PMC7819283_01
Timeline of clinical and diagnostic events. Weeks since initial presentation (antecedent pneumonia) are presented as gray blocks of 1 week each (bottom row). Clinical events are presented (top row) with inpatient weeks in dark gray and outpatient weeks as light gray blocks. Diagnostic testing and corresponding results, as well as selection and duration of antibiotics are indicated.
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F1
She was in her usual state of health until approximately 21/2 weeks prior to admission (Figure 1). Given concern for endocarditis, she was admitted to the inpatient cardiology floor for further evaluation (Figure 1).
Sequence alignment from Sanger and next generation sequencing reactions. Alignment of the two S. cristatus sequences detected by NGS (predominant sequence variant, sv-001; secondary sequence variant, sv-002) and the Sanger sequenced 16S rDNA PCR product are presented with gaps indicated by dashes and nucleotides conserved across all three sequences identified by asterixis.
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F2
These sequences were only 90.88% identical to each other, differing by 2 single nucleotide indels and 26 single nucleotide polymorphisms (Figure 2). The less abundant sequence (287 nt) was 90.88% identical to the original PCR product (Figure 2), but 100% identical to a type strain of Streptococcus oligofermentans (AS 1.3089, NR_103943), a heterotypic synonym of S. cristatus, and to other S. cristatus records. These findings supported the diagnosis of a polyclonal endocarditis with two genetically distinct strains of S. cristatus.