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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introduction</span><p id="par0085" class="elsevierStylePara elsevierViewall">Despite advances in diagnosis&#44; infective endocarditis &#40;IE&#41; remains a common cause of hospitalization&#44; with high morbidity and mortality rates&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> This may be due to the changing epidemiology of IE&#44; including increasing antimicrobial resistance&#44; more frequent heart surgery and prosthetic valve implantation&#44; and widespread use of intravenous drugs&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">IE was initially recognized to be a complication of intravenous drug use in the 1950s&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> It is a potentially fatal consequence of injecting illicit drugs&#44; such as heroin&#44; cocaine&#44; and methamphetamine&#46; Intravenous drug use increases IE risk through a variety of mechanisms&#46; Drug solutions may contain particulate matter &#40;e&#46;g&#46; talc&#41; that damage cardiac valves if injected intravenously&#46; In addition&#44; poor injection hygiene and injecting contaminated drug solutions can introduce high circulating bacterial loads&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">4</span></a> In intravenous drug users &#40;IDUs&#41;&#44; the incidence of IE is 2&#37;&#8211;5&#37; and it is responsible for 5&#37;&#8211;10&#37; of deaths&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">HIV infection increases the risk of IE&#46; In developed countries HIV infection among IDUs with IE ranges between 30&#37; and 70&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a> The tricuspid valve &#40;TV&#41; may be more susceptible to heroin use&#44; as heroin can cause an increase in pulmonary arterial pressure&#44; creating more turbulence at the TV&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In this article we describe an exceptional clinical case of an IE patient who was HIV-infected and also injected heroin&#46; We compare the case with data in the literature and analyze the differences&#44; and also review the clinical features of IE among IDUs&#44; nonaddicts&#44; and HIV-infected and uninfected patients&#46;</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Case report</span><p id="par0105" class="elsevierStylePara elsevierViewall">A 28-year-old Lithuanian woman was admitted to our hospital&#46; Her presenting complaints were bodily pain and general weakness&#46; She had been addicted to heroin for 10 years&#46; Her past medical history was significant for anemia and chronic pyelonephritis&#44; leading to stage 2 renal failure&#44; and infection with HIV for seven years&#46; She was an alcohol abuser and a smoker&#46; Physical examination on presentation showed body temperature of 36&#46;8<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; edema in the legs&#44; pale mucous membranes&#44; dry tongue&#44; normal cardiac rhythm and breath sounds&#44; respiratory rate 20&#47;min&#44; heart rate 88 beats&#47;min&#44; and blood pressure 120&#47;80 mmHg&#46; Laboratory tests revealed microscopic hematuria and leukocyturia and C-reactive protein &#40;CRP&#41; 28 mg&#47;l&#44; erythrocyte sedimentation rate &#40;ESR&#41; 45 mm&#47;h&#44; and hemoglobin 59 g&#47;l&#46; Ascites was found in the abdomen&#46; X-ray study showed no abnormalities in the thoracic organs&#46; On day 7 of hospital stay the patient&#39;s condition deteriorated&#46; The X-ray showed moderate bilateral hydrothorax&#44; with a slightly sharpened image of the lungs and an interstitial component&#44; local infiltration of the right cardiodiaphragmatic angle&#44; inflammatory lesions around the pleura on the left&#44; and enlarged cardiac diameter in both directions&#46; On day 8 echocardiography was performed&#44; which detected vegetations on the TV and the right atrium&#46; C-reactive protein was elevated &#40;38&#46;00 mg&#47;l&#41;&#46; Before the administration of antibiotics <span class="elsevierStyleItalic">Staphylococcus aureus</span> &#40;sensitive to penicillin&#44; oxacillin and erythromycin&#41; was detected in blood culture and <span class="elsevierStyleItalic">Escherichia coli</span> &#40;sensitive to ciprofloxacin and gentamicin&#41; in urine culture&#46; On the following day the patient was given ampicillin and ceftriaxone &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#44; by which time her temperature had risen to 38&#46;8<span class="elsevierStyleHsp" style=""></span>&#176;C&#46; After a few days echocardiography was repeated in order to assess changes&#44; and showed decreasing ejection fraction &#40;EF&#41; and increasing pericardial effusion &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#44; 11 days of treatment&#41;&#46; Antibiotic therapy was changed to ceftriaxone &#40;Oframax&#41; only &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Sepsis&#44; pneumonia&#44; toxic hepatitis and infectious endocarditis were additionally diagnosed&#46; The