Infective Endocarditis in Intravenous Drug Users a Review Article
Infective Endocarditis Related to Intravenous Drug User: Report of Four Cases
Ermira Muçoone, * , Arjan Harxhi1 , Amela Hasa2 , Pëllumb Pipero1 , Arta Kushi1 , Irena Ceko3 , Edmond Puca1 , Dhimitër Kraja1
1 Department of Infectious Diseases, Hospital University Center "Mother Theresa", Tirana, Albania
2 Department of Imaging Sciences, Hospital University Center "Mother Theresa", Tirana, Albania
3 Department of Toxicology, Hospital Academy Eye "Mother Theresa", Tirana, Republic of albania
Article Data
Commodity History:
Received Engagement: 02/11/2017
Revision Received Date: 22/01/2018
Acceptance Date: 07/03/2018
Electronic publication date: xiv/03/2018
Collection year: 2018
© 2018 Muço et al.
open-access license: This is an open access article distributed nether the terms of the Artistic Eatables Attribution 4.0 International Public License (CC-Past 4.0), a re-create of which is bachelor at: https://creativecommons.org/licenses/by/iv.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Objective:
To describe the clinical, laboratory, microbiological, and echocardiographic findings in 4 intravenous drug users with endocarditis hospitalized and followed in our Infectious disease Service, a tertiary university hospital as well equally to determine the efficacy of medical treatment.
Methods:
From a database of 35 subjects with endocarditis during five years, we fabricated a retrospective assay of data for four cases between the age of 24-33 years one-time which were intravenous drug users.
Results:
Infective endocarditis was encountered in four drug users with positive claret cultures ( Staphylococcus aureus was present in all the cases), vegetations in the tricuspid native valve in ultrasound, high fever (more 38oC). The four cases were male and the mean age was 29 years (range 24-33 years). Three out of the four cases presented with pulmonary involvement and just 1 with femoral and popliteal vein thrombosis. Two out of four cases had acute renal and hepatic failure and only ane had astute cutaneous vasculitis. Transesophageal Echocardiography (TEE) was besides performed in two cases. For all of them medical direction consisted of antibiotic therapy and 2 out of them underwent surgery considering of the persistence of valvular vegetations after antibiotic therapy. The prognosis was proficient with 0% mortality.
Conclusion:
Infective endocarditis should exist considered in the differential diagnosis of intravenous drug users presenting with various clinical scenarios. Echocardiography remains the main modality and should exist used serially to facilitate early diagnosis. The successful management of a complicated case oft requires the close cooperation of an communicable diseases physician, a cardiologist, an habit medico and occasionally a cardiac surgeon.
Keywords: Tricuspid valve endocarditis, Intravenous drug users, Staphylococcus aureus, Transthoracic echocardiography.
1. INTRODUCTION
Endocarditis, also called infective endocarditis, is an infection and inflammation of the centre valves and the inner lining of the heart chambers, which is chosen the endocardium. The infecting organism enters the bloodstream through a suspension in the skin acquired by a skin disorder or injury; a medical or dental procedure; or a skin prick, especially among intravenous drug users. Infective Endocarditis (IE) is i of the most severe complications in intravenous drug abusers. The tricuspid valve is the most ofttimes affected [1]. Staphylococcus aureus is the about common etiologic agent [2]. It is also estimated that the incidence of IE in intravenous drug abusers is 2 to 5% per year and the overall death rate is five to 10% [3].
2. METHODS
The material for this study is obtained from records of patients maintained by the authors in a tertiary care teaching institute. From a database of 35 subjects with endocarditis, nosotros studied iv cases betwixt historic period of 24-33 years old which were intravenous drug users. The records of these cases form the material for this analysis. Diagnosis of Infectious Endocarditis was based on the modified Duke criteria [4]. We studied parameters as patient personal data (age, sex, educational level), gamble factors, causative microorganism, number of positive blood cultures, elapsing of symptoms, blazon of valve involved, echocardiographic findings (vegetation site, vegetation size, complications); other radiological examinations results (electrocardiogram, chest radiograph, chest CT-browse); presence and type of embolic events; handling and mortality. Detailed laboratory workup including complete blood count, Erythrocyte Sedimentation Charge per unit (ESR), renal and liver function test and blood cultures were studied (Table 1 ).
