Hyperbaric Oxygen Therapy for the Adjunctive Treatment of Stroke Associated with Post-Cardiac Surgery Due To Native-Valve Endocarditis Infected by Cutibacterium Acnes: A Case Report

Hyperbaric Oxygen Therapy for the Adjunctive Treatment of Stroke Associated with Post-Cardiac Surgery Due To Native-Valve Endocarditis Infected by Cutibacterium Acnes: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case report Hyperbaric Oxygen Therapy for the Adjunctive Treatment of Stroke Associated with Post-Cardiac Surgery Due To Native-Valve Endocarditis Infected by Cutibacterium Acnes : A Case Report Pei-Ku Chen, Tzu-Ting Kuo, Szu-Ying Lin, Jiang-Hwa Kao, Yen-Wen Chen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-861270/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Stroke is an uncommon but significant complication of cardiac surgery. Cutibacterium (previously known as Propionibacterium) rarely causes infective endocarditis (IE), accounting for approximately 0.3% of all IE cases. Hyperbaric oxygen therapy (HBOT), involving the administration of 100% oxygen at a pressure of > 1.4 atmospheres absolute, increases the partial pressure of oxygen; therefore, it is recommended as an adjunctive treatment for stroke and some infections. However, there are no data supporting HBOT as an adjunctive therapeutic option for ischemic stroke related to post-cardiac surgery due to IE caused by Cutibacterium acnes . Case presentation: This study reports the case of an 68-year-old male patient who underwent cardiac surgery for native-valve IE caused by C . acnes . He underwent HBOT on postoperative day 11 for the treatment of ischemic stroke. The patient received 20 sessions of HBOT along with 6-week antimicrobial treatment with ceftriaxone and rehabilitation programs. Conclusions We have summarized the patient’s successful recovery and our clinical experience regarding the use of HBOT in our clinical setting. HBOT is an effective adjunctive therapeutic option for ischemic stroke related to post-cardiac surgery due to IE caused by C . acne s. Cardiac & Cardiovascular Systems Cardiothoracic Surgery Cutibacterium (Propionibacterium) acnes Hyperbaric oxygen therapy Infective endocarditis Stroke Background Hyperbaric oxygen therapy (HBOT), administration of 100% oxygen at pressures greater than 1.4 atmospheres absolute (ATA), increases the partial pressure of oxygen in the patient’s blood. HBOT, as a non-drug and non-invasive treatment, has been applied in the treatment of stroke since 1960s. It is proposed for the treatment of strokes based on pathophysiological principles that suggest it may decrease intracranial pressure and reduce cerebral edema, decrease lipid peroxidation, and stabilize the blood-brain barrier [ 1 – 3 ]. However, the use of HBOT for acute stroke remains controversial [ 3 , 4 ]. One prospective trial demonstrates that HBOT can prompt the neuroplasticity of brain tissues in post-stroke patients, even in the chronic phase [ 5 ]. Stroke is one of the major complications of cardiac surgery. Regarding perioperative stroke in cardiac surgery, the incidence of which varies according to the procedure, 2–13% of patients experience neurological sequelae during the postoperative period [ 6 – 8 ]. The effects of HBOT on post-cardiac surgery ischemic stroke are unclear and lack adequate evidence. HBOT is also useful in wound healing as well as deep and chronic infections such as osteomyelitis, necrotizing fasciitis, and chronic soft-tissue infection [ 9 , 10 ]. However, studies regarding its role in treating infective endocarditis (IE) are limited. A rat model of Staphylococcus aureus -caused IE showed that as an adjunctive therapy, HBOT reduced bacterial load and proinflammatory cytokine levels by augmenting the efficacy of tobramycin [ 11 ]. The mechanism underlying the synergistic effects of HBOT with antimicrobial agents against Cutibacterium acnes -caused IE, accounting for approximately 0.3% of all IE cases [ 12 ], remains unclear. Therefore, the present report describes a patient who underwent cardiac surgery due to native-valve IE caused by Cutibacterium acnes and was subsequently treated with HBOT for ischemic stroke during his surgical recovery. Case Presentation A 68-year-old man underwent mitral and tricuspid valve annuloplasty and aortic valve replacement, resulting from IE. The patient presented with congestive heart failure, pulmonary hypertension (right ventricular systolic pressure upon admission was 99.7 mmHg) and severe aortic regurgitation causing from right coronary cusp perforation. The patient’s only comorbidity was gout. Preoperatively, there was insufficient evidence of IE, however, the postoperative tissue culture yielded C. acnes . The patient was experiencing left-sided hemiparesis and left homonymous