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Ann Thorac Surg 2001;71:1365-1366
© 2001 The Society of Thoracic Surgeons

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Case report

Endocarditis after nipple piercing in a patient with a bicuspid aortic valve

^a Department of Cardiac Surgery, University of Ulm, Ulm, Germany

Accepted for publication May 31, 2000.

Adress reprint requests to Dr Ochsenfahrt, Department of Cardiac Surgery, University of Ulm, Steinhövelstr 9, D-89075 Ulm, Germany
e-mail: christoph.ochsenfahrt{at}medizin.uni-ulm.de

	Abstract

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Piercing the skin for cosmetic reasons can be dangerous in young adults who have previously undergone surgery for congenital defects of the heart. We report the case of a 24-year-old man in whom coarctation of the aorta had been corrected 15 years earlier. Two months after piercing his left nipple without antibiotic prophylaxis, he developed a local mastitis, followed by bacterial endocarditits that required replacement of the aortic valve.

	Introduction

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Endocarditis is a serious complication following skin lesions associated with soft tissue infection. Persons undergoing cosmetic procedures like skin piercing with an elevated risk for endocarditis caused by certain cardiac conditions are recommended to receive a prophylactic antibiotic regimen.

A 24-year-old man presented with moderate local mastitis and cellulitits of the thoracic wall following the implantation of a cosmetic ring (Fig 1). No prophylactic antibiotics had been given to cover this procedure. He also had a congenital bicuspid aortic valve and aortic coarctation, the latter having been treated surgically at the age of 9 years. He developed a mastitis shortly after implantation of the ring, followed a month later by nausea, fever, and diarrhea and, 2 days before admission, dyspnea and a productive cough with bloodstained sputum. On examination, a systolic murmur could be heard in the aortic area that extended into the carotic region. Laboratory investigation showed an elevated blood sedimentation rate, together with a moderate leukocytosis, and S epidermidis was grown in four blood cultures. The same bacteria was found in the microbiological sample of the local mastitis. Transthoracic and transesophageal echocardiography revealed severe insufficiency of the aortic valve, without vegetation, but with thickening of the cusps. The resected area of the coarctation showed only a moderate return of the stenosis. Other organic complications were excluded. Antibiotic treatment with amoxicillin and gentamicin was started at once and continued for 1 month until the signs of infection had disappeared. The patient was then accepted for elective replacement of the aortic valve after removal of the piercing ring. During the operation myocardial function was found to be unimpaired, but there was a moderate enlargement and severe myocardial hypertrophy of the left ventricle. A bicuspid aortic valve was found, with a perforation and endocardial deposits. The fibrous aortic ring was intact. We replaced the aortic valve with a Carbomedics prosthesis (Sulzer Carbomedics, Austin, TX) of size 23.

View larger version (158K): [in this window] [in a new window]   Fig 1. Radiograph of the chest showing the piercing of the left nipple antecedent to the diagnosis of endocarditis.

Postoperatively, the patient was given antibiotic treatment with gentamicin, vancomycin and ofloxacin for 2 weeks and, thereafter, was treated with Staphylex (Flucloxacillin, Smithkline Beecham, Pharma GmbH, Munich, Germany). He made a fast recovery from the surgical treatment, and could be transferred to his local hospital 10 days later. Ten days later he was admitted into a convalescent home.

Postoperative transthoracic echocardiography showed an elevated peak gradient of 43 mm Hg at the aortic valve prosthesis, so that transesophageal echocardiographic control was carried out. The prosthesis showed a regular function, a severe left ventricular hypertrophy and a consecutively increased cardiac output was found as a possible reason for the peak gradient of the valve prosthesis. No further complications appeared, and the patient was able to return to work 2 months after the operation.

	Comment

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In this case, the skin of a patient was pierced for cosmetic reasons without receiving the necessary antibiotic prophylaxis, although he had previously been treated surgically for coarctation of the aorta and was known to have a congenital bicuspid aortic valve. There is an established increase in the incidence of infective endocarditis in patients who have undergone surgery for congenital heart defects, and these patients are particularly liable to infection following a lesion of the skin [1, 2]. With a surgical history of resection for coarctation of the aorta, the incidence ranges from 0.7 to 1.2 cases per 1,000 patient-years and is even higher for a congenital bicuspid aortic valve [1, 3]. Prophylactic cover for these patients is recommended by the American Heart Association with an antistreptococcal penicillin or a first-generation cephalosporin before the procedure [4].

Piercing the body for cosmetic reasons is becoming an increasingly common practice in young adults today, and infective endocarditis as a severe complication independent of the localization of the piercing is frequently observed in patients with an increased risk factor [5, 6]. In our patient, two risk factors were present: the surgical treatment of the coarctation as a low risk and the congenital bicuspid aortic valve as a moderate risk for endocarditis following the American Heart Association [4]. The destroyed bicuspid aortic valve was replaced by a mechanical prosthesis without further complications [7].

All such patients must be warned of the possibility of endocarditis and the necessity for antibiotic prophylaxis, even in the case of such an apparently trivial lesion as piercing the skin for cosmetic reasons.

	References

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1. Morris C.D., Reller M.D., Menashe V.D. Thirty-year incidence of infective endocartitis after surgery for congenital heart defect. JAMA 1998;279:599-603.[Abstract/Free Full Text]
2. Lacassin F., Hoen B., Leport C., et al. Procedures associated with infective endocarditis in adults. A case control study. Eur Heart J 1995;16:1968-1974.[Abstract/Free Full Text]
3. De Gevigney G., Pop C., Delahaye J.P. The risk of infective endocarditis after cardiac surgical and interventional procedures. Eur Heart J 1995;16(Suppl B):7-14.
4. Dajeni A.S., Taubert K.A., Wilson W., et al. Prevention of bacterial endocarditis. Recommendations by the American Heart Association. Circulation 1997;96:358-365.[Abstract/Free Full Text]
5. Ramage I.J., Wilson N., Rhomson R.B. Fashion victim: infective endocarditis after nasal piercing. Arch Dis Child 1997;77:187.
6. Battin M., Fong L.V., Monro J.L. Gerbode ventricular septal defect following endocarditis. Eur J Cardiothorac Surg 1991;5:613-614.[Abstract/Free Full Text]
7. David T.E., Bos J., Christakis G.T., Brofman P.R., Wong D., Feindel C.M. Heart valve operations in patients with active infective endocarditis. Ann Thorac Surg 1990;49:701-705.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Christoph Ochsenfahrt Reinhard Friedl Andreas Hannekum Bernd A. Schumacher Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ochsenfahrt, C. Articles by Schumacher, B. A. Search for Related Content PubMed PubMed Citation Articles by Ochsenfahrt, C. Articles by Schumacher, B. A. Related Collections Congenital - acyanotic Valve disease