Clinical Presentation

IVDU and particularly HIV-positive IVDU are prone to acquire right-sided endocarditis and this has been well documented in older as well as in newer series [26,27]. Two-thirds of IVDU with infective endocarditis have no clinical evidence of underlying heart disease. Despite the fact that heart murmurs are predictive of infective endocarditis in IVDU, only 35% of addicts demonstrate heart murmurs on admission [27]. In recent years a higher prevalence of left-sided endocarditis has been reported in IVDU. For example, in a retrospective study of infective endocarditis in IVDU, 67 patients had vegetations documented by two-dimensional echocar-diogram. Left-sided involvement was present in 38 (57%) of these patients, a higher prevalence than reported in older series. Right-sided involvement was limited to only 27 (40%) cases. This change in epidemiology is important as left-sided endocarditis carries higher morbidity and mortality. In this study, valvular involvement was as follows: tricuspid valve alone or in combination with others, 52.2% of cases; aortic valve alone in 18.5% of cases; mitral valve alone in 10.8% of cases; and aortic plus mitral valves in 12.5% of cases [29]. Similarly, in the recent Spanish series the tricuspid valve is the most frequently affected (60-70%), followed by the mitral and aortic valves (20-30%) [26].

When patients have right-sided endocarditis, pulmonary symptoms such as pleuritic chest pain, cough, dyspnea and lung infiltrates representing septic emboli tend to dominate the clinical picture as well as signs and symptoms of right heart strain and failure. Many patients have in addition extravalvular sites of infection.

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