blood analysis was repeated&#44; showing CRP 30&#46;00 mg&#47;l and white blood cell count 7&#46;4&#215;10<span class="elsevierStyleSup">9</span>&#47;l&#46; The patient&#39;s condition continued to deteriorate&#44; with breathlessness and anasarca&#59; an audible grade 3 systolic murmur along the parasternal line and mild congestive rales in both lower lung fields were detected&#46; Secondary myocarditis was diagnosed&#46; Serum CD4&#43; cell count was 651&#47;mm<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a>&#44; and antiviral therapy for HIV was not initiated&#46; In order to assess the effect of antibiotic therapy&#44; blood and urine cultures were re-evaluated&#46; On day 8 bacteria were not detected in urine culture&#44; but <span class="elsevierStyleItalic">S&#46; epidermidis</span> was detected in blood cultures&#46; Antibiotic therapy was changed to a combination of oxacillin and gentamicin &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; On day 20 the echocardiogram showed significantly decreasing EF &#40;10&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The ECG showed sinus rhythm and inverted T waves in leads I&#44; aVL&#44; V5&#44; and V6&#46; An elevated D-dimer level &#40;2&#46;25 &#956;g&#47;ml&#41; was detected&#46; Repeat chest X-ray showed progression of pleuritic lesions on the right &#40;hydrothorax&#41;&#44; the right lung being almost completely covered with liquid&#44; and the mediastinum displaced to the left&#44; covering the lower left lung field&#46; While still in a critical condition&#44; the patient was given vancomycin &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#44; which led to regression of the abnormalities&#44; bacteria being undetectable in blood culture&#46; On day 44 the ECG showed sinus rhythm&#44; and there was reversal of T-wave inversion in leads I&#44; aVL&#44; and V5-V6&#46; On the chest X-ray the hydrothorax had disappeared&#46; After treatment with vancomycin&#44; echocardiography revealed a significant recovery of EF &#40;from 10&#37; to 50&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#44; 48 days of treatment&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">S&#46; aureus</span> is the causative agent in the majority of IE cases in IDUs&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a> It is the most common pathogen in isolated TV endocarditis&#44; accounting for 50&#37;&#8211;60&#37; of cases among IDUs&#46; However&#44; in our case&#44; <span class="elsevierStyleItalic">S&#46; aureus</span> affected not only the TV&#59; vegetations also appeared on the aortic valve &#40;AoV&#41;&#46; Less common infectious agents include methicillin-resistant <span class="elsevierStyleItalic">S&#46; aureus</span> &#40;MRSA&#41;&#44; <span class="elsevierStyleItalic">Streptococcus bovis</span> and other streptococci species&#44; and fungi&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Because material is injected intravenously&#44; the first valves to screen particulate matter would be on the right side of the heart&#46; In the present case the patient was addicted to heroin for 10 years&#46; The question arises&#58; why did the patient only develop infective endocarditis to after so many years&#63; Some authors argue that since cocaine has a shorter half-life than heroin it requires more frequent dosing&#44; increasing the bacterial load and incidence of endocarditis&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a> According to the literature&#44; if infective endocarditis affects the TV&#44; the prognosis is much more favorable than when it damages the MV or AoV&#46; In the present case the TV was the most seriously damaged valve&#44; but vegetations 6&#8211;7 mm in length were also observed on the noncoronary and right coronary leaflets of the AoV&#44; leading to complications involving both sides of the heart&#46; A study by Chambers et al&#46; comparing the clinical presentation of IE among intravenous drug addicts and nonaddicts showed that intravenous drug addicts were younger and had less underlying diseases than nonaddicts&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a> In the case presented the patient survived&#44; but according to data in the literature&#44; no other intravenous drug user with so many complications and such a severe condition has survived&#46; There are few clinical studies that analyze the influence of HIV infection in IDUs with IE&#46; Two studies showed that the risk of IE for those infected with HIV is increasing&#46; It is associated with decreased CD4&#43; cell counts&#44; and among HIV-infected patients with CD4&#43; cell counts of less than 200 cells&#47;&#956;l or with AIDS criteria&#44; the mortality rate is much higher&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">6&#44;8</span></a> In the present case&#44; despite the patient&#39;s diagnosis of HIV infection seven years previously&#44; there was no significant immunosuppression &#40;CD4&#43; count 651 cells&#47;&#956;l&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Diagnosis of