A Case Study of Endocarditis: Piercing to the Heart
Arcoma L. Gonzalez Lambert, ND
A small consequence of urban sprawl is that interesting cases are brought to my doorstep. R.G., a 32-year-old man, was seen with chills, fatigue, and shortness of breath of about 1 week’s duration and was in no apparent distress. He was presenting with initial symptoms that I commonly see in the office among patients with anemia and a urinary or kidney infection. Especially with male patients, it often takes several severe symptoms to bring them into the office, so usually they are more complex, with multiple diagnoses during the visit.
After performing an in-depth interview, the patient denied recent travels, burning on urination, or back pain. He had had blood work performed about 3 months ago confirming an absence of anemia. He denied any recent traumas, surgical procedures, or dental work. He works in an office, selling insurance, with no exposures to chemicals, pesticides, or other contaminants that could have brought on these acute symptoms. He denied being an intravenous drug user or having any recent trauma. He revealed a history of congenital aortic stenosis, which was repaired when he was an infant.
I performed a thorough physical examination, which was unremarkable, with the described exceptions. His mouth examination revealed infrequent and incomplete oral hygiene, with a barbell stud tongue piercing, including no active signs of infection. The piercing site was free of debris, exhibiting no exudates, no erythema, and no pain with gloved palpation around the site. When I listened to his heart, there was a wide split in the first heart sound, so I included infective endocarditis in my differential diagnoses. I asked him again when he last received dental work. He replied that he had completed a dental cleaning a little over a year ago. More questioning revealed that his tongue piercing had been performed more than 2 months previously. In retrospect, he did not believe that the tongue piercing was dental work because it was done in a tattoo establishment, and he did not believe that it was recent. I wondered if the piercing was a source of infection, with constant irritation leading to infection of his heart valves. I referred the patient immediately to the emergency department for evaluation and treatment, with a scheduled follow-up visit at my office in 1 month.
From “Art Work” to Aortic Valve Surgery
At the follow-up visit in my office, I reviewed the emergency department’s laboratory workup and findings with the patient. The laboratory tests showed an elevated erythrocyte sedimentation rate and elevated C-reactive protein level. Blood cultures were obtained, and the patient was immediately started on multiple broad-spectrum antibiotics until a sensitivity and specificity culture confirmed the organism. Within a few days, the blood culture and stud culture came back consistent with Haemophilus aphrophilus, normal flora for the mouth. Oral antibiotics were discontinued, and a peripherally inserted central catheter line was inserted to discharge a 6-week course of direct antibiotics. The patient was discharged with recommendations for follow-up surgery to replace his damaged aortic valves.
When I reexamined the patient at a subsequent follow-up visit, he had removed the tongue piercing, and his heart sounds were improving. I could still elucidate a slight systolic murmur, with a faint blowing diastolic murmur. The diastolic murmur could have been more pronounced in the last examination but may have been masked by the general inflammation in the heart. The patient asked if the valve replacement was completely necessary for his future health. I recommended the valve replacement to prevent any further degeneration of cardiopulmonary function.
Steps to Prevent Infection
I had several clinical learning moments during the management of this case, which I would like to share. We are undoubtedly more open to answering questions of our pierced patients that the rest of the medical community may not have time or openness to address. I would recommend prophylactic antibiotics before any piercing work, any tattoo work, or any possibility of insertion of foreign matter or normal flora. The harm of not doing so, as demonstrated with this patient, is much higher than the harm of antibiotics, leaky gut syndrome, or any other sequelae. I wonder if mouth rinsing with 3% hydrogen peroxide daily before and after the tongue piercing would have made a difference in the outcome of endocarditis. It is likely not the actual insertion of the piercing but the constant irritation of the wound and the normal flora being introduced that had inflamed the area. Keeping up with oral hygiene and more frequent dentist cleanings would help to reduce the nidus of infection.
Because of this young man, I am reminded that any gastrointestinal examination (including colonoscopy), urinary scoping (such as for interstitial cystitis), or implementation of any orifice could cause endocarditis. In training, it seemed that the concern with valvular heart disease was mostly for dental cleanings and dental work. This opened up a broader-spectrum concern for my practice.
Training for Body Art Practitioners
I found, within my research, that the state of Oregon has a Board of Body Art Practitioners, which is a testimony to our progressive heritage. I was unable to confirm that the training of Body Art Practitioners would include educating them about endocarditis and cautioning piercing or tattoo clients to seek medical advice before undergoing these procedures.
Arcoma Gonzalez Lambert, ND is an alumni of the National College of Natural Medicine. She has published several peer reviewed articles for ND Updates, includ-ing many on heart related illnesses, and authored or co-authored the article for AANP on Hypertension with Dr. Martin Milner.Dr. Gonzalez is an internationally recognized authority on avoidable causes of cardiopulmonary diseases, particularly unknowing exposures to industrial pollutants in air, water, the workplace (heavy metal exposures), and consumer products. After finding the true cause of the illness, she is particularly adept at dietary, nutritional, exercise, and rehabilitation using the strengths of naturopathic medicine.