Table 1. Epidemiological manifestations, clinical signs and symptoms, laboratory and imaging examinations, echocardiographic and microbiological data of infective endocarditis in four intravenous drug users.
| Epidemiological, Clinical, Laboratory, Radiological Data | Instance 1 | Case 2 | Example 3 | Case 4 |
|---|---|---|---|---|
| Patient´southward Age | 33 years erstwhile | 24 years former | 30 years old | 29 years onetime |
| Gender | Male | Male person | Male | Male |
| Duration and Kind of Drug Consumption | 11 years /Heroine | five years/Heroine | ix years/Heroine | seven years/Heroine |
| Elapsing of Symptoms | 5 days | eighteen days | 23 days | half dozen days |
| Symptoms | cough, chest hurting, fatigue, fever, myalgia, arthralgia. | cough, breast pain, dyspnea, fever, myalgia, arthralgia,. | cough, chest hurting, fatigue, high fever, myalgia, arthralgia | high fever, myalgia, arthralgia, fatigue |
| Etiological Agent | Staph. aureus | Staph. Aureus | Staph. aureus | Staph. Aureus, Acinetobacilis baumani, Strept.pneumonie |
| HIV | negative | Negative | Negative | Negative |
| Valve and Type of Valve Involved, Number and Size Vegetations. | Tricuspid, native, 1 vegetation, 2.7cmii | Tricuspid, native, i vegetation, 2.87cmtwo | Tricuspid, native, multiple, 2-ii.5 cm2 | Tricuspid, native, one vegetation, 0.4 cm2 |
| Vascular Phenomena | Septic pulmonary emboli | Septic pulmonary emboli | Septic pulmonary emboli, cutaneous vasculitis | |
| Events Observed | Staphylococcic pneumonia, acute renal and hepatic failure, conjunctival hemorrhage | Staphylococcic pneumonia, Popliteal-femoral venous thrombosis | Staphylococcic pneumonia, acute cardiac, renal and hepatic failure, cutaneous vasculitis | Popliteal-femoral venous thrombosis |
| Comorbidity | No | Hepatitis C | Hepatitis B, Hepatitis C | Hepatitis C |
| Surgery | No | Aye | No | No |
| Death | No | No | No | No |
| Elapsing of Hosp. | 54 days | 43 days | 63 days | 23 days |
| Treatment | Vancomycin2g/solar day, Gentamycin 1 mg/kg every eight hours, Cefepime4g/day; | Vancomycin 2g/mean solar day, Merepenem3g/day | Vancomycin2g/day, Merepenem3g/mean solar day, Rifampicine 600mg/24-hour interval; | Vancomycin2g/day, Gentamycin1 mg/kg every 8 hours, Ceftriaxone 2g/solar day |
3. RESULTS
All the four patients were men with a mean age of 29 years (range 24-33 years), and drug users. During hospitalization, none of the patients developed physical withdrawal state from heroin. Iii patients during their infirmary stay have been in Methadone maintenance treatment. In all the cases we diagnosed right-sided endocarditis with tricuspid valve affection. Echocardiography identified vegetations (i to multiple in case 3) that ranged in size from 2cm2 to 2.8cmii (Figs. 1 and 2 ). The first three cases had positive blood cultures for Staphylococcus aureus while the fourth case too Staphylococcus aureus had as well Acinetobacilis baumani and Streptococcus pneumonie. Fever was presented in all the cases. In cases 1, 2, 3, complications attributed to septic pulmonary emboli are pulmonary abscesses, unilateral pneumothorax, bilateral pleural effusions and empyema. Chest CT-scans showed multiple cavitary peripheral nodules associated with lung abscesses, and in case one wedge-shaped densities caused by septic infarcts (Figs. 3 - 6 ). Acute onset of respiratory distress occurred on case iii during the hospitalization and rapidly resulted in hypoxemia. Immediate chest radiograph demonstrated right pneumothorax afterward which an intercostal chest tube was inserted (Fig. 7 ). Besides pulmonary septic emboli (cases 1, 2, three), other embolic phenomena or metastatic foci were conjunctival hemorrhage (case 1), renal infarct (case 3), cutaneous vasculitis (case 3), popliteal-femoral venous thrombosis (case 2, four). The four patients were HIV negative; hepatitis C, HCV positive (case two, 3, 4) and hepatitis B, HBV positive (case 3). Transthoracic echocardiography was performed in all cases while transesophageal echocardiography (TEE) was also performed in two cases (case 1, 4). All the cases take hepatosplenomegaly confirmed in abdominal ultrasound. In the acute stage, medical management consisted only in antibody therapy based on antibiogram. In add-on to the treatment given to us by an communicable diseases physician, the cardiological and toxicological treatment was equally important. For all cases, after the treatment we repeated a transthoracic echocardiography. In the cases i and iv valvular vegetations disappeared (Fig. 8 ). In the cases two and 3 they persisted, and then the patients underwent surgery, but non in our country. Case 3, because of astute renal failure and severe anemia, did dialysis and transfusion. Although he had multiple vegetations in the tricuspid valve and severe tricuspid regurgitation with the comeback of cardiac part, he didn't undergo surgical intervention because of impossibility of doing this kinds of operations in our infirmary. Prognosis was proficient for all, with 0% mortality.
