NEUROLOGIC MANIFESTATIONS IN STAPHYLOCOCCUS-AUREUS ENDOCARDITIS - A REVIEW OF 260 BACTEREMIC CASES IN NONDRUG ADDICTS

PURPOSE: To investigate the neurologic manifestations of infective end ocarditis caused by Staphylococcus aureus in a population of nondrug a ddicts with special emphasis on the clinical presentation, epidemiolog y, and mortality. PATIENTS AND METHODS: During the period from 1982 to 1991 a total of 8.514 cases of bacteremia with S aureus were reported to the Staphylococcus Laboratory, Copenhagen, Denmark. The medical re cords of cases of suspected infective endocarditis were retrospectivel y reviewed and classified according to the new diagnostic criteria for endocarditis proposed by Durack. RESULTS: A total of 260 cases from 6 3 hospitals fulfilled the diagnostic criteria. Overall, 91 patients (3 5%) experienced neurologic manifestations. Sixty-one presented with ne urologic symptoms, whereas 30 patients developed neurologic complicati ons at various intervals (median: 10 days) after the debut of the dise ase. The most frequent neurologic manifestation was unilateral hemipar esis, which occurred in 41 patients (45%). Forty-two percent of the fe males had neurologic manifestations compared to only 30% of the males (P = 0.06). Cases with native mitral valve infection had a significant ly higher frequency of neurologic manifestations compared with all oth er valvular involvement (44% versus 29%, P = 0.02) but the frequency o f neurologic complications was only nonsignificantly higher in those p atients with native mitral valve infection than in those patients with native aortic valve infection (44% versus 31%, P = 0.10). Only two of the patients with tricuspid valve infection and none of those with co ngenital heart disorder experienced neurologic manifestations. A neuro logic manifestation occurred in 22 (35%) of the 63 episodes in which v egetations were detected on the echocardiograms, compared with 17 (26% ) of the 65 episodes Without vegetations (P = 0.38). The mortality was 74% in patients with major neurologic manifestations and 56% in patie nts without neurologic manifestations (P = 0.008); In patients with ne urologic complications the mortality was significantly higher among th ose treated with antibiotics alone as compared with those treated surg ically (65 of 81, 80% versus 2 of 10, 20%; P = 0.0003). CONCLUSIONS: I n a population of nondrug addicts with infective endocarditis caused b y S aureus the following main conclusions can be drawn: neurologic man ifestations occur with a higher frequency in patients with native mitr al valve infection. The presence of vegetations on echocardiograms is not a risk factor for developing neurologic complications but this con clusion is based on the results of transthoracic echocardiograms perfo rmed in only one half of the patients. The majority of the neurologic manifestations occur on presentation or shortly thereafter and the ris k of recurrent embolism is low. Mortality is increased in patients wit h neurologic manifestations. A neurologic event per se may constitute an indication for surgical treatment. (C) 1997 by Excerpta Medica, Inc .