IE is based on the Duke criteria&#44; which are divided into major and minor criteria&#46; A clinical diagnosis of IE requires two major&#44; one major and three minor&#44; or five minor criteria&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a> In the case presented&#44; vegetations and regurgitation were detected on transthoracic echocardiography and blood cultures were positive for a typical organism&#44; <span class="elsevierStyleItalic">S&#46; aureus</span> &#40;two major criteria&#41;&#44; and the patient was an intravenous drug user &#40;one minor criterion&#41;&#46; Due to the presence of two major Duke criteria&#44; a clinical diagnosis was made of infective endocarditis&#46; The key echocardiographic finding in right-sided endocarditis is that of vegetation&#40;s&#41; in association with the TV or rarely the pulmonary valve&#46; Tricuspid vegetations are often large&#44; in excess of 2 cm&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> In the case presented&#44; transesophageal echocardiography was not performed&#44; since transthoracic echocardiography showed vegetations on the TV and AoV&#44; the largest being 29 mm&#46; Diagnosis of IE takes into consideration such indicators as increased ESR and C-reactive protein&#44; splenic enlargement and microscopic hematuria&#46; In our case&#44; CRP of 38 mg&#47;l&#44; ESR of 45 mm&#47;h and hematuria &#40;800&#47;ml&#41; were detected&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Most patients have a benign presentation and the main concern for treatment will be the choice of appropriate antibiotics&#46; This essentially depends on the likely microorganisms&#44; the valves involved and the types of injected drugs the patient has used&#46; In our case only treatment with vancomycin was effective&#44; after which the patient&#39;s condition began to improve rapidly&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusions</span><p id="par0130" class="elsevierStylePara elsevierViewall">A severe and exceptional clinical case was presented&#46; The patient was an intravenous drug user&#44; had IE&#44; was HIV-infected&#44; and had damaged TV and AoV&#46; Heart&#44; respiratory and renal failure were rapidly progressing&#46; Despite additional complications&#44; the patient&#39;s condition improved significantly after administration of vancomycin&#44; with a significant recovery of EF &#40;from 10&#37; to 50&#37;&#41;&#46; Although the patient was given ceftriaxone&#44; oxacillin and gentamicin&#44; only vancomycin produced a good result&#46; It is important to note that even in a patient with a such severe condition&#44; immunosuppression was not detected &#40;CD4&#43; count 651 cells&#47;&#956;l&#41;&#46; The patient was relatively young&#44; and was therefore more likely to survive&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Protection of human and animal subjects</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Confidentiality of data</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Right to privacy and informed consent</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; The corresponding author is in possession of this document&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflict of interest</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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    "pdfFichero" => "main.pdf"
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    "fechaRecibido" => "2014-11-27"
    "fechaAceptado" => "2015-03-08"
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          "clase" => "keyword"
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            0 => "Infective endocarditis"
            1 => "HIV"
            2 => "Intravenous drug use"
            3 => "Tricuspid valve"
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          "titulo" => "Palavras-chave"
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          "palabras" => array:4 [
            0 => "Endocardite infecciosa"
            1 => "VIH"
            2 => "Utiliza&#231;&#227;o de f&#225;rmaco intravenoso"
            3 => "V&#225;lvula tric&#250;spide"
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    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Infective endocarditis is a common complication among injecting drug users&#46; Disease risk among these patients is increased by the spread of HIV infection&#46; In the following article&#44; we discuss the exceptional clinical presentation of a 28-year-old patient who used intravenous drugs &#40;heroin&#41; for 10 years&#44; had been infected with HIV for seven years and as a complication had developed <span class="elsevierStyleItalic">Staphylococcus aureus</span> infective endocarditis&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The patient came to the hospital in serious condition&#44; complaining of bodily pain&#44; swelling of the legs and general weakness&#46; During hospitalization&#44; besides infective endocarditis&#44; she was also diagnosed with anemia&#44; toxic hepatitis&#44; renal