 | Fig. (1). Case 1. Large vegetation, approximately 2.7cm2. |
 | Fig. (2). Case 2. Large vegetation, approximately 2.87cmii. |
 | Fig. (3). Case 1, CT showed pulmonary wedge-shape consolidations. |
 | Fig. (four). Case one, Radiograph on the left showed cavity peripheric nodules; two on the left before the treatment bilateral pulmonary consolidations and pleural and two on the right during the treatment effusion (before the treatment). On the correct there is right pulmonary consolidation (during the treatment). |
 | Fig. (5). Case 3, Radiograph showed right pleural effusion. |
 | Fig. (6). Instance 3, CT showed multiple peripheric crenel nodes presenting and discrete peripheric nodular consolidations; on the embolic abscesses, earlier the handling left before the treatment and on the right during the treatment. |
 | Fig. (vii). Case iii. Chest radiograph showing pneumothorax in diameter, attached to the tricuspid valve in the correct lung. Abscess germination in the right lung has caused a broncho-pleural fistula, pneumothorax and the air fluid level. |
 | Fig. (8). Instance 1. Disappearance of large vegetation in diameter, fastened to the tricuspid valve after antibiotic treatment. |
4. Discussion
Our study focused on investigating the clinical features of IE in four drug users. They were all heroin users, although the literature speaks for higher risk to cocaine users [v]. Our patients were young men from 24 to 33 years old. In keeping with the demographic characteristics of injection drug employ, this disease occurs nigh usually in immature males in their 20s and 30s [5]. IE should be suspected in whatever patient with unexplained fevers, night sweats, or signs of systemic illness, particularly if any of the following chance factors are nowadays [half dozen]. Amid injection drug users presenting with fever, 13% will have echocardiographic bear witness of IE [vii]. In drug users, injection of microorganisms or particulate affair from the peel itself or from within the drug material may generate transient or permanent endothelial harm to the tricuspid valve, thus providing an area for vegetations to develop. The tricuspid valve is mainly involved [8]. Endocarditis in people who utilise injection drugs is probable to be right-sided; therefore, septic pulmonary emboli are common, whereas manifestations of endocarditis (e.g., splinter and conjunctival hemorrhages) are less likely [ix]. All our cases had tricuspid valve affection and 3 of them presented with pulmonary complaints and chest radiographs and CT-scans showed multiple septic pulmonary emboli. These septic emboli had all imaging features to be diagnosed equally such. They were peripheric, cavity nodules with clearly identifiable feeding vessels, chosen feeding vessel sign [ten]. In case 1 there were evident wedge-shaped densities caused past septic infarcts. They were well-nigh 15 mm, the same range as prescribed in other studies [eleven]. Case 3, during the hospitalization, developed pneumothorax. Information technology was thought to exist a spontaneous pneumothorax, because he had not undergone any invasive procedure before its occurrence. Pneumothorax is a possible lethal complexity of septic pulmonary embolism in intravenous drug users with right-sided endocarditis and should be considered in such patients when respiratory distress occurs acutely during their hospitalization [12]. It must be due to progression of septic pulmonary infiltrates with subsequence leakage of air in the pleural cavity. Currently, betwixt xl% and 90% of intravenous drug users with IE are HIV infected, and the HIV epidemic has caused a decrease in the incidence of this affliction, probably due to changes in drug assistants habits undertaken by addicts in order to avoid HIV manual. In our instance, all the patients were HIV negative and three cases (case 2, iii,four) were HCV positive. In Republic of albania, HCV infection is more than common than HIV among People Who Inject Drugs (PWID). The 2011 Bio-BSS reported HCV prevalence at 28.8% among this high-run a risk group. The data from laboratory surveys of HBV amid PWID in 2003, 2006/07, 2009 and 2011 demonstrated prevalence rates of the surface antigen of the hepatitis B virus (HBsAg) at 10.1% (8 out of 79), 22.8% (38 out of 166), 20.2% (xx out of 99) and 23% respectively. The estimated prevalence of HIV among people who inject drugs is 0.five%, while around 28.8% are infected with HCV [13]. IE is often the event of acute Southward aureus infection of right-sided heart valves [xiv]. Claret cultures should be obtained before initiation of antibiotic therapy. Claret culture positive for S. aureus was identified in all of cases. In the cases 1, ii and 3 we obtained more than iii hemocultures, respectively 4, six and 7. Staphylococcal endocarditis in injection drug users is now the dominant class of the disease in many urban communities where in that location is a high incidence of injection drug utilise and homelessness. Example four had polymicrobial infection (Staph. Aureus, Acinetobacilis baumani,