hemianopia (National Institute of Health Stroke Scale: 14) after awaking from anesthesia postoperatively (day 0). The muscle power assessment with the Medical Research Council’s (MRC) scale was grade zero in the patient’s left limbs, with sensory loss at the left foot and calf. Computed tomography revealed no intracranial hemorrhage or proximal large vessel occlusion. Thrombolysis was not performed because the patient was still recuperating from major surgery. Magnetic resonance imaging of the brain revealed hyperintensity on diffusion-weighted imaging and hypointensity on apparent diffusion coefficient values involving the right high frontal and parietal areas of the brain, compatible with acute ischemic stroke. He underwent HBOT on postoperative day 11 for the treatment of ischemic stroke. The treatment protocol for HBOT was 90 minutes at 2.5 ATA with two air breaks, followed by a 15-minute compression and a 15-minute decompression. The patient received 20 sessions of HBOT along with 6-week antimicrobial treatment with ceftriaxone and rehabilitation programs. The patient’s muscle power recovered to MRC scale grade 4 + with minimal left-sided weakness. He was able to stand and walk slowly unassisted when he was discharged from the acute care ward. The patient was recovering well at his six months follow-up visit. He could move his limbs freely without assistance and his heart function was good although he had mild claw toes on the left foot and limited left ankle plantar flexion and dorsiflexion. Discussion And Conclusions This case report describes our experience using HBOT in a patient who underwent cardiac surgery due to native-valve endocarditis infected with C. acnes and experienced a post-surgery ischemic stroke. Based on pathophysiological principles and our clinical experience, we believe that HBOT benefited our patient. Possible mechanisms for the development of post-cardiac surgical strokes include atheromatous plaque fragments dislodged from the aorta during cross-clamping, decreased cerebral perfusion, and gas embolisms [ 6 , 7 , 13 ]. Cerebral edema and neuronal apoptosis follow the passage of air bubbles, inducing endothelial damage and an inflammatory response. This may lead to endothelial swelling, increased vascular resistance, leucocyte and platelet adherence, and damage to the blood-brain barrier. There is a major risk of significant air embolisms during procedures in which the left ventricle or aorta are opened, such as in valve replacement surgery [ 13 ], which could explain why our patient experienced a post-operative stroke. Similar Gibson et al [ 13 ], HBOT was administered for our patient in treating post-cardiac surgical stroke, basing on the reason that cerebral air embolism is the likely etiology theoretically and the nature of the operation the patient had received. HBOT also has bactericidal and bacteriostatic effects on both aerobic and anaerobic bacteria [ 14 ]. HBOT may have a direct antimicrobial effect, enhance the antimicrobial effects of the immune system, or work synergistically with certain antimicrobial agents [ 14 ]. The culture from the patient tissue showed the presence of C. acnes , a gram-positive anaerobic bacillus that is ubiquitous in the skin flora. Banzon et al [ 15 ] reported that the most common antibiotics used for the treatment of C. acnes infection were vancomycin (59%) and ceftriaxone (25%). Furthermore, the use of beta-lactams (benzylpenicillin was the most frequently used) and the addition of rifampicin or aminoglycosides for cases of C. acnes endocarditis have been elucidated in previous studies [ 16 ]. The antimicrobial therapy for C. acnes in combination with HBOT has not been previously addressed, and our case was the first to apply HBOT in this setting. HBOT has proven effective adjunctive treatment in chronic Lyme disease, clostridial myonecrosis, necrotizing fasciitis, and refractory osteomyelitis [ 9 , 17 ]. The antimicrobial effects of HBOT are believed to result from the formation of reactive oxygen species (ROS) [ 14 ], the reactive radicals that are continually produced as alternative metabolites of several cell biological pathways. HBOT promotes aerobic metabolism, leading to enhanced ROS production in bacteria. HBOT aims to induce the aerobic metabolism of bacteria and to reoxygenate the O 2 -depleted infectious tissues, thereby increasing the microbial susceptibility to antibiotics. In our patient, there was not enough evidence of IE preoperatively until the tissue culture was obtained. We believe that the debridement was not performed completely, and the bacteria were still present. Consequently, HBOT was considered an effective adjunctive therapeutic option in our case. Finally, HBOT facilitates wound healing by inducing angiogenesis [ 18 , 19 ] and