668496

research-article2016

CPJXXX10.1177/0009922816668496Clinical PediatricsAmdani and Aggarwal

Resident Rounds

Seizures in a Patient With Eczema

Clinical Pediatrics
1­–6
© The Author(s) 2016
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DOI: 10.1177/0009922816668496
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Shahnawaz M. Amdani, MBBS, MD1, Salaam Sallaam, MD1,
and Sanjeev Aggarwal, MD1
Case Report
A 17-year-old female with a past medical history of
bronchial asthma, bipolar disorder and severe atopic
dermatitis was evaluated in the emergency department
(ED) for 1 episode of generalized tonic-clonic seizure
(GTC). The seizure episode was preceded by a 2-day
history of fatigue and frontal headache. Her initial vital
signs were stable except of a temperature of 38°C.
Cardiovascular examination revealed normal heart
sounds with no evidence of a heart murmur, gallop, or
pericardial rub. Laboratory tests showed a normal white
cell counts and differentials, hemoglobin of 9.9 g/dL,
and platelets of 61 000. Blood urea nitrogen and creatinine were elevated at 34 mg/dL and 1.4 mg/dL, respectively. Lactate dehydrogenase and creatinine kinase
were also elevated at 433 and 788. Cerebral spinal fluid
analysis was negative. Blood, urine, and cerebrospinal
fluid cultures were obtained and the patient was started
empirically on ceftriaxone and vancomycin; awaiting
the final cultures results.
The initial chest radiograph and head computed
tomography (CT) were negative. A transthoracic echocardiogram (TTE) showed normal intracardiac anatomy,
normal valve morphology, no intracardiac shunts, normal aortic arch, and normal Doppler across all the
valves. There was no pericardial effusion and biventricular function was normal. The patient was admitted to
the general pediatric floor where she became hypotensive, tachypneic, and hypoxic despite being on a nonrebreather (NRB) mask. A repeat chest radiograph
showed massive pulmonary edema, and she was urgently
transferred to the intensive care unit (ICU) where she
was intubated and started on mechanical ventilation. On
admission to the ICU, she was febrile with a temperature
of 38°C, her blood pressure was 97/54 mm Hg, with a
pulse rate of 89 beats/min, and with an oxygen saturation of 99% on 60% FiO2 via mechanical ventilation. On
cardiac auscultation there was normal S1 and S2 and a
grade 3/6 holosystolic murmur heard at the apex and
radiating to the axilla. There was no diastolic murmur,
gallop, or pericardial rub. Coarse breath sounds were
heard in both sides of lung. Her skin examination
revealed extensive dryness and scarring over her entire
body, with small purple nodules noted on the soles of her
feet and the tips of her fingers.

Laboratory tests obtained on admission showed anemia
with hemoglobin of 9.6 mg/dL, thrombocytopenia with
platelet count of 55 000. Blood urea nitrogen and creatinine were elevated at 34 mg/dL and 1.1 mg/dL, respectively. Troponin I was elevated at 0.95. Her blood and
urine cultures grew methicillin-resistant Staphylococcus
aureus (MRSA).
An electroencephalogram (EEG) showed evidence of
severe neurological dysfunction consisting of slow
background activity during the awake state with poorly
formed sleep spindles during sleep. Head and neck magnetic resonance imaging/angiogram (MRI/MRA) with
contrast showed multiple cortical and subcortical
infarcts with the largest measuring 4.4 cm in the right
frontoparietal region. A repeat TTE 3 days after the initial study showed multiple vegetations on the anterior
and posterior leaflets of the mitral valve. There was
moderate mitral regurgitation with mitral valve stenosis.
There was no pericardial effusion, and she had normal
left ventricular function (Figures 1-5).
The diagnosis of infective endocarditis (IE) was considered “definitive” according to the modified Duke criteria, meeting 2 of the major criteria. Vancomycin was
continued and ceftriaxone was switched to cefepime for
broad antimicrobial coverage. She was also started on
levetiracetam per neurology recommendations. A brain
CT scan ruled out intracranial hemorrhage before she was
taken to the operative room. The surgery was planned for
the infective endocarditis due to the presence of heart failure symptoms refractory to medical management, locally
uncontrolled infection, and multiple embolic events.
Her preoperative transesophageal echocardiography
showed large vegetations involving mitral valve leaflets
with severe mitral valve insufficiency (Figures 6 and 7).
Surgical exploration revealed large, mobile vegetations
along the free edge of the anterior mitral valve leaflet with
a large abscess at the posterolateral commissure and several small abscesses along the posterior leaflet with
involvement of the chordae and the distal tips of the
1