Strept.pneumonie). This fact is seen in 15% of cases [15]. Urinalysis may show bear witness of gross or microscopic hematuria, proteinuria, or pyuria. White blood cell count may be normal or elevated. All the cases had leukocytosis and case 3 had proteinuria (6.6g/fifty/24 h). Baseline electrocardiography should be performed in patients with infectious endocarditis so that new cardiac manifestations can be recognized early (e.g., extension of valvular illness into the conduction system, ischemia secondary to emboli to the coronary circulation) [16]. We did electrocardiography to all our patients and case 3 had changes related to astringent tricuspid regurgitation. The American College of Cardiology and the American Middle Clan recommend that echocardiography should be performed to identify valvular abnormalities in all patients in whom there is moderate or high suspicion of endocarditis [17]. Transthoracic echocardiography is usually the initial imaging modality. However, transesophageal echocardiography may be necessary in some patients, such as those with staphylococcus bacteremia, limited transthoracic windows considering of obesity or mechanical ventilation, a prosthetic valve that renders visualization difficult secondary to shadowing, a history of endocarditis, or a structural valve aberration. We did transthoracic echocardiography to all our patients and transesophageal echocardiography to 50% of them. Tricuspid vegetations are oft large and may be in backlog of 2 cm [five]. In our cases, echocardiography showed the presence of tricuspid vegetations that ranged in size from 2cm2 to 2.8cmii. The choice of definitive antibiotic therapy is based on the causative microorganism and its antibiotic susceptibility, and whether the involved valve is native or prosthetic. Our patients had native valve and right sided endocarditis. The structural and functional integrity of cardiac valves may be damaged by infection. This may lead to valvular regurgitation or flow obstruction in valves with large vegetations [6]. Surgical intervention should be considered in patients with fungal infection, infection with aggressive antibiotic-resistant leaner or bacteria that reply poorly to antibiotics, left-sided infectious endocarditis caused by gram-negative bacteria, persistent infection with positive blood cultures after one week of antibiotic therapy, or ane or more embolic events during the first two weeks of antibiotic therapy [eighteen]. Surgical intervention is warranted for valve dehiscence, perforation, rupture or fistula, or a large perivalvular abscess. Cases 1 and 4 had total clinical and imaging improvement with a disappearance of valvular vegetations. Case ii and 3 had clinical improvement, but without disappearance of valvular vegetations. They both underwent surgery, merely because of the impossibility of realization of these kinds of operations in our land, they did it abroad. Still, it is worth saying that fifty% of cases had a very good prognosis. This fact is too noted in literature [19].
CONCLUSION
IE occurs in a wide range of underlying conditions where of import are intravenous drug users. It is an infection that can develop dramatically over a few days. A loftier degree of suspicion is required and early echocardiography is recommended in patients with unexplained fever and pulmonary events. Echocardiography remains the chief modality and should exist used serially to facilitate early diagnosis. Coexistent medical problems such equally hepatitis may exist nowadays. The successful direction of a complicated case oft requires the shut cooperation of an infectious disease physician, a cardiologist, an addiction medico and occasionally a cardiac surgeon. This population of patients is a challenge for healthcare system because care for them is expensive and prolonged. A sharp and early attention to them avoids a huge health and financial burden.
LIMITATIONS
This is a retrospective study. The lack of a computerized system for the patient medical data and a PACS (Picture Archiving and Advice System), fabricated the analysis difficult.
ETHICS APPROVAL AND CONSENT TO PARTICIPATE
Not applicative.
HUMAN AND ANIMAL RIGHTS
No animals/humans were used for studies that are the basis of this review.
CONSENT FOR PUBLICATION
A written informed consent was obtained from all patients when they were enrolled.
Conflict OF Interest
The authors declare no conflict of involvement, fiscal or otherwise.
ACKNOWLEDGEMENTS
Declared none.
Source: https://openinfectiousdiseasesjournal.com/VOLUME/10/PAGE/1/FULLTEXT/
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