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Scientific Article | Right-Sided Infective Endocarditis Due to Methicillin- Resistant Staphylococcus Aureus in an Injecting Drug User: Outbreak or Slow Epidemic? Adel Dimassi MD Monaco Cardio-Thoracic Center, Monte Carlo, Monaco Former Resident, Department of Medicine, Joan C. Edwards School of Medicine, Huntington Thomas Rushton MD, FACP, FIDSA, FSHEA Chief and Professor, Infectious Diseases Joan C. Edwards School of Medicine, Huntington Abstract We present a case of right-sided infective endocarditis due to methicillinresistant Staphylococcus aureus that occurred in an injectable drug user. Traditionally, cities such as Detroit and San Francisco have been associated with certain bacterial infections. Upon further review, these relationships appear more tenuous and argue that identification to the level of “strain” will be required to support such claims. We argue here that this was a case that was part of a larger epidemic that has been slowly evolving over the past several years. Introduction Staphylococcus aureus (SA) is a common etiology for infective endocarditis (IE) in both injectable drug users (IDUs) and non-injectable drug users. It may also occur as a healthcare associated infection (i.e., hemodialysis or line-associated). Worldwide regional variation has recently been described (1). Historically, MRSA has been specifically associated with IDU and IE in Detroit, Michigan although the majority of cases involving the right side of the heart were infected with methicillin-sensitive Staphylococcus aureus (2,3). Huntington, a metropolitan city in WV, appears to frequently receive illegal drugs via illicit trade based in Detroit (4,5). We report an unexpected case of MRSA IE in an IDU living in Huntington and question whether this was related to contact with IDU from Detroit or a reflection of a change in the epidemiology of MRSA. Case report A 41 year old black woman presented to the emergency department complaining of confusion and right forearm and breast pain for four days. She reported chronic injectable cocaine use. She habitually licked the needle prior to selfadministration. She had contact with “drug dealers” from Detroit, Michigan. On examination, she was febrile, tachycardic and tachypneic. Her right wrist and forearm were edematous and erythematous. Her mouth revealed extensive dental decay and cheilitis. There was no meningsmus or cervical lymphadenopathy. She had poor air entry bilaterally with bibasilar rales. Heart sounds were normal and a murmur was not appreciated. The toxicology screen was positive for benzodiazepines and cocaine. Her blood test showed leukocytosis with left shift. Hepatitis C serology was positive, but HIV was negative. Her purified protein derivative TB skin test was interpreted as negative. Her ECG did not disclose a conduction delay. The chest x-ray showed left upper lobe and right medial base densities and the computerized tomogram of the chest revealed septic emboli scattered throughout both lungs. Shortly after admission, blood cultures grew MRSA. Tricuspid valve vegetations were detected via transesophogeal echocardiogram (TEE). A subcutaneous abscess of the forearm was incised and drained. She was treated successfully with vancomycin, gentamicin and rifampin. Follow-up TEE was negative for vegetations. Discussion MRSA IE associated with IDU appears to be very uncommon in the Huntington/Tri-State metropolitan area. This patient was the first treated with this diagnosis in the nearly ten years that one of us had been in practice here (TR, personal communication). Epidemiologically, the question is whether this is the marker of an outbreak or a “slow epidemic”? Bacterial infections in IDU are not uncommon where SA, with or without resistance, is frequently isolated (6). In a study reported in 1987, Chambers and others determined that there was a relationship of risk between cocaine use, IDU and IE (7). International surveillance has determined that SA is the most common pathogen found in IE worldwide (1). As noted, injectable substance users in Detroit develop SA IE and also MRSA IE (2,3). On the other hand, the characteristics of SA have changed dramatically in this new century. Multiple studies have demonstrated that MRSA, originally associated within the hospital milieu, is now frequently isolated in the community setting, presenting as increasingly severe skin and soft tissue infections (8,9). The predominant clone, USA300, has reached Europe, along with other clones, and demonstrates its ability to transform MSSA to MRSA by the type IV SCCmec chromosome which encodes for methicillin resistance and transforms other Staphylococcus species (10,11). 18 West Virginia Medical Journal
| Scientific Article This patient might have experienced an infection with an USA300 clone of MRSA which created her soft tissue infection. Once she became bacteremic, right-sided IE developed. If so, her connection with Detroit is less remarkable. It is useful to consider the history and epidemiology of Serratia marcescens in San Francisco, California: IDU-associated IE has been caused by Serratia marcescens (12,13). It has been suggested that this organism became part of the endogenous microbial flora due to biological warfare experiments conducted by the US military after World War II. Culture media were placed at various geographic points to determine the effectiveness of off-shore disbursement methods. The wild strain of this bacterium grows as red-pigmented colonies which allowed for rapid identification in environmental