Infective endocarditis as a complication of heroin use

Neurological complications of drug abuse: pathophysiological mechanisms

Drug abuse is associated with a variety of neurological complications. The use of certain recreational drugs shows a marked temporal association with the onset of both haemorrhagic and ischaemic strokes, the majority of which develop within minutes to 1 h after the administration of the index drug. Delayed onset of stroke has also been observed. Acute, severe elevation of blood pressure, cardiac dysrhythmias, cerebral vasospasm, vasculitis, embolization due to infective endocarditis or dilated cardiomyopathy, embolization due to foreign material injected with the diluents under non-sterile conditions and 'street drug' contaminants with cardiovascular effects have been suggested as possible underlying mechanisms. Rupture of aneurysms and arteriovenous malformations have been detected in up to half of the patients with haemorrhagic stroke due to cocaine abuse. The less common findings reported have included a mycotic cerebrovascular aneurysm in a patient with infective endocarditis and haemorrhagic stroke. In addition to stroke, cocaine seems to provoke vascular headache. Seizures precipitated by recreational drug abuse are usually caused by acute intoxication in contrast to the withdrawal seizures encountered in subjects with alcohol abuse. Movement disorders and cerebral atrophy correlating with the duration of abuse have been described. Snorting of organic solvents may cause encephalopathy. Cases of spongiform leukoencephalopathy in heroin addicts have also been reported. Peripheral neuropathy is occasionally precipitated by drug poisoning after intravenous administration. Impurities of the drug, risky administration techniques, and the use of mixtures of various drugs, frequently with simultaneous alcohol drinking, should be taken into account when assessing the background of the adverse event as well as the overall lifestyle of the addicted subjects.

Group A streptococcus endocarditis: report of five cases and review of literature

Group A streptococcus is an uncommon cause of infective endocarditis. We report five probable cases during a 10-year period (1980-1989) from a 750-bed community-teaching hospital. None of the patients were drug abusers. Group A streptococcus is the cause of infective endocarditis in between 0 and 5% cases in reported series. Since the introduction of penicillin 69 cases of group A streptococcus endocarditis have been reported in the literature. Clinical details of 14 patients, none of whom were drug abusers, are available. Included are our five cases. Eight patients had no underlying valve lesions. The overall mortality was 21% but only 15% for patients treated approximately. Among the 25 reported IV drugs abusers with group A streptococcus endocarditis and known valve involvement, right-sided heart valves were involved in 19 and left sided in six. The overall mortality was 9%.

Bacterial endocarditis at a small community hospital

Clinical features, microbiology, and predisposing factors are described in 56 patients with bacterial endocarditis (BE) treated over a 12-year period at a small community hospital in Hawaii. The average age of patients was 52.0 years. The mean duration of symptoms was 28.8 days (range 1 to 240 days). Streptococci was the most frequently identified causative organism, present in 61% of the cases. Gram-negative bacilli were isolated from six patients (11%). Fourteen patients (25%) required cardiac surgery; the most common condition leading to surgery was severe valvular insufficiency, followed by congestive heart failure and recurrent embolism. Eighty-two percent of the patients in the series survived. The leading causes of death were congestive heart failure and cerebrovascular accidents.

Tricuspid valve endocarditis

TVE is mainly a disease of intravenous drug abusers. Although the infecting organisms are often highly virulent, they frequently respond to medical treatment. The prognosis for patients with TVE is fairly good. About 25% of TVE patients require surgical intervention. Persistent sepsis and intractable congestive heart failure are indications for surgery. Tricuspid valvulectomy without prosthetic replacement is the surgical intervention of choice. Right-sided heart failure is the principal complication after valvulectomy without a prosthesis. A significant percentage of patients require insertion of prosthetic valves at a future date.

Glomerulonephritis in bacterial endocarditis

The introduction of antibiotic therapy and changing epidemiologic patterns have altered the nature of glomerulonephritis as it occurs during the course of bacterial endocarditis. Observations made predominantly in the pre-antibiotic era suggested that infections with less virulent organisms, by virtue of their indolent subacute course, favored an antibody response predisposing to immune complex glomerulonephritis. Although antibiotic prophylaxis and therapy have reduced the incidence of both Streptococcus viridans bacterial endocarditis and concomitant glomerulonephritis, Staphylococcus aureus has become a major cause of acute bacterial endocarditis with a high incidence of glomerulonephritis. Parenteral drug abuse itself, which has emerged as a major factor predisposing to endocarditis, may also favor the development of glomerulonephritis. The course of glomerulonephritis has been altered in association with these changes in etiology and epidemiology. This review summarizes the clinical and morphologic features of glomerulonephritis as it currently occurs during the course of bacterial endocarditis.

Infective endocarditis in the narcotic addict

As long as the illicit use of heroin and other drugs continues in our society, infective endocarditis will remain a significant medical problem in the drug-using population. The majority of infections are produced by S. aureus, and the tricuspid valve is most commonly involved. Addicts, unlike the general population, may also develop endocarditis with a variety of gram-negative bacilli and have a higher incidence of fungal infection. The outcome of each individual infection is dependent on the prompt recognition of the underlying valvular infection and the institution of antimicrobial therapy. Infection of the tricuspid valve has a much more favorable prognosis than does infection of the aortic or mitral valves. Fungal endocarditis, and frequently gram-negative bacillary endocarditis, require valvular surgery to effect a cure.

A collaborative study of infective endocarditis in the 1970s. Emphasis on infections in patients who have undergone cardiovascular surgery

Twenty-six major cardiovascular centers participated in a cooperative study of all cases of infective endocarditis occurring during a single calendar year to obtain an overview of infective endocarditis. The study was designed to learn which patients appear to be at highest risk to develop this infection after palliative or reparative cardiovascular surgery. Of 278 patients developing infective endocarditis during the year at these medical centers, 63 (23%) had had previous cardiovascular surgery and 215 had not. Seventy percent of the 278 patients had recognized congenital or acquired heart disease before developing the infection. Rheumatic heart disease accounted for over half of the patients with underlying structural heart disease. A majority (55%) of the 63 patients who had been operated on before developing endocarditis had prosthetic valves inserted. Of those who did not require prosthetic valves, the majority had congenital heart disease with systemic artery-to-pulmonary artery shunts. Although these data were obtained from a selected group of patients, they confirm a significant risk of endocarditis in patients with prosthetic valves and suggest that in postoperative patients with non-valvular congenital heart disease, the highest risk appears to be in cyanotic patients with palliative pulmonary artery-to-systemic artery shunts.