failure&#44; ascites&#44; sepsis&#44; and pneumonia&#46; A completely disrupted tricuspid valve&#44; damaged aortic valve&#44; and fibrosis of the mitral valve were detected&#46; Echocardiographic and radiologic data showed that the patient&#39;s condition continued to deteriorate day by day&#44; with significant progression of heart failure&#44; ejection fraction decreasing from 45&#37; to 10&#37;&#44; and development of myocarditis&#44; hydrothorax and pericarditis&#46; However&#44; this progressive worsening of the patient&#39;s condition ceased when vancomycin was administered&#46; To the authors&#8217; knowledge&#44; this is the first such case described in the literature in which significant improvement was observed despite the patient&#39;s complex condition with associated complications&#46;</p></span>"
      ]
      "pt" => array:2 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A endocardite infecciosa &#233; uma complica&#231;&#227;o comum entre os consumidores de drogas injet&#225;veis&#46; O risco desta doen&#231;a nestes pacientes aumenta com a propaga&#231;&#227;o da infe&#231;&#227;o do VIH&#46; Neste artigo&#44; discute-se a apresenta&#231;&#227;o cl&#237;nica de uma jovem doente que consumiu drogas intravenosas &#40;hero&#237;na&#41; durante dez anos e que h&#225; sete anos que est&#225; infetada pelo VIH&#46; Para al&#233;m disso&#44; desenvolveu endocardite infecciosa causada por <span class="elsevierStyleItalic">Staphylococcus aureus</span>&#46; De 28 anos de idade apresentou-se no hospital em estado grave&#44; queixando-se de dores no corpo&#44; pernas inchadas e de um estado geral de fraqueza&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Durante o internamento&#44; para al&#233;m da endocardite infecciosa&#44; foi-lhe tamb&#233;m diagnosticado &#8211; anemia&#44; hepatite t&#243;xica&#44; insufici&#234;ncia renal&#44; ascite&#44; sepsis e pneumonia&#46; Foram tamb&#233;m detetadas interrup&#231;&#227;o total da v&#225;lvula tric&#250;spide&#44; v&#225;lvula a&#243;rtica danificada e fibrose da v&#225;lvula mitral&#46; De acordo com a avalia&#231;&#227;o ecocardiogr&#225;fica e dados radiol&#243;gicos&#44; a situa&#231;&#227;o da doente continuou a deteriorar-se&#58; a insufici&#234;ncia card&#237;aca progrediu significativamente&#44; a fra&#231;&#227;o de eje&#231;&#227;o diminuiu de 45&#37; para 10&#37; e desenvolveram-se miocardite&#44; hidrot&#243;rax e pericardite&#46; No entanto&#44; apesar da situa&#231;&#227;o grave da doente progredir de modo cont&#237;nuo&#44; houve uma melhoria assim que lhe foi administrada vancomicina&#46; De acordo com os autores&#44; este ser&#225; o primeiro caso cl&#237;nico descrito na literatura que revelou uma melhoria significativa apesar da situa&#231;&#227;o complexa da doente com demais complica&#231;&#245;es&#46;</p></span>"
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        "titulo" => "<span class="elsevierStyleSectionTitle" id="sect0025">List of abbreviations</span>"
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            "definicion" => array:16 [
              0 => array:2 [
                "termino" => "AoV"
                "descripcion" => "<p id="par0005" class="elsevierStylePara elsevierViewall">aortic valve</p>"
              ]
              1 => array:2 [
                "termino" => "CHF"
                "descripcion" => "<p id="par0010" class="elsevierStylePara elsevierViewall">congestive heart failure</p>"
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              2 => array:2 [
                "termino" => "CRP"
                "descripcion" => "<p id="par0015" class="elsevierStylePara elsevierViewall">C-reactive protein</p>"
              ]
              3 => array:2 [
                "termino" => "EF"
                "descripcion" => "<p id="par0020" class="elsevierStylePara elsevierViewall">ejection fraction</p>"
              ]
              4 => array:2 [
                "termino" => "ESR"
                "descripcion" => "<p id="par0025" class="elsevierStylePara elsevierViewall">erythrocyte sedimentation rate</p>"
              ]
              5 => array:2 [
                "termino" => "HF"
                "descripcion" => "<p id="par0030" class="elsevierStylePara elsevierViewall">heart failure</p>"
              ]
              6 => array:2 [
                "termino" => "ICU"
                "descripcion" => "<p id="par0035" class="elsevierStylePara elsevierViewall">intensive care unit</p>"
              ]
              7 => array:2 [
                "termino" => "IDUs"
                "descripcion" => "<p id="par0040" class="elsevierStylePara elsevierViewall">intravenous drug users</p>"
              ]
              8 => array:2 [
                "termino" => "IE"
                "descripcion" => "<p id="par0045" class="elsevierStylePara elsevierViewall">infective endocarditis</p>"
              ]
              9 => array:2 [
                "termino" => "LV"
                "descripcion" => "<p id="par0050" class="elsevierStylePara elsevierViewall">left ventricle&#47;left ventricular</p>"
