Portal de Periódicos da CAPES

Case report of Staphylococcus aureus endocarditis after navel piercing

2003; Lippincott Williams & Wilkins; Volume: 22; Issue: 1 Linguagem: Inglês

10.1097/00006454-200301000-00025

1532-0987

Jason B. Weinberg, R. Alexander Blackwood,

Body Image and Dysmorphia Studies

A 13-year-old girl with surgically corrected congenital heart disease presented with a 3-day history of fever 1 month after piercing her navel. An echocardiogram demonstrated a vegetation within her right ventricle to pulmonary artery conduit, and several blood cultures were repeatedly positive for Staphylococcus aureus. Surgical replacement of the conduit in conjunction with intravenous antibiotic therapy was curative. Body modifications, including tattooing and body piercing, have been performed for a variety of reasons in several cultures. In western culture piercing of the ear lobe is a common and accepted practice. However, piercing of other sites such as the eyebrow, lip, tongue, nipple, nose, navel or genitals has been gaining popularity. A substantial proportion of young people, as much as 30 to 50% in some surveys, has at least one piercing at a site other than the ear. Body piercing has been reported in individuals as young as 11 years of age. 1, 2 Body piercing is associated with noninfectious complications such as prolonged bleeding and keloid formation. 3 Infectious complications include the transmission of blood-borne viruses (HIV and hepatitis B, C and D) and acute bacterial invasion at the site of piercing, with Staphylococcus aureus being the most common organism associated with cutaneous infections. 3 More severe infectious complications such as septic arthritis and acute glomerulonephritis have occurred after ear piercing. 4 Infectious endocarditis has been previously reported as an infrequent complication after body piercing. 5–8 We report the first documented case of bacterial endocarditis after navel piercing. Case report. The patient was a 13-year-old girl who presented to her local physician with a 3-day history of low grade fever, nausea, vomiting and abdominal pain. There was no history of cough, runny nose, headache, diarrhea, joint swelling or rash. Past medical history was significant for D-transposition of the great arteries, which was managed surgically with balloon septostomy and Blalock-Taussig shunt shortly after birth and a Rastelli procedure at 3 years of age. Pediatric Cardiology evaluation 4 months before presentation revealed that the right ventricle to pulmonary artery conduit was functioning well at that time. Approximately 1 month before presentation, the patient pierced her own naval at home using a sewing needle before insertion of a naval ring. The skin had been cleaned with rubbing alcohol (isopropanol) before the procedure, but no prophylactic antibiotics were administered. Two days after the piercing, the entry site became tender and erythematous and looked "infected" to the patient. The inflammation gradually resolved after removal of the navel ring. There was no recent history of trauma, surgical procedures or dental procedures, and there had been no recent antibiotic use. On initial examination the patient had a temperature of 101°F, blood pressure of 73/48 mm Hg, heart rate of 122/min, respiratory rate of 22/min, weight of 38 kg and oxygen saturation on room air of 97%. Because she was extremely ill appearing, lethargic and confused, her primary care physician referred her to the emergency department and subsequent admission to the pediatric intensive care unit. Physical examination was notable for crackles at the right lung base and a Grade II/VI systolic murmur with a softer diastolic component. The abdomen was diffusely tender with rebound but no guarding. The liver was palpable 4 cm below the right costal margin with no splenomegaly or other abdominal mass. Cranial nerves were intact. There were no signs of trauma. Admission laboratory studies revealed a white blood cell count of 5.3 × 103 cells/mm3, with 89% neutrophils, 6% lymphocytes and 4% monocytes; a hemoglobin of 10.7 g/dl; and a platelet count of 57 000/mm3. The erythrocyte sedimentation rate was 40 mm/h, C-reactive protein 25.6 mg/dl, fibrinogen 542 mg/dl, and aspartate aminotransferase and alanine aminotransferase of 61 and 53 IU/l, respectively. There were occasional erythrocytes on urinalysis. Analysis of cerebrospinal fluid (CSF) revealed 4 red blood cells/mm3 and 13 white blood cells/mm3, with a differential of 75% neutrophils, 3% lymphocytes and 22% histiocytes. CSF protein was 37 mg/dl, and glucose was 70 mg/dl. A Gram-stained