|Year : 2021 | Volume
| Issue : 3 | Page : 91-93
A case of left-sided infective endocarditis in intravenous drug abuser with mycotic aneurysm and myocardial infarction with nonobstructive coronaries
Nitin Rustogi, Suguna Kari
Department of Medicine, ABVIMS and RML Hospital, New Delhi, India
|Date of Submission||22-Feb-2021|
|Date of Decision||20-Jun-2021|
|Date of Acceptance||31-Jul-2021|
|Date of Web Publication||29-Sep-2021|
Dr. Nitin Rustogi
Department of Medicine, ABVIMS and RML Hospital, New Delhi - 110 001
Source of Support: None, Conflict of Interest: None
Left-sided Infective endocarditis (IE) is an uncommon occurrence in intravenous drug users (IVDU) in clinical practice. This case describes a 28-year-old male IVDU who presented with abdominal pain, fever, and breathlessness and diagnosed with aortic valve IE. This case highlights the possibility of left-sided IE in IVDU and rare complications of ST-elevation Myocardial Infarction with Non-obstructive Coronaries and Mycotic Aneurysm (MA) associated with it.
Keywords: Endocarditis, intravenous drug users, mycotic aneurysm, myocardial infarction
|How to cite this article:|
Rustogi N, Kari S. A case of left-sided infective endocarditis in intravenous drug abuser with mycotic aneurysm and myocardial infarction with nonobstructive coronaries. J Prim Care Spec 2021;2:91-3
|How to cite this URL:|
Rustogi N, Kari S. A case of left-sided infective endocarditis in intravenous drug abuser with mycotic aneurysm and myocardial infarction with nonobstructive coronaries. J Prim Care Spec [serial online] 2021 [cited 2022 Sep 27];2:91-3. Available from: https://www.jpcsonline.org/text.asp?2021/2/3/91/327058
| Introduction|| |
Left sided endocarditis is associated with higher risks of systemic embolization of septic foci than right sided endocarditis, which then form nidus for mycotic aneurysm. Mycotic Aneurysms (MA) are commonly found in intracranial arteries compared to visceral arteries. Here is a case IVDU who presented with left sided endocarditis, who later on developed ST Elevation Myocardial Infarction and Mycotic Aneurysm of Aorta
| Case Report|| |
A 28-year-old male with a history of intravenous drug abuse presented to the emergency department with complaints of fever abdominal pain, and breathlessness for the past 10 days. On examination, the patient was febrile (102°F), blood pressure of 100/40 mmHg, pulse rate 130/min with bounding pulses, and respiratory rate 24/min. Systemic examination revealed hepatosplenomegaly, early diastolic murmur in the neo-aortic area and bilateral basal crepitations.
Laboratory findings revealed a total leukocyte count of 18,000/mm3 with neutrophilia and deranged renal functions. Ultrasonography of the abdomen was done to evaluate abdominal pain, which showed multiple hypoechoic areas in the spleen suggestive of splenic abscesses. As index of suspicion of endocarditis was high in this patient 2 dimensional (2D) Echocardiography was done which showed severe aortic regurgitation with an oscillating mass of 2.5 cm. The patient was started on antibiotics after taking three sets of blood cultures from different sites. After an incubation period of 48 h Enterococcus was grown and antibiotics were tailored according to sensitivity. On the 5th day of admission, the patient developed sudden chest pain associated with feeling of impending doom and diaphoresis, urgent electrocardiogram was done which showed ST-segment elevation in leads II, III, AVF, and V2-V5 [Figure 1], and cardiac troponins were raised. 2D ECHO revealed hypokinesia of anterior, anteroseptal, and anterolateral with Ejection Fraction 35%.
|Figure 1: Twelve lead electrocardiogram showing ST elevation in leads II, III, AVF, and V2-V5 with Q waves in II, III, and AVF|
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Computerized tomography (CT) aortography showed saccular outpouching of size 8 mm × 18 mm × 15 mm (AP × TR × CC) arising from the left anterolateral wall of the aortic root at sinus level suggestive of the mycotic aneurysm (MA), neck of the aneurysm 16 mm and dome measured 18 mm [Figure 2]. However, CT coronary angiography did not show any obstruction.
|Figure 2: Computerized tomographic aortography showing mycotic aneurysm of aorta|
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Hence, a final diagnosis of Native Aortic valve Enterococcal Endocarditis in IVDU complicated by Mycotic Aneurysm and Myocardial Infarction with Non Obstructive Coronaries (MINOCA) was made.
| Discussion|| |
Infective endocarditis (IE) involves the right side of the heart more commonly in IVDU as compared to the left side. In the year 1950, IE was recognized as a complication of intravenous drug use, less commonly affecting the left side of the heart. Younger males are frequently affected by IE after drug use as compared to nonusers. In this age group, Staphylococcus aureus is the most common cause of IE.