              ]
              10 => array:2 [
                "termino" => "MRSA"
                "descripcion" => "<p id="par0055" class="elsevierStylePara elsevierViewall">methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span></p>"
              ]
              11 => array:2 [
                "termino" => "MV"
                "descripcion" => "<p id="par0060" class="elsevierStylePara elsevierViewall">mitral valve</p>"
              ]
              12 => array:2 [
                "termino" => "RBC"
                "descripcion" => "<p id="par0065" class="elsevierStylePara elsevierViewall">red blood cells</p>"
              ]
              13 => array:2 [
                "termino" => "RC"
                "descripcion" => "<p id="par0070" class="elsevierStylePara elsevierViewall">right coronary</p>"
              ]
              14 => array:2 [
                "termino" => "RV"
                "descripcion" => "<p id="par0075" class="elsevierStylePara elsevierViewall">right ventricle&#47;right ventricular</p>"
              ]
              15 => array:2 [
                "termino" => "TV"
                "descripcion" => "<p id="par0080" class="elsevierStylePara elsevierViewall">tricuspid valve</p>"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">AoV&#58; aortic valve&#59; EF&#58; ejection fraction&#59; IS&#58; interventricular septum&#59; LV&#58; left ventricle&#47;left ventricular&#59; LVESD&#58; left ventricular end-systolic diameter&#59; LVPW&#58; left ventricular posterior wall&#59; MMI&#58; myocardial mass index&#59; MV&#58; mitral valve&#59; PV&#58; pulmonary valve&#59; RA&#58; right atrial&#59; RC&#58; right coronary&#59; RV&#58; right ventricle&#47;right ventricular&#59; TV&#58; tricuspid valve&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Before antibiotic therapy<br>&#40;day 8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">After treatment with ampicillin &#43; ceftriaxone &#40;day 11&#41;</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">After treatment with oxacillin &#43; gentamicin<br>&#40;day 20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">After treatment with vancomycin<br>&#40;day 48&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">EF 27&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">EF 45&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">EF 20&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">EF 10&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">EF 50&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vegetations on TV and right atrium&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Large florid vegetations on TV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vegetations on TV leaflets &#40;largest 29 mm&#41;&#44; vegetations on AoV and RC leaflet &#40;up to 6-7 mm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vegetations on AoV and MV not visible&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Regurgitation&#58; grade 3&#8211;4 TV&#44; grade 1 MV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade 4 TV regurgitation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Regurgitation&#58; grade 2 PV&#44; grade 1 MV&#44; grade 4 TV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pericardial effusion&#58; 12&#46;6 mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pericardial effusion&#58; 16 mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pericardial effusion&#58; 12&#8211;14 mm &#40;no tamponade&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pericardial effusion&#58; 5 mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Grade 4 TV leakage&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade 4 TV leakage&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade 4 TV leakage&#44; grade 1 AoV leakage&#44; grade 1 MV leakage&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ascending aorta&#58;<br>28 mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ascending aorta&#58;<br>22 mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Significant RV and RA volume overload&#44; RV dilatation&#44; dyskinetic IS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LV concentric hypertrophy&#44; dilatation of right heart chambers dominant&#59; LVESD&#58; 35 mm&#59; IS&#58; 15 mm&#59; LVPW&#58; 14 mm&#59; MMI&#58; 132 g&#47;m<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LV non-dilated&#44; poor systolic function&#59; RV poor systolic function&#59; MV leaflets fibrosed&#59; LVESD&#58; 39 mm&#44; IS&#58; 9 mm&#44; LVPW&#58; 11 mm&#44; MMI&#58; 69 g&#47;m<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Recovery of LV systolic function&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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Case report
Infective endocarditis in an HIV-infected intravenous drug user
Endocardite infecciosa no VIH – fármaco intravenoso utilizado em doente infetado
Karolina Mėlinytėa, Jurgita Savickaitėa, Daiva Emilija Rekienėb,
Corresponding author
daiva.rekiene@gmail.com

Corresponding author.