suppressing interferon-γ and proinflammatory cytokines such as interleukin (IL)-1, IL-6, and tumor necrosis factor-α [ 18 ]. HBOT induces partial high tension of oxygen in the circulating plasma and stimulates oxygen-dependent collagen matrix formation, an essential phase in wound healing [ 20 ]. Our patient had undergone major open-heart surgery, including pericardiotomy and sternotomy, aortic valve replacement, tricuspid annuloplasty, mitral annuloplasty, and aortotomy. We believe that HBOT accelerated his wound healing and recovery, benefiting our patient enough for him to participate in rehabilitation programs within first month, which is considered the gold recovery phase after a stroke. In conclusion, our patient demonstrated good recovery from ischemic stroke related to post-cardiac surgery due to IE infection by C. acnes despite a delay of one week before HBOT initiation. HBOT was effective as an adjunctive therapeutic option in our setting, However, evidence on when to apply HBOT and the number of intervention cycles for effective therapeutic outcomes requires further studies. Abbreviations HBOT Hyperbaric oxygen therapy ATA Atmospheres absolute IE Infective endocarditis MRC Medical Research Council’s ROS Reactive oxygen species IL Interleukin Declarations Availability of data and materials: The datasets used and analyzed during the current study are available from the corresponding author on reasonable request. Ethics approval and consent to participate: Not applicable. Consent for publication: Written informed consent was obtained from the patient for publication of this case report. Competing interests : The authors have no conflicts of interests to disclose. Funding: This research did not receive any grant from funding agencies in the public, commercial or not-for-profit sectors. Authors’ contributions: Writing-original draft: P.K.C, T.T.K. Writing-review & editing: P.K.C, S.Y.L, J.H.K, Y.W.C. Patient care: T.T.K, S.Y.L. Supervision: Y.W.C. Validation: T.T.K, S.Y.L, J.H.K, Y.W.C All authors read and approved the final manuscript. Acknowledgment The authors would like to thank all the healthcare workers in the Taipei Veterans General Hospital and Taipei Municipal Gan-Dau Hospital for their valuable contribution to patient care, as well as, Vikas Narang, Editaghe, a division of Cactus Communications for the help with language editing. References Calvert JW, Cahill J, Zhang JH. Hyperbaric oxygen and cerebral physiology. Neurol Res. 2007;29(2):132–41. Veltkamp R, Siebing DA, Sun L, Heiland S, Bieber K, Marti HH, et al. Hyperbaric oxygen reduces blood-brain barrier damage and edema after transient focal cerebral ischemia. Stroke. 2005;36(8):1679–83. Bennett MH, Weibel S, Wasiak J, Schnabel A, French C, Kranke P. Hyperbaric oxygen therapy for acute ischaemic stroke. Cochrane Database Syst Rev. 2014;11:CD004954. Ding Z, Tong WC, Lu X-X, Peng H-P. Hyperbaric oxygen therapy in acute ischemic stroke: a review. Interv Neurol. 2014;2(4):201–11. Efrati S, Fishlev G, Bechor Y, Volkov O, Bergan J, Kliakhandler K, et al. Hyperbaric oxygen induces late neuroplasticity in post stroke patients-randomized, prospective trial. PLoS One. 2013;8(1):e53716. Roach GW, Kanchuger M, Mangano CM, Newman M, Nussmeier N, Wolman R, et al. Adverse cerebral outcomes after coronary bypass surgery. Multicenter Study of Perioperative Ischemia Research Group and the Ischemia Research and Education Foundation Investigators. N Engl J Med. 1996;335(25):1857–63. McKhann GM, Grega MA, Borowicz LM Jr, Baumgartner WA, Selnes OA. Stroke and encephalopathy after cardiac surgery: an update. Stroke. 2006;37(2):562–71. Chen PK, Shih CC, Lin FC, Perng DW, Chou KT, Kou YR, et al. Prolonged use of noninvasive positive pressure ventilation after extubation among patients in the intensive care unit following cardiac surgery: The predictors and its impact on patient outcome. Sci Rep. 2019;9(1):9539. Tibbles PM, Edelsberg JS. Hyperbaric-oxygen therapy. N Engl J Med. 1996;334(25):1642–8. Yu WK, Chen YW, Shie HG, Lien TC, Kao HK, Wang JH. Hyperbaric oxygen therapy as an adjunctive treatment for sternal infection and osteomyelitis after sternotomy and cardiothoracic surgery. J Cardiothorac Surg. 2011;6:141. Lerche CJ, Christophersen LJ, Kolpen M, Nielsen PR, Trøstrup H, Thomsen K, et al. Hyperbaric oxygen therapy augments tobramycin efficacy in experimental Staphylococcus aureus endocarditis. Int J Antimicrob Agents. 2017;50(3):406–12. Lalani T, Person AK, Hedayati SS, Moore L, Murdoch DR, Hoen B, et al. Propionibacterium endocarditis: a case series from the International Collaboration on Endocarditis Merged Database and Prospective Cohort Study. Scand J Infect Dis. 2007;39(10):840–8. Gibson AJ, Davis FM. Hyperbaric oxygen therapy in the treatment of post cardiac surgical strokes-a case series and review of the literature. Anaesth Intensive Care. 2010;38(1):175–84. Memar MY, Yekani M, Alizadeh N, Baghi HB. Hyperbaric oxygen therapy: antimicrobial mechanisms and clinical application for infections. Biomed Pharmacother. 