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Dispatch
Haemophilus aphrophilus
Endocarditis after Tongue Piercing
Hossein Akhondi* and Ali R. Rahimi*
*Mercer School of Medicine, Savannah, Georgia, USA
Suggested citation for this article:
Akhondi H, Rahimi AR. Haemophilus aphrophilus endocarditis after
tongue piercing. Emerg Infect Dis [serial online] 2002 Aug [date
cited];8. Available from: URL: http://www.cdc.gov/ncidod/EID/vol8no8/01-0458.htm
Piercing invades
subcutaneous areas and has a high potential for infectious complications.
The number of case reports of endocarditis associated with piercing
is increasing. We studied a 25-year-old man with a pierced tongue, who
arrived at Memorial Health University Medical Center with fever, chills,
rigors, and shortness of breath of 6 days' duration and had an aortic
valvuloplasty for correction of congenital aortic stenosis.
Body piercing poses a risk for serious disease. Because it invades subcutaneous
areas, piercing has a high potential for infectious complications. Such
complications result from introduction of skin or mucous membrane microflora
into subcutaneous tissue or from the ongoing presence of colonies of these
microflora at the piercing site. Pain, edema, and prolonged bleeding may
occur immediately after piercing (1), and a cyst, scar,
or keloid may form at the piercing site. In various surveys, the rate
of earlobe piercing infections alone has been estimated at 11% to 24%.
Skin lesions or anatomic abnormalities at the site of piercing, as well
as valvular heart disease, are risk factors for complications (2).
Staphylococcal endocarditis of the mitral valve after nasal piercing (3),
Neisseria endocarditis after tongue piercing (4), and Staphylococcus
epidermidis endocarditis and mastitis following nipple piercing have
been reported (5). Even though a consistent correlation
is not known between piercing and endocarditis, the number of case reports
is increasing, and a correlation may well exist.
Persons at high risk for complications should be treated with preventive
antibiotics, just as persons at high risk for complications receive antibiotic
treatment before dental procedures. The correlation between dental procedures
and endocarditis has been reviewed by Van der Meer et al., who prospectively
examined all cases of infective endocarditis in the Netherlands over a
2-year period (6). Of 427 patients who had been hospitalized,
64 had previous dental or other procedures in the preceding 3 months.
Only 48 of the 438 patients met the qualification of having native-valve
and
cardiovascular anomalies that increased their risk of getting endocarditis.
Using these 48 patients as study cases, the researchers found no significant
difference in presence of dental procedures between patients and matched
controls without endocarditis (odds ratio 1.2, 95% confidence interval
0.03 to 2.3). Two other studies (7,8) reported similar
results. No study has examined the correlation between piercing and endocarditis.
In the United States, body piercing, which is becoming increasingly common,
is mainly performed by unlicenced practitioners. Only 26% of states have
regulatory authority over tattooing establishments, and only six of these
states exercise authority over body-piercing establishments. Piercing
occurs in regulated and unregulated shops, department stores, jewelry
shops, homes, or physicians’ offices. Generally no antibiotic is used,
and sterilization methods vary. Studies show that ear piercing can cause
cephalic tetanus (a local form of tetanus caused by wounds or other head
and neck infections) (8), Pseudomonas infections,
or perichondrial auricular abscesses, especially with Pseudomonas aeruginosa.
Tongue or oral piercing can cause Ludwig’s angina (2,9,10)
or may be complicated by normal oral flora, such as Haemophilus aphrophilus,
as in this case. Genital piercing may result in Escherichia coli infection
and may increase the risk for sexually transmitted diseases through tissue
damage and exposure and unwanted pregnancy because of condom rupture (11).
Systemic infections, such as toxic shock syndrome or sepsis, have also
been reported (10). Among noninfectious cases, granulomatous
perichondritis of the nasal ala, sarcoidlike foreign body reaction from
multiple piercing, paraphimosis from a distal penis pierce, and speech
impairment, together with difficulty in chewing and swallowing from oral
jewelry, have been reported (1,2,9,10). Metal-associated
problems include allergy (especially to nickel), eczematous rash, and
lymphocytoma (2,9,10,12). We describe
an incidence of H. aphrophilus endocarditis following tongue piercing.
Case Report
A 25-year-old man arrived at Memorial Health University Medical Center
with fever, chills, rigors, and shortness of breath of 6 days' duration.
He had a history of aortic valvuloplasty at 8 years of age for correction
of congenital aortic stenosis. At admission, the patient had fever of
38.9°C and a grade III/VI ejection systolic murmur accompanied by a grade
II/VI diastolic blowing murmur best heard in the left sternal border area.
The oral cavity was pink, and no inflammation or exudates were noticed
on the pharynx. The middle portion of the tongue had been pierced, and
a bispherical stud was in place (Figure). The piercing
was performed 2 months before onset of illness. Extensive tattoos on the
shoulders, arms, and upper torso dated back 3 years. The patient had previous
dental work done but always with antibiotic prophylaxis.
Laboratory tests showed erythrocyte sedimentation rate of 41 mm/hr (normal
rate, 0–15 mm/hr) and elevated C-reactive protein of 5.1
mg/dL (normal level 0–1). Transthoracic echocardiography was not
conclusive; a transesophageal echocardiogram showed remnants of a bicuspid
and deformed aortic valve with multiple vegetative lesions. Blood cultures
were obtained, and the patient was started on triple antibiotics (ampicillin,
nafcillin, and gentamycin). Wet preparation and acridine orange stain
of the blood specimen showed gram-negative pleomorphic rods. Two of the
conventional chocolate-agar cultures turned positive approximately 4 days
after incubation and were consistent with H. aphrophilus (β-lactamase
negative, lactose fermenting, and Mannose fermenting). The stud culture
was also positive for H. aphrophilus. Antibiotics were modified
because of sensitivity to ceftriaxone and gentamycin, and the patient
was discharged to complete the 6-week course through a peripherally inserted
central catheter line at home. Aortic valve replacement was recommended
after completion of antibiotic therapy, but the patient did not return
for treatment.
Conclusions
Our case demonstrates H. aphrophilus endocarditis possibly caused
by tongue piercing (or as a complication of the ongoing presence of the
stud) in a patient with congenital heart disease. Colonization around
the stud likely caused bacteremia and endocarditis. H. aphrophilus
is commonly isolated from the upper respiratory tracts of humans and
animals; however, its prevalence is unknown. In a previous study of piercing
complications in patients with congenital heart disease (13),
43% of the study population had earlobe piercing; of these, 6% took antibiotics
before piercing. Twenty-three percent of patients had piercing-related
infections 1 week to 3 years after piercing. Most infections were local
skin infections; no endocarditis was reported in that study.
Until prospective randomized studies shed light on the relationship between
piercing and endocarditis, prophylactic measures are indicated and should
be formulated, particularly for persons at high risk, e.g., those with
structural heart diseases.
Dr. Akhondi is a second-year resident with the Department of Internal
Medicine at Mercer University School of Medicine, Savannah Campus at Memorial
Health University Medical Center in Savannah, Georgia.
Dr. Rahimi is the associate director of Internal Medicine Education,
chief of the Geriatrics Division, and professor of medicine at Mercer
University School of Medicine, Savannah campus.
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