Children’s Hospital of Michigan, Detroit, MI, USA

Corresponding Author:
Shahnawaz M. Amdani, Children’s Hospital of Michigan,
3901 Beaubien Street, Detroit, MI 48201, USA.
Email: shaanamdani@gmail.com

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Clinical Pediatrics 

Figure 1. Transthoracic echocardiogram revealing severe
mitral regurgitation.

papillary muscles. There was no involvement of the mitral
valve annulus or the conduction area. Surgical repair
included debridement of the mitral valve abscesses, and
mitral valve replacement with a 31-mm St Jude mechanical valve in the supra-annular position.
Postoperatively, her peripheral blood culture continued to grow staph aureus, therefore her antibiotics were
changed to cover a possible MRSA prosthetic valve
endocarditis to intravenous cefepim, daptomycin, gentamycin, and levofloxacin. She was extubated 6 days after
surgery with gradual recovery of her mental and functional status. She followed an intensive program of
physical and respiratory rehabilitation, which resulted in
good recovery with some residual left-sided weakness,
changes in speech, and difficulties finding words. She
was discharged home after 3weeks of hospitalization.
Her discharge echocardiogram showed normal functioning prosthetic mitral valve with no stenosis or regurgitation. She continued to have normal left ventricular
function. Three weeks after her discharge she was
admitted to an outside hospital with fatigue, stomach,
and back pain. While trying to get a CT scan for her
head, she arrested and she was resuscitated but never
regained consciousness and subsequently passed away.

Final Diagnosis
The final diagnosis was embolic stroke secondary to
mitral valve MRSA endocarditis.

Discussion

Figure 2. Transthoracic echocardiogram revealing
vegetation in the anterior leaflet of the mitral valve.

Atopic dermatitis is one of the most common chronic
inflamatory skin diseases, affecting up to 20% of children and 1% to 3% of adults.1 Atopic dermatitis is a
common skin condition in children but very few cases
are reported when this condition is associated with acute
native valve endocarditis. Colonization of S aureus is
commonly observed in skin lesions of atopic dermatitis
patients, and scratching of the pruritic lesions may lead
to reiterative bacteremia and endocarditis (see Figure 8).
In native valve endocarditis, S aureus accounts for 30%
to 35% of cases, whereas in a patient with atopic dermatitis, it is found to be exclusively due to S aureus. This
could be the result of frequent staphylococcal bacteremia in patients with atopic dermatitis.2
The combination of antimicrobial peptides known as
cathelicidins (LL-37) and beta-defensins (HBD-2) is
shown to have synergistic antimicrobial activity in the
body for effective killing of S aureus. Ong et al3 suggested
that a deficiency in the expression of those peptides in the
atopic skin may account for the susceptibility of patients
with atopic dermatitis to skin infection with S aureus.

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Amdani and Aggarwal

Figure 3. Transthoracic echocardiogram – Apical view revealing vegetation in the anterior and posterior mitral valve leaflet.

Figure 4. Transthoracic echocardiogram – Parasternal long axis view revealing vegetation in the anterior and posterior mitral
valve leaflet.

Recently, an association between allergic disease and
epilepsy in childhood was reported. Silverberg et al4
found that children with ≥1 allergic disease had a higher
odds of epilepsy compared with nonallergic children in
a US population-based study. They also found that
severe atopic dermatitis was associated with even higher
risk of epilepsy compared with mild/moderate disease.4

Chen et al5 also reported an increased incidence of epilepsy in atopic dermatitis cohort when compared to their
control in Taiwan.
We performed review of the literature regarding
atopic dermatitis and infective endocarditis in children. A total of 4 cases (including ours) were reported
(Table 1).

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Clinical Pediatrics 

Figure 5. Transhoracic echocardiogram – Apical view revealing flow acceleration across the mitral valve secondary to
restricted mobility of the mitral valve leaflets.

Figure 6. Transhoracic echocardiogram – Apical view revealing flow acceleration across the mitral valve secondary to
restricted mobility of the mitral valve leaflets.

The prevalence of endocarditis in patients with S
aureus bacteremia has been reported as 10% to 20%,
and there is increasing agreement that echocardiography
should be a routine procedure in these patients.8,9
Staphylococcus aureus endocarditis course is fulminate
when it involves the mitral or aortic valve, with a widespread metastatic infection and death in approximately
25% to 30% of cases.10 Embolic phenomena occur in

20% to 50% of cases and are frequently the first presentation of infective endocarditis. The occurrence of
embolic events confers a worse prognosis, particularly if
associated with a neurologic event.8,9,11 Approximately
one-fifth of patients with native-valve endocarditis have
ischemic stroke. Moderate to large infarcts were 5 times
more frequent with Staph aureus endocarditis than with
nonvirulent Streptococcus sp. endocarditis.12

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Amdani and Aggarwal

Figure 7. Transesophageal echocardiogram – revealing flow acceleration across the mitral valve secondary to restricted
mobility of the mitral valve leaflets.

