CASE REPORT “Kissing” Vegetation in a Rare Case of Infective Endocarditis by Gemella sanguinis Sameer Chadha, MD, On Chen, MD, Vijay Shetty, MD, Adnan Sadiq, MD, Gerald Hollander, MD, Robert Frankel, MD and Jacob Shani, MD Abstract: Infective endocarditis (IE) is usually caused by Streptococ- cus, Staphylococcus or Enterococcus species or slow-growing HACEK organisms. We report an extremely rare case of IE caused by Gemella sanguinis. Key Indexing Terms: Kissing vegetation; Infective endocarditis; Gemella sanguinis. [Am J Med Sci 2013;345(6):507–508.] A 73-year-old male with history of hypertension came to our emergency department with complaints of generalized fatigue and malaise for 2 weeks. The review of systems was negative for any cough, abdominal pain, nausea, vomiting, diar- rhea or urinary complaints. The patient also denied any chest pain, shortness of breath or palpitations but did report a recent decrease in exercise tolerance due to weakness. On vital signs, the patient was found to be febrile with a temperature of 102.2°F. The physical exam was significant for an early diastolic murmur of aortic regurgitation heard best in the left third intercostal space and a holosystolic murmur of mitral regur- gitation heard best at the apex. The laboratory work showed a white count of 12.9 K/UL and elevated acute phase reactants (C-reactive protein— 17.3 mg/dL and erythrocyte sedimentation rate— 110 mm/hr). The chest X-ray showed no evidence of any acute cardio- pulmonary disease and the urinalysis was also negative. The echocardiogram revealed a large highly mobile vegetation on the aortic valve “kissing” the anterior leaflet of mitral valve, along with severe aortic regurgitation and mitral regurgitation (Figures 1 and 2, Video 1, Supplemental Digital Content 1, http://links.lww.com/MAJ/A23). The blood cultures grew gram-positive cocci in pairs, identified as Gemella sanguinis. A diagnosis of infective endocarditis (IE) was made according to the modified Duke’s criteria and patient was started on intravenous daptomycin and gentamicin. He responded extremely well to the treatment and after the blood cultures were negative, underwent a successful bioprosthetic aortic and mitral valve replacement. Gemella sp. consists of catalase-negative, facultatively anaerobic and Gram-positive coccoid organisms that grow in clusters, pairs or chains. They are normal commensals of the oral mucosa, gastrointestinal and genitourinary tracts. Gemella morbillorum and Gemella haemolysans have been previously associated with IE. However, G sanguinis is an extremely rare cause of IE. There have been only 5 prior reported cases of IE due to G sanguinis. 1–5 Collins et al 1 described for the first time G sanguinis as the cause of IE in 1998. Gundre et al 4 described the first case of prosthetic valve endocarditis caused by G sanguinis as a conse- quence of persistent dental infection. All cases of the G sanguinis IE were associated with a preexisting valvular condition like rheu- matic heart disease, repaired ventricular septal defect, prosthetic valves, regurgitant valvular lesions or a dental infection as the source of bacteremia. A prolonged course of parenteral antibiotic FIGURE 1. Parasternal long axis view showing vegetation on the aortic valve. LA, left atrium; LV, left ventricle, Ao, aorta; RV, right ventricle; AL, anterior leaflet of the mitral valve; PL, posterior leaflet of the mitral valve; V, vegetation. FIGURE 2. Parasternal long axis view showing vegetation “kissing” anterior leaflet of the mitral valve. LA, left atrium; LV, left ventricle, Ao, aorta; RV, right ventricle; AL, anterior leaflet of the mitral valve; PL, posterior leaflet of the mitral valve; V, vegetation. From the Department of Cardiology, Maimonides Medical Center, Brooklyn, New York. Submitted October 17, 2013; accepted in revised form October 31, 2012. The authors have no financial or other conflicts of interest to disclose. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.amjmedsci.com). Correspondence: Sameer Chadha, MD, 950 49th Street, Apt 7E, Brooklyn, NY 11219 (E-mail: sameer_n_heart@yahoo.co.in). The American Journal of the Medical Sciences  Volume 345, Number 6, June 2013 507