title: Case series of infective endocarditis caused by Granulicatella species.
abstract: BACKGROUND
  Nutritionally variant streptococci (NVS) are Gram-positive cocci characterized by their dependence on pyridoxal or cysteine supplementation for growth in standard blood culture media. They are responsible for severe infections in immunocompetent and immunosuppressed hosts, including infective endocarditis (IE). NVS have been divided into two different genera, Granulicatella and Abiotrophia.
  
  
  METHODS
  We report four cases of IE caused by Granulicatella species, including clinical presentation, echocardiographic characteristics, treatments received, and outcomes. We also performed a literature search for previously reported cases of IE caused by Granulicatella species to better characterize this condition.
  
  
  RESULTS
  A total of 29 cases of Granulicatella endocarditis were analyzed, including the four newly reported cases. The aortic (44%) and mitral (38%) valves were those most commonly affected. Multivalvular involvement was observed in 13% of cases. The mean vegetation length was 16mm. Complications were frequent, including heart failure (30%), embolism (30%), and perivalvular abscess (11%). The most frequent antibiotic regimen (85%) was penicillin or one of its derivatives plus gentamicin. The mortality rate was 17%.
  
  
  CONCLUSIONS
  Endocarditis due to Granulicatella species is a rare and severe condition. Complications are frequent despite the use of appropriate antibiotic regimens.
authors.affiliation: Heart Institute (InCor), University of Sao Paulo Medical School, Av. Dr. Eneas de Carvalho Aguiar, 44, Bloco 1, sala CCIH, Cerqueira Cesar-SP, Sao Paulo, 05403-000, Brazil. Electronic address: eduardo.adam@incor.usp.br.
authors.forename: Eduardo Leal
authors.initials: EL
authors.lastname: Adam
authors.affiliation: Heart Institute (InCor), University of Sao Paulo Medical School, Av. Dr. Eneas de Carvalho Aguiar, 44, Bloco 1, sala CCIH, Cerqueira Cesar-SP, Sao Paulo, 05403-000, Brazil.
authors.forename: Rinaldo Focaccia
authors.initials: RF
authors.lastname: Siciliano
authors.affiliation: Heart Institute (InCor), University of Sao Paulo Medical School, Av. Dr. Eneas de Carvalho Aguiar, 44, Bloco 1, sala CCIH, Cerqueira Cesar-SP, Sao Paulo, 05403-000, Brazil.
authors.forename: Danielle Menosi
authors.initials: DM
authors.lastname: Gualandro
authors.affiliation: Heart Institute (InCor), University of Sao Paulo Medical School, Av. Dr. Eneas de Carvalho Aguiar, 44, Bloco 1, sala CCIH, Cerqueira Cesar-SP, Sao Paulo, 05403-000, Brazil.
authors.forename: Daniela
authors.initials: D
authors.lastname: Calderaro
authors.affiliation: Heart Institute (InCor), University of Sao Paulo Medical School, Av. Dr. Eneas de Carvalho Aguiar, 44, Bloco 1, sala CCIH, Cerqueira Cesar-SP, Sao Paulo, 05403-000, Brazil.
authors.forename: Victor Sarli
authors.initials: VS
authors.lastname: Issa
authors.affiliation: Heart Institute (InCor), University of Sao Paulo Medical School, Av. Dr. Eneas de Carvalho Aguiar, 44, Bloco 1, sala CCIH, Cerqueira Cesar-SP, Sao Paulo, 05403-000, Brazil.
authors.forename: Flavia
authors.initials: F
authors.lastname: Rossi
authors.affiliation: Heart Institute (InCor), University of Sao Paulo Medical School, Av. Dr. Eneas de Carvalho Aguiar, 44, Bloco 1, sala CCIH, Cerqueira Cesar-SP, Sao Paulo, 05403-000, Brazil.
authors.forename: Bruno
authors.initials: B
authors.lastname: Caramelli
authors.affiliation: Heart Institute (InCor), University of Sao Paulo Medical School, Av. Dr. Eneas de Carvalho Aguiar, 44, Bloco 1, sala CCIH, Cerqueira Cesar-SP, Sao Paulo, 05403-000, Brazil.
authors.forename: Alfredo Jose
authors.initials: AJ
authors.lastname: Mansur
authors.affiliation: Heart Institute (InCor), University of Sao Paulo Medical School, Av. Dr. Eneas de Carvalho Aguiar, 44, Bloco 1, sala CCIH, Cerqueira Cesar-SP, Sao Paulo, 05403-000, Brazil.
authors.forename: Tania Mara Varejao
authors.initials: TM
authors.lastname: Strabelli
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D056568:Carnobacteriaceae; D004697:Endocarditis, Bacterial / Q000175:diagnosis* / Q000188:drug therapy / Q000382:microbiology; D005260:Female; D016908:Gram-Positive Bacterial Infections / Q000175:diagnosis* / Q000188:drug therapy / Q000382:microbiology; D006801:Humans; D008297:Male; D008875:Middle Aged
keywords: Endocarditis; Granulicatella spp; Nutritionally variant streptococci