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Editor,—We report a case of infective endocarditis occurring after nasal piercing.
A previously well 14 year old girl presented three weeks after nasal piercing and metal stud insertion. After insertion she developed progressive ‘flu’ like symptoms with fever, myalgia, headache, nausea, and vomiting. Examination revealed a normally developed girl who was pyrexial (39.4°C) and uncomfortable, with suprapubic and epigastric tenderness.
Examination of her cardiovascular system demonstrated no abnormality.
Investigations showed a neutrophil leucocytosis, a raised C reactive protein and erythrocyte sedimentation rate. Blood and urine cultures were taken. Because of her persisting abdominal pain a laparoscopy and appendicectomy were performed and showed no abnormalities.
Despite treatment with flucloxacillin, cefotaxime, and metronidazole she proceeded to rigor. Nasal swabs and blood and urine cultures repeatedly grew Staphylococcus aureus despite appropriate antibiotic treatment.
Subsequently she developed signs of focal septic embolisation and an echocardiogram was performed, revealing a large vegetation on the anterior leaflet of the mitral valve with no evidence of valvular incompetence. The size of the vegetation1 and the blood culture results indicating the likely infecting organism to beS aureus. A diagnosis of infective endocarditis was made and she was treated with high dose flucloxacillin and vancomycin. Subsequently she developed clinical signs of mitral regurgitation confirmed on echocardiography. She developed an allergic rash to flucloxacillin and treatment was changed to vancomycin alone for the last three weeks of her six week treatment. The mitral valve vegetation decreased in size after treatment but she was left with minor degree of mitral incompetence evident clinically and echcardiographically.
Infective endocarditis due to S aureus in the absence of an underlying cardiac defect is uncommon.2 In vitro studies have demonstrated the ability of S aureus to induce a tissue factor promoting adherence to valve endothelium, altering host responses and partially protecting from antimicrobial treatment resulting in a prolonged bacteraemia.
Initial treatment of infective endocarditis comprises intravenous benzylpenicillin and gentamicin. If staphylococcal infection is confirmed then flucoxacillin is added and treatment continued for six weeks, using vancomycin in cases of penicillin allergy.2
Nasal carriage of S aureus renders piercing of this area more likely to result in infective endocarditis, however piercing of any mucous membrane may result in bacteraemia and infective endocarditis.
We report for the first time infective endocarditis arising after nasal piercing in a person with a structurally normal heart, and emphasise the importance in excluding this diagnosis in patients with a persisting pyrexia after recent invasive adornment.
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