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Janeway lesions are painless, macular, hemorrhagic, irregularly-shaped lesions that occur on the palms and soles. The pink macular lesions on our patient’s right hand, we believe, represented Janeway lesions (Fig. 1, arrow). Moreover, a pronounced subungual splinter hemorrhage was also seen at the patient’s thumb (Fig. 1, arrowhead). Make your tax-deductible gift and be a part of the cutting-edge research and care that’s changing medicine. Our mission is to be a relentless force for a world of longer, healthier lives.

• Active endocarditis, emergency intervention, dialysis, liver disease, enterococcal infections, lung disease, prosthetic valve endocarditis, aortic valve disease, and multivalve disease are predictors of increased short-term mortality after surgery for DUA-IE.
• SBE often develops on abnormal valves after asymptomatic bacteremia due to periodontal, gastrointestinal, or genitourinary infections.
• The diagnosis of infective endocarditis is usually based on a constellation of clinical findings rather than a single definitive test result.
• In this article we explore these different proposed mechanisms for the increased prevalence of right-side endocarditis in IDUs.

Procedures requiring antibiotic prophylaxis

Levine et al. [7] have proposed that intrinsic differences in the endothelium of valves on the right and left sides of the heart may cause certain organisms to adhere to particular valves. They postulate that differences in shapes and sizes of bacteria may make an organism uniquely susceptible or resistant to changes in hemodynamic flow, resulting in deposition on particular valves [7]. Mere physical differences between bacteria do not explain a predilection for specific valves. In a large series of patients with bacterial endocarditis, Watanakunakorn and Burkert [33] observed that 48% of nonaddicts in their series had S. Aureus predominantly affected left-side valves in this nonaddict population.

Management of Infective Endocarditis in People Who Inject Drugs

• Antibiotic treatment should start immediately after blood cultures are obtained.
• The patient, however, did not improve and 2 weeks after admission, had a cardiac arrest and died.
• DU-IE were least common in West North Central and West South Central regions (28%).
• A 45-year-old African American male with a medical history significant for active IDU, hypertension, type II diabetes mellitus, hepatitis C, history of osteomyelitis and cerebrovascular accident was brought to emergency room for mental status changes.
• Most procedures for which prophylaxis is required for high-risk patients are oral-dental procedures that manipulate the gingiva or the periapical region of teeth or perforate the oral mucosa.

Aureus further activates the extrinsic clotting cascade, which is essential to vegetation formation, by initiating the expression of tissue factor [52]. Aureus produces coagulase and is able to promote conversion of fibrinogen to fibrin, thus acting as a procoagulant. Formation of a fibrin coat protects vegetation and enhances its ability to propagate and invade surrounding tissue while preventing host clearance. Interactions with platelet-fibrin thrombus of damaged endothelium and MSCRAMM also occur [52]. In addition, many staphylococcal strains are resistant to platelet microbicidal proteins [54]. All patients at risk for IE should receive antibiotic cover for invasive procedures (see Tables 2 and 3, overleaf).

Who gets Intravenous Drug Abuse Endocarditis? (Age & Sex Distribution)

It has been shown that the addictive drug itself may cause endothelial damage, priming a valve for endocarditis. Haverkos and Lange [26] have suggested that drug-induced pulmonary hypertension may cause increased pressure gradients and turbulence. Such hemodynamic changes would lead to right-side valve dysfunction and subsequent damage to valve leaflets. Definitions of terms used in the Duke criteria for the diagnosis of infective endocarditis (IE). It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases ones chances of getting a condition compared to an individual without the risk factors.

Clinical Topics

Diagnosis of culture negative IE is made by modified culture conditions, serology, molecular techniques or immunohistology of the surgically removed specimens. Diagnosis of infective endocarditis is largely based on Duke Criteria, which includes pathologic findings on blood or valve vegetation cultures and clinical findings. Infective endocarditis commonly presents with fever, occurring iv drug use in up to 96% of cases [3]. It is usually absent on patients started on antibiotics, antipyretics, elderly patients, with heart failure or renal failure. The disease itself had been known to have unusual and non-specific presentations with case reports citing neuropsychiatric manifestations such as symptoms of transient ischemic attack (TIA) or stroke, seizures, or agitation [4].