2019;109:440–7. Banzon JM, Rehm SJ, Gordon SM, Hussain ST, Pettersson GB, Shrestha NK. Propionibacterium acnes endocarditis: a case series. Clin Microbiol Infect. 2017;23(6):396–9. Lindell F, Söderquist B, Sundman K, Olaison L, Källman J. Prosthetic valve endocarditis caused by Propionibacterium species: a national registry-based study of 51 Swedish cases. Eur J Clin Microbiol Infect Dis. 2018;37(4):765–71. Huang CY, Chen YW, Kao TH, Kao HK, Lee YC, Cheng JC, et al. Hyperbaric oxygen therapy as an effective adjunctive treatment for chronic Lyme disease. J Chin Med Assoc. 2014;77(5):269–71. Benson RM, Minter LM, Osborne BA, Granowitz EV. Hyperbaric oxygen inhibits stimulus-induced proinflammatory cytokine synthesis by human blood-derived monocyte-macrophages. Clin Exp Immunol. 2003;134(1):57–62. Sureda A, Batle JM, Martorell M, Capó X, Tejada S, Tur JA, et al. Antioxidant response of chronic wounds to hyperbaric oxygen therapy. PLoS One. 2016;11(9):e0163371. Godman CA, Chheda KP, Hightower LE, Perdrizet G, Shin DG, Giardina C. Hyperbaric oxygen induces a cytoprotective and angiogenic response in human microvascular endothelial cells. Cell Stress Chaperones. 2010;15(4):431–42. Supplementary Files CAREchecklistEnglish20131.pdf Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-861270","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case report","associatedPublications":[],"authors":[{"id":52222000,"identity":"f0056dfa-963c-4b21-bed7-d312e7939418","order_by":0,"name":"Pei-Ku Chen","email":"","orcid":"https://orcid.org/0000-0001-6421-7135","institution":"Taipei Municipal Gan-Dau Hospital","correspondingAuthor":false,"prefix":"","firstName":"Pei-Ku","middleName":"","lastName":"Chen","suffix":""},{"id":52222001,"identity":"3c261fad-39cb-4748-8c92-1c6944085b8b","order_by":1,"name":"Tzu-Ting Kuo","email":"","orcid":"","institution":"Taipei Veterans General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Tzu-Ting","middleName":"","lastName":"Kuo","suffix":""},{"id":52222002,"identity":"81b76acd-dfbd-4d62-a722-ea48142befab","order_by":2,"name":"Szu-Ying Lin","email":"","orcid":"","institution":"Taipei Municipal Gan-Dau Hospital","correspondingAuthor":false,"prefix":"","firstName":"Szu-Ying","middleName":"","lastName":"Lin","suffix":""},{"id":52222003,"identity":"e1febe08-1fdc-4bbb-9187-93a55474405c","order_by":3,"name":"Jiang-Hwa Kao","email":"","orcid":"","institution":"Taipei Municipal Gan-Dau Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jiang-Hwa","middleName":"","lastName":"Kao","suffix":""},{"id":52222004,"identity":"bbc06c10-d38c-4255-832a-5099fe8f5cd1","order_by":4,"name":"Yen-Wen Chen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAuklEQVRIiWNgGAWjYHACNiD+JwdiHXhAgpYDxmAtCaRoSWwAMYnSYnAj+dmDjzvupM8PO/wQaIudnG4DQS1p5oYzzzzL3Xg7zQCoJdnY7AAhLbdz2KR525hzN85OAGk5kLiNKC1/25jTDWenfyBBC2Pb4QR56RwibZG8/8xMsrctzXCDdE7BgQQDIvzCd+bwM4mfbTby8rPTN3/4UGEnR1CLAkyBAZhhQEA5CMg3oDNGwSgYBaNgFKADACLzSgWkUmCXAAAAAElFTkSuQmCC","orcid":"","institution":"Taipei Veterans General Hospital","correspondingAuthor":true,"prefix":"","firstName":"Yen-Wen","middleName":"","lastName":"Chen","suffix":""}],"badges":[],"createdAt":"2021-08-31 11:07:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-861270/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-861270/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":19592486,"identity":"a502e9e8-ad61-4df8-93ae-de48c6817116","added_by":"auto","created_at":"2022-03-25 00:51:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":235804,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-861270/v1/7701d54b-3832-47f4-9db4-2070f6a9fa9c.pdf"},{"id":13716430,"identity":"4d93f004-a3e6-4e8b-a835-4d0154a92be2","added_by":"auto","created_at":"2021-09-17 14:54:23","extension":"pdf","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":681443,"visible":true,"origin":"","legend":"","description":"","filename":"CAREchecklistEnglish20131.pdf","url":"https://assets-eu.researchsquare.com/files/rs-861270/v1/d61536861ef28c3972a1dd74.