The danger of wearing your heart on your sleeve Christopher Michael Orton, Karl Norrington, Harith Alam, Rafael AlonsoGonzalez, Michael Gatzoulis PII: DOI: Reference:

S0167-5273(14)00718-9 doi: 10.1016/j.ijcard.2014.04.059 IJCA 17960

To appear in:

International Journal of Cardiology

Received date: Accepted date:

2 April 2014 4 April 2014

Please cite this article as: Orton Christopher Michael, Norrington Karl, Alam Harith, Alonso-Gonzalez Rafael, Gatzoulis Michael, The danger of wearing your heart on your sleeve, International Journal of Cardiology (2014), doi: 10.1016/j.ijcard.2014.04.059

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C.Orton, K.Norrington, H.Alam, R. Alonso, M.Gatzoulis

The danger of wearing your heart on your sleeve

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Authors: Christopher Michael Orton Karl Norrington Harith Alam Rafael Alonso-Gonzalez Michael Gatzoulis

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Affiliation (all authors): Department of Cardiology, Royal Brompton Hospital, Sydney Street, London, SW3 6NP United Kingdom. Corresponding author: Christopher Michael Orton Email: [email protected]

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A 20 year old male gardener presented to his local hospital with fever, diarrhoea, shortness of breath and pleuritic chest pain.

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He had a background of an open valvotomy for congenital aortic stenosis aged 18 months followed by the Ross procedure aged 18 years. There were no other comorbidities. He was on no regular medication and he denied recent travel or illicit drug use.

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He had undergone a tattoo to his left arm eight weeks earlier, to commemorate his congenital heart disease (figure 1A). Four weeks later he developed intermittent pleuritic chest pain associated with dyspnoea and fevers four days prior to admission with profound frequent watery diarrhoea.

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At presentation, he was tachypnoeic (22 bpm), tachycardic (137 bpm), hypotensive (96/50 mm Hg), and pyrexial (39°C). Oxygen saturations were 98% on room air. Further examination revealed good dentition, mild facial acne, bitten nails and several tattoos, including the recent 12cm tattoo of the left arm, which did not appear infected. There was a palpable precordial thrill with a 4/6 ejection systolic murmur at the upper left sternal border, with reduced air entry at the right lung base. There were no peripheral stigmata of infective endocarditis nor peripheral oedema. Abdominal examination demonstrated mild left upper quadrant tenderness with no palpable organomegaly nor features of peritonitis. ECG showed sinus tachycardia with no significant ST changes, chest x-ray demonstrated bilateral cavitating parenchymal lung lesions and a prominent cardiac silhouette consistent with right heart enlargement. Urinalysis was only positive for trace haematuria, peripheral blood demonstrated haemaglobin 138 g/L, white cell count 12.6 x109/L, platelet count 189x109/L, creatinine 82µM, glucose 5.9 mM and a c-reactive protein (CRP) of 177 mg/L. There was mild respiratory alkalosis on arterial blood gas analysis with a mildly elevated lactate (pH 7.49, pO2 10.2 kPa, pCO2 3.9 kPa, base excess -0.3 mM, lactate 1.9 mM). Following initial fluid and electrolyte replacement, three sets of peripheral blood cultures were taken, which returned positive on day 2 with methicillin-

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C.Orton, K.Norrington, H.Alam, R. Alonso, M.Gatzoulis

sensitive Staphalococcus Aureus. Empirical vancomycin 1g BD I.V., rifampicin 300mg BD P.O. and gentamicin 1mg/kg TDS I.V. were initiated to cover prosthetic valve endocarditis.

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Transthoracic echocardiography revealed mild dilatation of the right ventricle and atrium with impairment of systolic function. The pulmonary homograft leaflets were restricted and oedematous with independently mobile echogenic structures attached (figure 1B). Peak doppler gradient was 78mmHg suggesting severe conduit stenosis. There was mild pulmonary and tricuspid regurgitation. The pulmonary autograft in the aortic position appeared normal in morphology and function, as were the mitral valve and left ventricle.

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On day 3 the patient was transferred to a tertiary cardiac centre. He remained pyrexial with CRP climbing further to 214mg/L. Following microbiological advice, his antibiotic regime was changed to flucloxacillin 2g 4 hourly I.V., meropenem 1g TDS I.V. and rifampicin 300mg BD. CT chest confirmed multiple bilateral cavitating lesions in the lung fields, with confluent opacification in the right lower lobe and bilateral pleural effusions. Despite a gradual fall in CRP, he continued to spike temperatures with intermittent violent rigors and pleuritic chest pain. Repeat transthoracic echocardiography showed increasing transpulmonary gradient (90 mmHg) and advancing right ventricular impairment. A CT pulmonary angiogram was performed on Day 13 showing evidence of new cavitating lesions associated with bilateral subsegmental pulmonary emboli and a classical wedge shaped infarct in the right lower lobe (Figure 1C).

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In view of ongoing sepsis, pulmonary embolization and worsening haemodynamics despite appropriate antibiotic therapy, the decision was made to proceed with surgery. Indeed, the infected conduit and surrounding tissue were removed and replaced with an aortic homograft on day 14. Rapid clinical improvement ensued. Antibiotic therapy was completed for a 6-week post-operative course with normalisation of CRP. The patient remained well and apyrexial. The excised pulmonary homograft tissue was positive for Staphalococcus Aureus on culture (Figure 1D and 1E). Bacterial endocarditis in patients with congenital or structural heart disease remains of concern. The recent change in antibiotic prophylaxis policy should not undermine the ongoing need for primary prevention1-3. Suboptimal oral or skin hygiene are common vectors for infection4. In our case acne, nail biting and tattooing were all risk factors. This is speculative but given the timing of events the latest commemorative tattoo of the patient was the culprit factor. Timely transfer to a tertiary centre in cases of prosthetic valve endocarditis is paramount as management of this is jointly medical and surgical. The need for educating patients and the profession alike on proactive, primary prevention of endocarditis including avoidance of tattooing in patients at risk, is as pressing today as ever.

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C.Orton, K.Norrington, H.Alam, R. Alonso, M.Gatzoulis References

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1. Nishimura RA, Carabello BA, et al. ACC/AHA 2008 guideline update on valvular heart disease: focused update on infective endocarditis: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2008; 118(8):887.

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2. Habib G, Hoen B, et al. Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009): the Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and the International Society of Chemotherapy (ISC) for Infection and Cancer. Eur Heart J. 2009; 30(19):2369.

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3. Centre for Clinical Practice. Prophylaxis against infective endocarditis. Antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures. London (UK): National Institute for Health and Clinical Excellence (NICE); 2008 Mar. 107 p. (Clinical guideline; no. 64).

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4. Satchithananda D, Walsh J, Schofield PM. Featured clinical case: Bacterial endocarditis following repeated tattooing. Heart 2001; 85:11-12 doi:10.1136/heart.85.1.11

Figure 1 legend

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A. Tattoo left upper arm B. Septic embolic disease (arrow) demonstrated on CT chest C. Large pulmonary homograft vegetation (arrow) on Echocardiography D. Haematoxylin and eosin stain of valve leaflet with thrombus and S. Aureus colonies (arrow) on low power microscopy. E. Haematoxylin and eosin stain of valve leaflet with S. Aureus colonies in purple under high power microscopy. B E

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C.Orton, K.Norrington, H.Alam, R. Alonso, M.Gatzoulis

The danger of wearing your heart on your sleeve.

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