Embolic stroke complicating Staphylococcus aureusendocarditis circumstantially linked to rectal trauma from foreign body: a first case report
© Pandey et al; licensee BioMed Central Ltd. 2005
Received: 27 January 2005
Accepted: 27 May 2005
Published: 27 May 2005
Diagnostic and therapeutic instrumentation of the lower gastrointestinal tract has been reported to result in bacteremia and endocarditis. No such case has been reported in persons with a history of rectal foreign body insertion despite its potential for greater trauma.
A 58-year-old male was admitted with confusion and inability to speak. His past history was notable for hospitalization to extract a retained plastic soda bottle from the rectosigmoid two years prior. On examination, he was febrile, tachycardic and hypotensive. There was an apical pansystolic murmur on cardiac examination. He had a mixed receptive and expressive aphasia, and a right hemiparesis. On rectal examination he had perianal erythema and diminished sphincter tone. Magnetic resonance imaging of the brain showed infarction of the occipital and frontal lobes. Transesophageal Echocardiography of the heart revealed vegetations on the mitral valve. All of his blood culture bottles grew methicillin sensitive Staphylococcus aureus. He was successfully treated for bacterial endocarditis with intravenous nafcillin and gentamicin. The rectum is frequently colonized by Staphylococcus aureus and trauma to its mucosa can lead to bacteremia and endocarditis with this organism.
In the absence of corroborative evidence such as presented here, it is difficult to make a correlation between staphylococcal endocarditis and anorectal foreign body insertion due to patients being less than forthcoming
There is a potential risk of staphylococcal bacteremia and endocarditis with rectal foreign body insertion. Further studies are needed to explore this finding. Detailed sexual history and patient counseling should be made a part of routine primary care.
There is a large body of surgical literature reporting anal eroticism resulting in rectal trauma and retained foreign bodies [1, 2], but there is no report of bacteremia or endocarditis occurring in these patients. Staphylococcus aureus is an aggressive pathogen and bacteremia with this organism can infect healthy heart valves. The rectal mucosa is a major site of colonization by this organism. We describe a patient with a past history of surgical extraction of a retained plastic soda bottle from the rectosigmoid, who later developed staphylococcal endocarditis resulting in septic embolism and stroke. No such case has been reported in the literature.
Foreign bodies in the rectum and methods of their extraction have been amply chronicled in the surgical literature . Sexual stimulation is the reason in a majority of these cases . Local trauma, perforation, and resultant peritonitis are well known complications . An unlimited PUBMED search for articles on bacteremia or endocarditis related to rectal foreign body insertion was unfruitful (We tried MeSH terms anal/rectal/colorectal/foreign bodies/anorectal /sexual deviation for the purpose). Bacteremia and septicemia from barium enema , and therapeutic anal dilatation  have been published. Procedures like fiberoptic sigmoidoscopy are known to cause endocarditis , but septic stroke resulting from endocarditis related to lower gastrointestinal instrumentation has also not been reported.
The patient's history of anorectal insertion of a plastic soda bottle for sexual gratification is consistent with published reports of use of large objects for this purpose . The resultant rectal trauma can easily lead to bacteremia. Rectal carriage of Staphylococcus aureus is well documented and is a potential source of infection . This organism tends to be more abundant on the rectal mucosa than within the feces . In a study of gastrointestinal colonization, Staphylococcus aureus grew from the culture of rectal swabs in 60% cases versus 53% positive culture of nasal swabs taken from the same subjects . This organism is known to cause endocarditis of normal heart valves [11, 12]. Neurologic complications of infective endocarditis, particularly embolic events, tend to be higher in cases of endocarditis caused by Staphylococcus aureus .
It is known that few patients with rectal foreign bodies will freely admit to transanal introduction . This explains to some extent the paucity of literature linking this practice with bacteremia or endocarditis. We believe our patient was habituated to rectal insertion of foreign bodies and that is evident from his previous history along with the clinical findings of perianal erythema and diminished sphincter tone . In the absence of a reliable history from the patient, the link between endocarditis and rectal trauma in this case is based on circumstantial evidence. A further study of patients with well-documented evidence of rectal foreign body insertion could be the next step to explore this important observation.
The rectum is a frequent site of Staphylococcus aureus carriage. Trauma from foreign objects in the rectum carries a risk of staphylococcal bacteremia that is known to result in endocarditis of both normal and abnormal heart valves. Further studies are needed to explore this finding. It is important to get a detailed sexual history from patients visiting primary care clinics. Patient education and warning may help prevent catastrophic complications of this risky practice.
Claudia Hall, NP for providing additional clinical information.
A written consent was obtained from the patient for publication of study.
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