The 2015 American Heart Association (AHA) guidelines on managing IE (published in Circulation) suggest avoiding surgery in people who inject drugs because of the risk of prosthetic infection. The 2020 joint guidelines of the American College of Cardiology (ACC) and AHA on valvular heart disease (published in JACC) provide only limited guidance. They do say valve repair is preferable to valve replacement when feasible (as is usually the case in younger patients). The two major criteria are sustained bacteremia and involvement of the endocardium, which can be determined either by using an echocardiogram searching for vegetations, abscesses or new valvular regurgitation.

Differential Diagnosis

Patients who require antibiotic therapy for any reason should have at least 3 sets of blood cultures drawn before antibiotics are started. Although pre-existing endothelial damage is considered necessary for vegetation formation, the explanation of particle- or drug-induced valvular damage may be too simplistic. In a study by Reiner et al. [30], heroin addicts with Staphylococcus aureus endocarditis did indeed have significantly more right-side involvement; however, addicts with enterococcal endocarditis had significantly more left-side involvement. There was no difference between the 2 groups in predisposing heart lesions to account for the left-side preference in the enterococcal endo-carditis patients. Serratia marcescens has been shown to preferentially attack left-side valves in IDUs without preexisting heart lesions [31]. Similarly, a study by Mathew et al. [32] showed that streptococcal endocarditis in a group of IDUs localized to left-side valves, whereas S.

• On physical examination, there were bilateral inspiratory crackles over bilateral lung bases.
• The content published in Cureus is the result of clinical experience and/or research by independent individuals or organizations.
• The local Ethics Committee approved the study (authorization n 12113_oss) and, given the retrospective and non-interventional nature of the study, granted a waiver of informed consent.
• Prevention for those at risk usually involves awareness of the risks, and preventative antibiotics prior to certain surgical, dental and medical procedures.

Clinical Considerations

Prolonged infection may cause splenomegaly or clubbing of fingers and toes. Although oral antibiotics may be the agent of choice in certain circumstances, parenteral antibiotics are the standard therapy for DUA-IE. Patients with IE often receive six weeks of antibiotics, but guidelines support an abbreviated course for certain scenarios of right-sided IE, which is more common in DUA-IE. There has been a continuous debate as to whether it is ethical to withhold valve surgery in an active, noncompliant drug user. The first valve surgery is normally offered to those patients who are willing to undergo drug rehabilitation program and be compliant with treatment. However, any IDU who becomes non-compliant, relapses, and acquires a second episode of IE generally will not be offered further valve surgeries (21).

What is the Prognosis of Intravenous Drug Abuse Endocarditis? (Outcomes/Resolutions)

The tricuspid valve may be more susceptible to heroin use, as heroin can cause an increase in pulmonary arterial pressure, creating more turbulence at the tricuspid valve. Substances such as cocaine and metamphetamines, on the other hand, increase systemic afterload, causing increased turbulence at the sites of the aortic and mitral valves. Therefore, any shifts in the incidence of right versus left-sided IE may reflect the availability of certain illicit substances (6, 10). Infective endocarditis, also called bacterial endocarditis, is an infection caused by bacteria that enter the bloodstream and settle in the heart lining, a heart valve or a blood vessel.

• Initial tests were notable for a urine drug screen positive for cocaine, marijuana, methadone, and opioids.
• Diminution of vegetation size can be followed by serial echocardiography.
• The first valve surgery is normally offered to those patients who are willing to undergo drug rehabilitation program and be compliant with treatment.
• Moreover, since we could not identify any predictor of a futile surgery, this reinforces the concept that any patient with a complicated IE deserves surgery without delay, irrespective of its aetiology.
• Patients who use illicit intravenous drugs have a much higher incidence of right-sided endocarditis (about 30 to 70%).