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eHyperbaric Oxygen Therapy for the Adjunctive Treatment of Stroke Associated with Post-Cardiac Surgery Due To Native-Valve Endocarditis Infected by \u003cem\u003eCutibacterium Acnes\u003c/em\u003e: A Case Report\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eHyperbaric oxygen therapy (HBOT), administration of 100% oxygen at pressures greater than 1.4 atmospheres absolute (ATA), increases the partial pressure of oxygen in the patient\u0026rsquo;s blood. HBOT, as a non-drug and non-invasive treatment, has been applied in the treatment of stroke since 1960s. It is proposed for the treatment of strokes based on pathophysiological principles that suggest it may decrease intracranial pressure and reduce cerebral edema, decrease lipid peroxidation, and stabilize the blood-brain barrier [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, the use of HBOT for acute stroke remains controversial [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. One prospective trial demonstrates that HBOT can prompt the neuroplasticity of brain tissues in post-stroke patients, even in the chronic phase [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStroke is one of the major complications of cardiac surgery. Regarding perioperative stroke in cardiac surgery, the incidence of which varies according to the procedure, 2\u0026ndash;13% of patients experience neurological sequelae during the postoperative period [\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The effects of HBOT on post-cardiac surgery ischemic stroke are unclear and lack adequate evidence.\u003c/p\u003e \u003cp\u003eHBOT is also useful in wound healing as well as deep and chronic infections such as osteomyelitis, necrotizing fasciitis, and chronic soft-tissue infection [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, studies regarding its role in treating infective endocarditis (IE) are limited. A rat model of \u003cem\u003eStaphylococcus aureus\u003c/em\u003e-caused IE showed that as an adjunctive therapy, HBOT reduced bacterial load and proinflammatory cytokine levels by augmenting the efficacy of tobramycin [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The mechanism underlying the synergistic effects of HBOT with antimicrobial agents against \u003cem\u003eCutibacterium acnes\u003c/em\u003e-caused IE, accounting for approximately 0.3% of all IE cases [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], remains unclear.\u003c/p\u003e \u003cp\u003eTherefore, the present report describes a patient who underwent cardiac surgery due to native-valve IE caused by \u003cem\u003eCutibacterium acnes\u003c/em\u003e and was subsequently treated with HBOT for ischemic stroke during his surgical recovery.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 68-year-old man underwent mitral and tricuspid valve annuloplasty and aortic valve replacement, resulting from IE. The patient presented with congestive heart failure, pulmonary hypertension (right ventricular systolic pressure upon admission was 99.7 mmHg) and severe aortic regurgitation causing from right coronary cusp perforation. The patient\u0026rsquo;s only comorbidity was gout. Preoperatively, there was insufficient evidence of IE, however, the postoperative tissue culture yielded \u003cem\u003eC. acnes\u003c/em\u003e. The patient was experiencing left-sided hemiparesis and left homonymous hemianopia (National Institute of Health Stroke Scale: 14) after awaking from anesthesia postoperatively (day 0).\u003c/p\u003e \u003cp\u003eThe muscle power assessment with the Medical Research Council\u0026rsquo;s (MRC) scale was grade zero in the patient\u0026rsquo;s left limbs, with sensory loss at the left foot and calf. Computed tomography revealed no intracranial hemorrhage or proximal large vessel occlusion. Thrombolysis was not performed because the patient was still recuperating from major surgery. Magnetic resonance imaging of the brain revealed hyperintensity on diffusion-weighted imaging and hypointensity on apparent diffusion coefficient values involving the right high frontal and parietal areas of the brain, compatible with acute ischemic stroke.\u003c/p\u003e \u003cp\u003eHe underwent HBOT on postoperative day 11 for the treatment of ischemic stroke. The treatment protocol for HBOT was 90 minutes at 2.5 ATA with two air breaks, followed by a 15-minute compression and a 15-minute decompression. The patient received 20 sessions of HBOT along with 6-week antimicrobial treatment with ceftriaxone and rehabilitation programs.\u003c/p\u003e \u003cp\u003eThe patient\u0026rsquo;s muscle power recovered to MRC scale grade 4\u0026thinsp;+\u0026thinsp;with minimal left-sided weakness. He was able to stand and walk slowly unassisted when he was discharged from the acute care ward. The patient was recovering well at his six months follow-up visit. He could move his limbs freely without assistance and his heart function was good although he had mild claw toes on the left foot and limited left ankle plantar flexion and dorsiflexion.\u003c/p\u003e"},{"header":"Discussion And Conclusions","content":"\u003cp\u003eThis case report describes our experience using HBOT in a patient who underwent cardiac surgery due to native-valve endocarditis infected with \u003cem\u003eC. acnes\u003c/em\u003e and experienced a post-surgery ischemic stroke. Based on pathophysiological principles and our clinical experience, we believe that HBOT benefited our patient.