Endocarditis in 5%–15% of the patients is caused by enterococci and it usually occurs in the older age group, particularly men.
The presentation of enterococcal endocarditis is typically subacute and infrequently associated with peripheral stigmata of endocarditis. Risk factors for enterococcal endocarditis may include urinary tract infection or instrumentation.
MA is a rare, potential complication of IE that carries significant mortality risk. The pathogenesis begins with bacterial infiltration into the vessel wall, which may occur directly through trauma, by local extension from an existing infection, or by seeding from a distant site through septic embolism or bacteremia. A robust inflammatory response ensues, resulting in rapid, focal wall degeneration.
Acute coronary syndrome is a rare complication in IE, account for only 3% in this population. The mechanism is mostly attributed to the obstructive lesion, such as coronary embolism, obstruction of the coronary ostia by large vegetation, or coronary artery compression due to abscess or pseudoaneurysms formation. Yeoh et al. reported that myocardial infarction is a rare complication of bacterial IE due to coronary artery septic emboli, representing only <1% of complications related to IE. Rischin et al. reported a case of multi embolic STEMI after aortic valve endocarditis. Singh et al. reported a case of acute inferior wall STEMI after aortic valve endocarditis due to septic embolism. Regmi et al. also reported a case of STEMI secondary to coronary embolization from mitral valve endocarditis. However, there is only one case reported by Liu et al. which showed STEMI with nonobstructive coronaries secondary to IE.
This case highlights the rare complications of IE and challenges the notion that it classically affects the right side of the heart in IVDU. Endocarditis of the left side is mostly caused with S. aureus but in our case, it was caused by Enterococcus bacteria.
| Key Points|| |
- Infective endocarditis can affect left side of the heart in IVDU
- Enterococcal endocarditis may be fatal
- Mycotic aneurysm is rare but fatal complication of IE
- MI in infective endocarditis should be suspected in patients who have sudden worsening in clinical condition.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Hussey HH, Katz S. Infections resulting from narcotic addiction; report of 102 cases. Am J Med 1950;9:186-93.
Welton DE, Young JB, Gentry WO, Raizner AE, Alexander JK, Chahine RA, et al.
Recurrent infective endocarditis: Analysis of predisposing factors and clinical features. Am J Med 1979;66:932-8.
Ortiz-Bautista C, López J, García-Granja PE, Sevilla T, Vilacosta I, Sarriá C, et al.
Current profile of infective endocarditis in intravenous drug users: The prognostic relevance of the valves involved. Int J Cardiol 2015;187:472-4.
Deipolyi AR, Rho J, Khademhosseini A, Oklu R. Diagnosis and management of mycotic aneurysms. Clin Imaging 2016;40:256-62.
Manzano MC, Vilacosta I, San Román JA, Aragoncillo P, Sarriá C, López D, et al
. Síndrome coronario agudo en la endocarditis infecciosa acute coronary syndrome in infective endocarditis. Rev Esp Cardiol 2007;60:24-31.
Yeoh J, Sun T, Hobbs M, Looi JL, Wong S. An uncommon complication of infective bacterial endocarditis. Heart Lung Circ 2012;21:811-4.
Rischin AP, Carrillo P, Layland J. Multi-embolic ST-elevation myocardial infarction secondary to aortic valve endocarditis. Heart Lung Circ 2015;24:e1-3.
Singh M, Mishra A, Kaluski E. Acute ST-elevation myocardial infarction due to septic embolism: A case report and review of management options. Catheter Cardiovasc Interv 2015;85:E166-71.
Regmi N, Pandey S, Neupane S. ST-elevation myocardial infarction: An unusual presentation of infective endocarditis. J Cardiovasc Echogr 2017;27:99-100.
Liu YH, Lee WH, Chu CY, Su HM, Lin TH, Yen HY, et al.
Infective endocarditis complicated with nonobstructive ST elevation myocardial infarction related to septic embolism with intracranial hemorrhage: A case report. Medicine (Baltimore) 2018;97:e13089.
[Figure 1], [Figure 2]