smear of the CSF showed no organisms. Intravenous vancomycin, ceftriaxone and gentamicin were administered after the acquisition of blood and urine cultures. The initial hypotension, abdominal pain and confusion resolved with intravenous hydration. A chest roentgenogram demonstrated a left lower lobe infiltrate. Computer-assisted tomography (CT) scans of the abdomen and head were normal. An electrocardiogram was unchanged from previous examinations, showing sinus tachycardia, right ventricular hypertrophy and right atrial enlargement. An echocardiogram demonstrated a thin, mobile mass at the level of the pulmonary valve that prolapsed through the valve during diastole. The hospital course was significant for daily temperature elevations to 40°C and blood cultures that grew methicillin-susceptible S. aureus. CSF and urine cultures were sterile. Treatment was initially begun with intravenous vancomycin; this was subsequently changed to intravenous nafcillin and gentamicin along with oral rifampin. Blood cultures became sterile on the seventh hospital day. Chest roentgenogram and CT scan of the chest after an episode of hemoptysis on Hospital Day 10 demonstrated multiple new bilateral pulmonary nodules with early cavitation, consistent with septic emboli. On Hospital Day 17 surgery was done for conduit replacement with an aortic homograft. The patient was discharged home on Hospital Day 22, having defervesced after the surgical procedure. She completed an additional 3 weeks of therapy with intravenous gentamicin and 8 weeks of therapy with intravenous nafcillin. There was no bacterial growth from the conduit that was removed during surgery. Discussion. S. aureus is the most frequent organism associated with infectious complications of body piercing. 3 Infectious endocarditis after body piercing is well-documented 5–8; however, this is the first reported case of bacterial endocarditis in a patient with congenital heart disease after navel piercing. Endocarditis was diagnosed by the presence of fever in conjunction with positive blood cultures and the demonstration of a vegetation on echocardiogram ∼1 month after the navel piercing. The interval between piercing and clinical presentation was longer than previously reported for endocarditis after body piercing. 5–8 Our patient developed localized inflammation at the site of piercing, presumably resulting in transient bacteremia and subsequent seeding of the conduit. The piercing was the only risk factor other than the underlying congenital heart disease and subsequent surgical repair. The American Heart Association recommends antibiotic prophylaxis for prevention of bacterial endocarditis in selective patients with heart disease after oral surgical procedures including teeth cleanings 9 because of the risk of transient bacteremias. Surgical incision requires no prophylaxis other than routine surgical scrubbing protocols, and at present no antibiotic prophylaxis is recommended for ear piercing. However, prophylaxis for other body piercings has yet to be addressed. Unlike surgical incisions most body piercing is performed outside of a professional medical setting, such as with our patient, making the risk of a transient bacteremia in these situations somewhat higher. In a recent survey of 151 patients with congenital heart disease, 64 patients reported having an ear piercing and no patient reported having another body part pierced. 10 There were no reported cases of endocarditis associated with the piercings. Despite the absence of body piercing other than ear piercing in the study population, 60% of the physicians surveyed in the study believed that antibiotic prophylaxis should be offered for tattooing or body piercing. There are currently insufficient scientific data to support any recommendation for antibiotic prophylaxis for body piercing. Navel piercing, like other body piercings, carries a risk of endocarditis to patients with congenital heart disease. It would therefore seem prudent to counsel these patients on the risk of endocarditis resulting from body piercing infections, along with other more common infectious and noninfectious complications. Because of the severe consequences of bacterial endocarditis, along with the relative ease of administration and low cost of single dose prophylaxis, the recommendation for antibiotic prophylaxis may be prudent until definitive scientific data regarding antibiotic prophylaxis for body piercing are obtained. Acknowledgment. JW was supported by a Pediatric Infectious Diseases Society Fellowship Award sponsored by Merck and Co. (Whitehouse Station, NJ).