\u003c/p\u003e \u003cp\u003ePossible mechanisms for the development of post-cardiac surgical strokes include atheromatous plaque fragments dislodged from the aorta during cross-clamping, decreased cerebral perfusion, and gas embolisms [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Cerebral edema and neuronal apoptosis follow the passage of air bubbles, inducing endothelial damage and an inflammatory response. This may lead to endothelial swelling, increased vascular resistance, leucocyte and platelet adherence, and damage to the blood-brain barrier. There is a major risk of significant air embolisms during procedures in which the left ventricle or aorta are opened, such as in valve replacement surgery [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], which could explain why our patient experienced a post-operative stroke. Similar Gibson \u003cem\u003eet al\u003c/em\u003e [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], HBOT was administered for our patient in treating post-cardiac surgical stroke, basing on the reason that cerebral air embolism is the likely etiology theoretically and the nature of the operation the patient had received.\u003c/p\u003e \u003cp\u003eHBOT also has bactericidal and bacteriostatic effects on both aerobic and anaerobic bacteria [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. HBOT may have a direct antimicrobial effect, enhance the antimicrobial effects of the immune system, or work synergistically with certain antimicrobial agents [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The culture from the patient tissue showed the presence of \u003cem\u003eC. acnes\u003c/em\u003e, a gram-positive anaerobic bacillus that is ubiquitous in the skin flora. Banzon \u003cem\u003eet al\u003c/em\u003e [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] reported that the most common antibiotics used for the treatment of \u003cem\u003eC. acnes\u003c/em\u003e infection were vancomycin (59%) and ceftriaxone (25%). Furthermore, the use of beta-lactams (benzylpenicillin was the most frequently used) and the addition of rifampicin or aminoglycosides for cases of \u003cem\u003eC. acnes\u003c/em\u003e endocarditis have been elucidated in previous studies [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The antimicrobial therapy for \u003cem\u003eC. acnes\u003c/em\u003e in combination with HBOT has not been previously addressed, and our case was the first to apply HBOT in this setting.\u003c/p\u003e \u003cp\u003eHBOT has proven effective adjunctive treatment in chronic Lyme disease, clostridial myonecrosis, necrotizing fasciitis, and refractory osteomyelitis [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The antimicrobial effects of HBOT are believed to result from the formation of reactive oxygen species (ROS) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], the reactive radicals that are continually produced as alternative metabolites of several cell biological pathways. HBOT promotes aerobic metabolism, leading to enhanced ROS production in bacteria. HBOT aims to induce the aerobic metabolism of bacteria and to reoxygenate the O\u003csub\u003e2\u003c/sub\u003e-depleted infectious tissues, thereby increasing the microbial susceptibility to antibiotics. In our patient, there was not enough evidence of IE preoperatively until the tissue culture was obtained. We believe that the debridement was not performed completely, and the bacteria were still present. Consequently, HBOT was considered an effective adjunctive therapeutic option in our case.\u003c/p\u003e \u003cp\u003eFinally, HBOT facilitates wound healing by inducing angiogenesis [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] and suppressing interferon-γ and proinflammatory cytokines such as interleukin (IL)-1, IL-6, and tumor necrosis factor-α [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. HBOT induces partial high tension of oxygen in the circulating plasma and stimulates oxygen-dependent collagen matrix formation, an essential phase in wound healing [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Our patient had undergone major open-heart surgery, including pericardiotomy and sternotomy, aortic valve replacement, tricuspid annuloplasty, mitral annuloplasty, and aortotomy. We believe that HBOT accelerated his wound healing and recovery, benefiting our patient enough for him to participate in rehabilitation programs within first month, which is considered the gold recovery phase after a stroke.