DESCRIPTION

A 28-year-old male intravenous drug user presented with abdominal pain, sepsis (temperature 38.6°C, C-reactive protein 352 mg/l, white cell count 21.6×10⁹/l) and dyspnoea (91% oxygen saturation on 15 l/min oxygen). Physical examination revealed an early diastolic murmur, generalised abdominal guarding and a 12×8 cm necrotic leg ulcer (fig 1). Detailed history revealed the patient was struggling with venous access and had resorted to injecting heroin into his leg ulcer. A computerised tomography (CT) pulmonary angiogram excluded pulmonary emboli, but abdominal CT demonstrated multiple infarcts in his spleen and kidney. An urgent transoesophageal echocardiogram revealed large vegetations prolapsing into the left ventricle (fig 2) consistent with aortic valve infective endocarditis. The infective endocarditis had also destroyed his aortic valve cusps resulting in severe aortic regurgitation (fig 3). Serial blood cultures subsequently revealed group A streptococcus infection for which a prolonged course of intravenous antibiotics was commenced. Three weeks later, the patient underwent open cardiothoracic surgery, without event, to replace his aortic value. The leg ulcer slowly healed over the next few months following considerable input and care from the tissue viability team.

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Figure 1

Necrotic leg ulcer.

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Figure 2

Transoesophageal echocardiogram showing the aortic valve vegetations.

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Figure 3

Doppler showing the severe aortic regurgitation.

Although right-sided infective endocarditis is most frequently associated with intravenous drug use, recent reports now suggest that left-sided infective endocarditis is becoming increasingly more common, with aortic valve involvement predictive of increased morbidity and mortality.1^–3 Common pathogens responsible for infective endocarditis in intravenous drug users include Staphylococcus aureus, Staphylococcus epidermidis and streptococcal spp, although unusual infections such as Pseudomonas aeruginosa, fungi, bartonella, salmonella and listeria may be encountered.3 With appropriate medical and surgical treatment, intravenous drug users with infective endocarditis have an in-hospital survival rate of 91%.1

This case demonstrates the lengths to which intravenous drug users will go to sustain their addiction and the complications which may result. Clinicians treating known IVDU patients who present with sepsis and dyspnoea should have a low threshold for requesting an echocardiogram.