Controversy exists regarding the relationship between
corticosteroids and the predisposition to infectious diseases.
The detrimental effects of corticosteroids on host defense
mechanisms are well known, but it is generally agreed that a
short burst leads to few infectious complications, while the
risk is greater to patients on long-term corticosteroid
therapy.13 However, it is believed that some infections are
more common and possibly more severe in corticosteroidtreated patients, namely, staphylococcal, tuberculosis, listeria,
and gram-negative infections in the bacterial group, as well as
certain viral, fungal, and parasitic infections. It seems possible
therefore that the interference, however, small, of corticosteroids particularly systemic steroids with the ability of the
immune system to check the spread of tissue infection and to
clear bacteria from blood, can be sufficient to predispose a
patient to develop bacteremia. Hence, when possible patients
with eczema should be treated with topical steoroids.
In addition to correct surgical treatment, postoperative
antibiotic therapy is essential in acute native valve endocarditis as in our patient, and even after negative blood cultures
have been established, the use of intravenous antibioitics—
followed by oral antibiotics has been recommended.
Figure 8. Pathogenesis of endocarditis (From
Tomás Carmona I, Diz Dios P, Scully C. Efficacy of
antibiotic prophylactic regimens for the prevention of
bacterial endocarditis of oral origin. J Dent Res. 2007
Dec;86(12):1142-59. Reprinted with permission).

Conclusion
Atopic eczema in patients with valvular or structural
heart disease represents a potential risk factor for S

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Clinical Pediatrics 

Table 1. Case Reports of Children With Infective Endocarditis and Atopic Dermatitis.
Author

Age
(Years)

Gender

1

Pike and Warner6

3.5

Male

2

Onoda et al7

16

Male

3

Onoda et al7

14

Male

4

Current case

17

Female Eczema, asthma, high serum
IgE (> 20 000 IU/mL)

Case

Comorbidities
Asthma, high serum IgE
(38 720 µg/L) defective
neutrophils migration
High serum IgE (12 100 IU/
mL)
High serum IgE (13 110 IU/
mL)

CHD
VSD

BCx

Valve
involved

Surgical
treatment

S aureus Tricuspid Vegetectomy, VSD
repair

None MRSA

Aortic

None S aureus Mitral
None MRSA

Mitral

Valve replacement,
annulus repair
Vegetectomy,
commissure
repair
Valve replacement

Abbreviations: BCx, blood culture; CHD, Congenital heart disease; MRSA, methicillin-resistant Staphylococcus aureus; VSD, Ventricular septal
defect.

aureus endocarditis. Patients with eczema who have a
history of native valve endocarditis should be managed
more aggressively for eczema by altering dietary patterns, ensuring adequate skin hydration with emollients
and use of topical steroids as needed to reduce the frequency of flare-ups as these can be the triggers for bacteremia and endocarditis. Physicians caring for such
patients should be aware of this possible association,
and closer attention to skin care plus appropriate anti
staphylococcal measures must be considered in their
management.12
Even with the higher risk of epilepsy in patients with
atopic dermatitis, once must consider the possibility of
septic emboli and infective endocarditis in those patients.
Author Contributions
SMA proposed the idea of the case report, completed the literature review, formed the first draft of the manuscript and edited
the final version of the manuscript. SS completed the literature
review and formed the first draft of the manuscript. SA completed the literature review, helped with the formation of the first
draft of the manuscript and helped with final edition of the
manuscript.

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.

Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.

References
1. Kondo N, Kondo N, Fukuda I. Rising awareness of the
relationship between infective endocaritis and atopic dermatitis. Circ J. 2013;77:1693-1694.

2. Mohiyiddeen G, Brett I, Jude E. Infective endocarditis
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dermatitis: a case report. J Med Case Rep. 2008;2:143.
3. Ong PY, Ohtake T, Brandt C, et al. Endogenous antimicrobial peptides and skin infections in atopic dermatitis. N
Engl J Med. 2002;347:1151-1160.
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study. Allergy. 2014;69:95-103.
5. Chen MH, Wu YH, Su TP, et al. Risk of epilepsy among
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diseases. Med Clin North Am. 1973;57:1277-1287.

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