cultures. While it was hypothesized that the experiments created environmental contamination that led to infections associated with IDU in San Francisco, later analysis proved that military strain was different from that found in such patients a quarter of a century later (12). More recently, Spaargaren and colleagues describe an outbreak of lymphogranuloma venereum (LGV) L2b occurring in Amsterdam and San Francisco, which is equally illustrative (14). Researchers in Amsterdam detected an ongoing outbreak of LGV proctitis. From 2002-2005, cases were analyzed using the polymerase chain reaction assay. These were compared to samples collected in San Francisco in the 1980’s. What appeared at first to be an outbreak associated only with Amsterdam is now correctly identified as an ongoing “slowly evolving epidemic” that involves both Europe and the United States, with the L2b strain implicated in patients infected over almost a quarter of a century (14). While a city or defined geographic boundary may become associated with a particular infection or strain, it would be incorrect to conclude that this represents a localized, isolated event. A community based study showed that individuals in nonhealthcare locations had an overall Staphylococcus aureus colonization rate of almost 27% and an MRSA colonization rate of 1% (15). Conclusion This patient received her cocaine through contacts originating in Detroit, a city associated with MRSA IE. Concomitantly, the epidemiology of MRSA was shifting from a nosocomial, hospital-based infection, to a community –acquired epidemic. It now appears that these new, more virulent strains spread quite rapidly by skin and soft-tissue infections. The most common type isolated is the USA300 strain. This patient might have been colonized by contact with her Detroit-based dealers or she might have been infected with the USA300 strain. At first, it was an attractive hypothesis that the Huntington- Detroit relationship connected both the illicit drug trade and MRSA IE associated with IDU. A review of other geographically identified infections, and the dramatic shift in the epidemiology of MRSA that was just coming to light when this patient was diagnosed, argues that she was part of a larger epidemic. Merely knowing the genus and species of a bacterial infection now seems woefully inadequate. It would appear that precise identification, at least to the level of “strain”, should be employed to establish the exact nature of the infection present (16). The threat to public welfare produced by infections such as MRSA is critical enough to warrant this analysis and hopefully lead to effective control measures. References 1. Fowler VG, Miro JM, Hoen V, Cabell CH, Abrutyn GR, et al. Staphylococcus aureus endocarditis: a consequence of medical progress. JAMA. 2005; 293: 3012-3021. 2. Crane LR, Levine DP,. Levine, Zervos MJ, Cummings G. Bacteremia in narcotic addicts at the Detroit Medical Center. I. Microbiology, epidemiology, risk factors, and empiric therapy. Rev Infect Dis. 1986; 8: 364-373. 3. Levine DP, Crane LR, Zervos MJ. Bacteremia in narcotic addicts at the Detroit Medical Center.II. Infectious endocarditis: a prospective comparative study. Rev Infect Dis. 1986; 8: 374-396. 4. Manolatos T. and Shepardson D. Detroit’s drug trade linked to 4 West Virginia slayings: Huntington police blame city for a ‘substantial amount of our violent crime.’ The Detroit News, May 25, 2005. www. detnews.com, accessed July 21, 2007. 5. U.S. Census Bureau. Census 2000 PHC T- 29. Ranking tables for population of metropolitan statistical areas, micropolitan statistical areas, combined statistical areas New England city and town areas, and combined New England city and town areas: 1990-2000; table 1a. www.census. gov/population/cen2000/phct29/tab01a.pdf. Internet release date: December 30, 2003; accessed May 4, 2007. 6. Gordon RJ and Lowy FD. Bacterial infections in drug users. N Engl J Med. 2005; 353: 1945-54. 7. Chambers HF, Morris DL, Tauber MG, et al. Cocaine use and the risk for endocarditis in intravenous drug users. Ann Intern Med. 1987; 106: 833-36. 8. King MD, Humphrey BJ, Wang YF, Kourbatova EV, et al. Emergence of community-acquired methicillin-resistant Staphylococcus aureus USA 300 clone as the predominant cause of skin and softtissue infections. Ann Intern Med. 2006; 309-17. 9. Johnson JK, Khoie T, Shurland S, Kreisel K, et al. Skin and soft tissue infections caused by methicillin-resistant Staphylococcus aureus USA300 clone. Emerg Infect Dis. 2007; 13: 1195-1200. 10. Tristan A, Bes M, Meugnier H, Lina G, et al. Global distribution of Panton-Valentine leukocidin-positive methicillin-resistant Staphylococcus aureus, 2006. Emerg Infect Dis. 2007 ; 13 : 594-600. 11. Hiramatsu K, Kuroda M, Baba T, Ito T, and Okuma, K. Application of genomic information to diagnosis, management, and control of bacterial infections: the Staphylococcus aureus model. In: Persing DH, Tenover FC, Versalovic J, Tang Y-W, et al, (eds). Molecular microbiology: diagnostic principles and practice. Washington D.C.: ASM Press, 2004; pp.:407-18. 12. Yu VL. Serratia marcescens: historical perspective and clinical review. N Engl J Med. 1979; 300: 887-893. 13. Mills J, Drew D. Serratia marcescens endocarditis. Ann Intern Med. 1976; 85: 397. 14. Spaargaren J, Schachter J, Moncada J, de Vries HJC, Fennema HSA, et al. Slow epidemic of lymphogranuloma venereum L2b strain. Emerg Infect Dis. 2005 ; 11 : 1787-88. Please contact authors for additional references. January/February, 2009, Vol. 105 19
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