Infective Endocarditis After Body Art: A Review of the Literature and Concerns

doi:10.1016/j.jadohealth.2008.02.008

Journal of Adolescent Health

Volume 43, Issue 3, September 2008, Pages 217-225

https://doi.org/10.1016/j.jadohealth.2008.02.008 Get rights and content

Abstract

Purpose

Infective endocarditis (IE) is a rare but dangerous complication of tattooing and body piercing in adolescents and young adults 15–30 years of age, with and without congenital heart disease (CHD). Because body art, including tattooing and piercing, is increasing and IE cases continue to be reported in the literature, a longitudinal assessment of IE and body art cases is important to examine for trends.

Methods

A 22-year (1985–2007) longitudinal electronic Medline and Scopus review of all published cases of IE and body art was conducted.

Results

In all, 22 specific cases of IE spanning 1991–2007 have been reported that were associated with piercing the tongue (seven), ear lobes (six), navel (five), lip (one), nose (one), and nipple (one), and reported in one heavily tattooed person; other general IE cases have also been mentioned. Twelve cases were in females, and one patient died; nine of these individuals had CHD. Twenty-one cases have been published in the 10 years from 1997–2007.

Conclusions

Although there is no denominator to assess the real risk, this review provides more evidence of IE and body art concerns, and should stimulate further discussion regarding IE antibiotic prophylaxis. It is believed that IE is triggered by normal flora at the body art site, microorganism colonization around the jewelry, or by a localized site infection that stimulates episodes of transient bacteremia (commonly caused by staphylococi) and then seeds various areas of the heart. Frequently in such cases the mitral or aortic valves need to be replaced. For individuals with CHD who want body art, prophylactic antibiotic regimens have been suggested since 1999. Millions of tattoos and body piercings are done yearly, and more IE cases are therefore suspected. An international electronic repository of body art complications would provide better documentation. Body art procurement for many persons in this age group is a matter of “when, not if”; thus proactive, frequent, targeted educational strategies for adolescents and artists practicing body art are suggested.

Section snippets

Methods

Although both tattooing and body piercing have existed for a long time, the medical literature before 1985 had scant information about body art. Thus a 22-year longitudinal electronic Medline and Scopus review was conducted for all published cases of IE and body art from January 1985 to December, 2007. Medical articles had to match against (1) MeSH or keyword term relating to endocarditis and (2) MeSH or keyword terms relating to body art, body piercing, or tattooing. All articles relating to

Results

Since 1991, at least 22 cases of IE have been associated with piercing of the tongue (seven cases) [10], [12], [18], [19], [20], [21], [22], [23], ear lobes (six cases) [13], [16], [17], [24], [25], [26], navel (five cases) [15], [27], [28], [29], [30], lip (one case) [17], nose (one case) [31], and nipple (one case) [32], and reported in one heavily tattooed male [33] (Table 1). Several other recent cases were presented but further details could not be obtained as patient and physician

Incidence of IE

Although still rare, the incidence of IE is reported to be 1.7–6.2 cases per 100,000 individuals in the United States and 3.3 cases per 100,000 individuals in the United Kingdom [36]. The incidence seems to be increasing [11], [35], with an estimated 15,000–20,000 new IE cases diagnosed yearly [9], [11], [36]. Mortality rates range between 4% and 50% [28]. In persons without CHD, post–body art IE seem to target the mitral valve, and these patients were treated successfully with intravenous

Added in Press

Yoshinaga M, Niew K, Ishiwada N, et al. Risk factors for in-hospital mortality during infective endocarditis in patients with congenital heart disease. Am J Cardiol 2008;101:114–8.

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