Myasthenia, Spondylitis and Enterococcus faecalis Endocarditis

Parasympathomimetics, immunosuppression and plasmapheresis have considerably improved management and prognosis of myasthenia gravis. Side effects of these measures, however, may complicate the course of the disease. In a 66-year-old male with myasthenia gravis and lower back pain, blood cultures, echocardiography and magnetic resonance imaging led to the diagnosis of endocarditis and spondylodiscitis. Enterococcus faecalis grew in the blood cultures as well as on the aortic and tricuspid valve vegetations which were resected during cardiac surgery. Possible sources of the infection might be E. faecalis infections of catheter tips during a 46-day stay in the intensive care unit 11 months earlier where he had undergone plasmapheresis, hemodiafiltration and mechanical ventilation, or recurrent diarrheas since 18 months. Infection was favored by immunosuppression with glucocorticoids and azathioprine which received the patient because of myasthenia gravis and hypothyroidism. Patients with myasthenia gravis require close follow up, including infection parameters, especially when they receive immunosuppressive therapy and when microorganisms known to cause endocarditis, are identified.