\u003c/p\u003e \u003cp\u003eIn conclusion, our patient demonstrated good recovery from ischemic stroke related to post-cardiac surgery due to IE infection by \u003cem\u003eC. acnes\u003c/em\u003e despite a delay of one week before HBOT initiation. HBOT was effective as an adjunctive therapeutic option in our setting, However, evidence on when to apply HBOT and the number of intervention cycles for effective therapeutic outcomes requires further studies.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHBOT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHyperbaric oxygen therapy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eATA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAtmospheres absolute\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInfective endocarditis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMRC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMedical Research Council\u0026rsquo;s\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eROS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eReactive oxygen species\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInterleukin\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Written informed consent was obtained from the patient for publication of this case report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e The authors have no conflicts of interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis research did not receive any grant from funding agencies in the public, commercial or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWriting-original draft: P.K.C, T.T.K. Writing-review \u0026amp; editing: P.K.C, S.Y.L, J.H.K, Y.W.C. Patient care: T.T.K, S.Y.L. Supervision: Y.W.C. Validation: T.T.K, S.Y.L, J.H.K, Y.W.C\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank all the healthcare workers in the Taipei Veterans General Hospital and Taipei Municipal Gan-Dau Hospital for their valuable contribution to patient care, as well as, Vikas Narang, Editaghe, a division of Cactus Communications for the help with language editing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCalvert JW, Cahill J, Zhang JH. Hyperbaric oxygen and cerebral physiology. Neurol Res. 2007;29(2):132\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVeltkamp R, Siebing DA, Sun L, Heiland S, Bieber K, Marti HH, et al. Hyperbaric oxygen reduces blood-brain barrier damage and edema after transient focal cerebral ischemia. Stroke. 2005;36(8):1679\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBennett MH, Weibel S, Wasiak J, Schnabel A, French C, Kranke P. Hyperbaric oxygen therapy for acute ischaemic stroke. Cochrane Database Syst Rev. 2014;11:CD004954.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDing Z, Tong WC, Lu X-X, Peng H-P. Hyperbaric oxygen therapy in acute ischemic stroke: a review. Interv Neurol. 2014;2(4):201\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEfrati S, Fishlev G, Bechor Y, Volkov O, Bergan J, Kliakhandler K, et al. Hyperbaric oxygen induces late neuroplasticity in post stroke patients-randomized, prospective trial. PLoS One. 2013;8(1):e53716.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoach GW, Kanchuger M, Mangano CM, Newman M, Nussmeier N, Wolman R, et al. Adverse cerebral outcomes after coronary bypass surgery. Multicenter Study of Perioperative Ischemia Research Group and the Ischemia Research and Education Foundation Investigators. N Engl J Med. 1996;335(25):1857\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcKhann GM, Grega MA, Borowicz LM Jr, Baumgartner WA, Selnes OA. Stroke and encephalopathy after cardiac surgery: an update. Stroke. 2006;37(2):562\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen PK, Shih CC, Lin FC, Perng DW, Chou KT, Kou YR, et al. Prolonged use of noninvasive positive pressure ventilation after extubation among patients in the intensive care unit following cardiac surgery: The predictors and its impact on patient outcome. Sci Rep. 2019;9(1):9539.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTibbles PM, Edelsberg JS. Hyperbaric-oxygen therapy. N Engl J Med. 1996;334(25):1642\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYu WK, Chen YW, Shie HG, Lien TC, Kao HK, Wang JH. Hyperbaric oxygen therapy as an adjunctive treatment for sternal infection and osteomyelitis after sternotomy and cardiothoracic surgery. J Cardiothorac Surg. 2011;6:141.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLerche CJ, Christophersen LJ, Kolpen M, Nielsen PR, Tr\u0026oslash;strup H, Thomsen K, et al. Hyperbaric oxygen therapy augments tobramycin efficacy in experimental Staphylococcus aureus endocarditis. Int J Antimicrob Agents. 