MANAGEMENT OF A PATIENT WHO INJECT DRUGS, PRESENTING WITH RIGHT-SIDED INFECTIVE ENDOCARDITIS

Abstract

Background. Right-sided infective endocarditis (RSIE) benefits from a special reference in the latest European Society of Cardiology (ESC) guidelines for the management infectious endocarditis, due to its epidemiology, prognosis, complications, medical and surgical management and presentation particularities (1). The main risk factor for RSIE is the use of intravenous drugs, a behavior that also explains the growing incidence of RSIE in developed countries, especially among the young population (2,6). Material and methods. We present the case of a young intravenous drug user (IDU) admitted to our hospital for fatigue, fever and generalized arthralgias, which developed shortly after self-administration of iv. heroin. The clinical presentation suggestive for sepsis, together with the high suspicion for RSIE guided the subsequent paraclinical investigations and empirical antibiotic therapy. Results. The positive diagnosis of sepsis was made once the first blood culture confirmed the presence of methicillin-sensitive Staphylococcus aureus (MSSA), in addition to a SOFA score of 4. Confirmation of RSIE came with the echocardiographic description of vegetations on the tricuspid valve, summing up 1 major and 3 minor modified Duke criteria. The patient had a slow, but favorable evolution, however, he developed severe tricuspid insufficiency, the infection persisted under antibiotic therapy with an increased risk of septic embolization, all of which qualified the patient for cardiac surgery to remove the infectious focus and restore the functionality of the tricuspid valve. Conclusions. In this case, the same behavior that generated the pathology, iv. drug use, also determined deferral of the surgery, under conditions of hemodynamic stability, until a long-term withdrawal of heroin was attained. The patient was discharged upon request before the end of the antibiotic treatment, thus reiterating the need to routinely approach RSIE in IDU in a multidisciplinary “endocarditis team”. The main goal of this approach is to increase adherence to treatment, as well as to decrease morbidity and mortality of all causes, the risk of RSIE recurrence and IDU resumption.

Keywords

• right-sided infective endocarditis (rsie)
• tricuspid valve
• duke criterion
• methicillin-sensitive staphylococcus aureus (mssa)
• intravenous drug user (idu)
• heroin