 6 hours. Repeat blood cultures on day 4, 6, and 7 were negative. A transthoracic echocardiography (TTE) showed evidence of thickened aortic and mitral valve likely degenerative calcification. A transesophageal echocardiography (TEE) was recommended with the suspicion of infective endocarditis (IE) from the association between Weissella confusa bacteremia and IE per previous literature. In comparison of TEE versus TTE, TEE has higher sensitivity to detect IE in those with prolonged bacteremia, unknown source of bacteremia, persistent fever, and preexisting valvular disease.1,2 Because of the need for TEE, the gastroenterology team was consulted for upper endoscopy to screen for esophageal varices prior to the TEE. After discussion with the cardiology team, the TEE was completed without the need for a preoperative upper endoscopy. The TEE demonstrated new moderate aortic regurgitation, a thickened aortic valve consistent with aortic stenosis, but no obvious mobile vegetation. However, a multidisciplinary team conference recommended to proceed with a positron emission tomography to look for disseminated disease since positive findings would strongly support the diagnosis.3 Interestingly, the positron emission tomography scan showed a metabolically active focus adjacent to the aortic valve consistent with IE but no extracardiac foci indicative of dissemination. The patient was treated with penicillin V 4 million units every 4 hours for 2 weeks followed by oral Received: 22 February 2022 | Accepted: 4 August 2022