2017;50(3):406\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLalani T, Person AK, Hedayati SS, Moore L, Murdoch DR, Hoen B, et al. Propionibacterium endocarditis: a case series from the International Collaboration on Endocarditis Merged Database and Prospective Cohort Study. Scand J Infect Dis. 2007;39(10):840\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGibson AJ, Davis FM. Hyperbaric oxygen therapy in the treatment of post cardiac surgical strokes-a case series and review of the literature. Anaesth Intensive Care. 2010;38(1):175\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMemar MY, Yekani M, Alizadeh N, Baghi HB. Hyperbaric oxygen therapy: antimicrobial mechanisms and clinical application for infections. Biomed Pharmacother. 2019;109:440\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBanzon JM, Rehm SJ, Gordon SM, Hussain ST, Pettersson GB, Shrestha NK. Propionibacterium acnes endocarditis: a case series. Clin Microbiol Infect. 2017;23(6):396\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLindell F, S\u0026ouml;derquist B, Sundman K, Olaison L, K\u0026auml;llman J. Prosthetic valve endocarditis caused by Propionibacterium species: a national registry-based study of 51 Swedish cases. Eur J Clin Microbiol Infect Dis. 2018;37(4):765\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuang CY, Chen YW, Kao TH, Kao HK, Lee YC, Cheng JC, et al. Hyperbaric oxygen therapy as an effective adjunctive treatment for chronic Lyme disease. J Chin Med Assoc. 2014;77(5):269\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBenson RM, Minter LM, Osborne BA, Granowitz EV. Hyperbaric oxygen inhibits stimulus-induced proinflammatory cytokine synthesis by human blood-derived monocyte-macrophages. Clin Exp Immunol. 2003;134(1):57\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSureda A, Batle JM, Martorell M, Cap\u0026oacute; X, Tejada S, Tur JA, et al. Antioxidant response of chronic wounds to hyperbaric oxygen therapy. PLoS One. 2016;11(9):e0163371.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGodman CA, Chheda KP, Hightower LE, Perdrizet G, Shin DG, Giardina C. Hyperbaric oxygen induces a cytoprotective and angiogenic response in human microvascular endothelial cells. Cell Stress Chaperones. 2010;15(4):431\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Cutibacterium (Propionibacterium) acnes, Hyperbaric oxygen therapy, Infective endocarditis, Stroke","lastPublishedDoi":"10.21203/rs.3.rs-861270/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-861270/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eStroke is an uncommon but significant complication of cardiac surgery. Cutibacterium (previously known as Propionibacterium) rarely causes infective endocarditis (IE), accounting for approximately 0.3% of all IE cases. Hyperbaric oxygen therapy (HBOT), involving the administration of 100% oxygen at a pressure of \u0026gt;\u0026thinsp;1.4 atmospheres absolute, increases the partial pressure of oxygen; therefore, it is recommended as an adjunctive treatment for stroke and some infections. However, there are no data supporting HBOT as an adjunctive therapeutic option for ischemic stroke related to post-cardiac surgery due to IE caused by \u003cem\u003eCutibacterium acnes\u003c/em\u003e.\u003c/p\u003e\u003ch2\u003eCase presentation:\u003c/h2\u003e \u003cp\u003eThis study reports the case of an 68-year-old male patient who underwent cardiac surgery for native-valve IE caused by \u003cem\u003eC\u003c/em\u003e. \u003cem\u003eacnes\u003c/em\u003e. He underwent HBOT on postoperative day 11 for the treatment of ischemic stroke. The patient received 20 sessions of HBOT along with 6-week antimicrobial treatment with ceftriaxone and rehabilitation programs.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eWe have summarized the patient\u0026rsquo;s successful recovery and our clinical experience regarding the use of HBOT in our clinical setting. HBOT is an effective adjunctive therapeutic option for ischemic stroke related to post-cardiac surgery due to IE caused by \u003cem\u003eC\u003c/em\u003e. \u003cem\u003eacne\u003c/em\u003es.\u003c/p\u003e","manuscriptTitle":"Hyperbaric Oxygen Therapy for the Adjunctive Treatment of Stroke Associated with Post-Cardiac Surgery Due To Native-Valve Endocarditis Infected by Cutibacterium Acnes: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-09-17 14:54:21","doi":"10.21203/rs.3.rs-861270/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a0c5387f-d6d6-4b73-953f-2d910188328c","owner":[],"postedDate":"September 17th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":7253964,"name":"Cardiac \u0026 Cardiovascular Systems"},{"id":7253965,"name":"Cardiothoracic Surgery"}],"tags":[],"updatedAt":"2022-03-25T00:51:26+00:00","versionOfRecord":[],"versionCreatedAt":"2021-09-17 14:54:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-861270","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-861270","identity":"rs-861270","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}