, Albinas Naudžiūnasb, Aušra Burkauskienėc, Laima Jankauskienėb
a Lithuanian University of Health Sciences, Faculty of Medicine, Kaunas, Lithuania
b Clinic of Internal Diseases, Lithuanian University of Health Sciences, Kaunas, Lithuania
c Institute of Anatomy, Lithuanian University of Health Sciences, Kaunas, Lithuania
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introduction</span><p id="par0085" class="elsevierStylePara elsevierViewall">Despite advances in diagnosis&#44; infective endocarditis &#40;IE&#41; remains a common cause of hospitalization&#44; with high morbidity and mortality rates&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> This may be due to the changing epidemiology of IE&#44; including increasing antimicrobial resistance&#44; more frequent heart surgery and prosthetic valve implantation&#44; and widespread use of intravenous drugs&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">IE was initially recognized to be a complication of intravenous drug use in the 1950s&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> It is a potentially fatal consequence of injecting illicit drugs&#44; such as heroin&#44; cocaine&#44; and methamphetamine&#46; Intravenous drug use increases IE risk through a variety of mechanisms&#46; Drug solutions may contain particulate matter &#40;e&#46;g&#46; talc&#41; that damage cardiac valves if injected intravenously&#46; In addition&#44; poor injection hygiene and injecting contaminated drug solutions can introduce high circulating bacterial loads&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">4</span></a> In intravenous drug users &#40;IDUs&#41;&#44; the incidence of IE is 2&#37;&#8211;5&#37; and it is responsible for 5&#37;&#8211;10&#37; of deaths&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">HIV infection increases the risk of IE&#46; In developed countries HIV infection among IDUs with IE ranges between 30&#37; and 70&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a> The tricuspid valve &#40;TV&#41; may be more susceptible to heroin use&#44; as heroin can cause an increase in pulmonary arterial pressure&#44; creating more turbulence at the TV&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In this article we describe an exceptional clinical case of an IE patient who was HIV-infected and also injected heroin&#46; We compare the case with data in the literature and analyze the differences&#44; and also review the clinical features of IE among IDUs&#44; nonaddicts&#44; and HIV-infected and uninfected patients&#46;</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Case report</span><p id="par0105" class="elsevierStylePara elsevierViewall">A 28-year-old Lithuanian woman was admitted to our hospital&#46; Her presenting complaints were bodily pain and general weakness&#46; She had been addicted to heroin for 10 years&#46; Her past medical history was significant for anemia and chronic pyelonephritis&#44; leading to stage 2 renal failure&#44; and infection with HIV for seven years&#46; She was an alcohol abuser and a smoker&#46; Physical examination on presentation showed body temperature of 36&#46;8<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; edema in the legs&#44; pale mucous membranes&#44; dry tongue&#44; normal cardiac rhythm and breath sounds&#44; respiratory rate 20&#47;min&#44; heart rate 88 beats&#47;min&#44; and blood pressure 120&#47;80 mmHg&#46; Laboratory tests revealed microscopic hematuria and leukocyturia and C-reactive protein &#40;CRP&#41; 28 mg&#47;l&#44; erythrocyte sedimentation rate &#40;ESR&#41; 45 mm&#47;h&#44; and hemoglobin 59 g&#47;l&#46; Ascites was found in the abdomen&#46; X-ray study showed no abnormalities in the thoracic organs&#46; On day 7 of hospital stay the patient&#39;s condition deteriorated&#46; The X-ray showed moderate bilateral hydrothorax&#44; with a slightly sharpened image of the lungs and an interstitial component&#44; local infiltration of the right cardiodiaphragmatic angle&#44; inflammatory lesions around the pleura on the left&#44; and enlarged cardiac diameter in both directions&#46; On day 8 echocardiography was performed&#44; which detected vegetations on the TV and the right atrium&#46; C-reactive protein was elevated &#40;38&#46;00 mg&#47;l&#41;&#46; Before the administration of antibiotics <span class="elsevierStyleItalic">Staphylococcus aureus</span> &#40;sensitive to penicillin&#44; oxacillin and erythromycin&#41; was detected in blood culture and <span class="elsevierStyleItalic">Escherichia coli</span> &#40;sensitive to ciprofloxacin and gentamicin&#41; in urine culture&#46; On the following day the patient was given ampicillin and ceftriaxone &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#44; by which time her temperature had risen to 38&#46;8<span class="elsevierStyleHsp" style=""></span>&#176;C&#46; After a few days echocardiography was repeated in order to assess changes&#44; and showed decreasing ejection fraction &#40;EF&#41; and increasing pericardial effusion &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#44; 11 days of treatment&#41;&#46; Antibiotic therapy was changed to ceftriaxone &#40;Oframax&#41; only &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Sepsis&#44; pneumonia&#44; toxic hepatitis and infectious endocarditis were additionally diagnosed&#46; The blood analysis was repeated&#44; showing CRP 30&#46;00 mg&#47;l and white blood cell count 7&#46;4&#215;10<span class="elsevierStyleSup">9</span>&#47;l&#46; The patient&#39;s condition continued to deteriorate&#44; with breathlessness and anasarca&#59; an audible grade 3 systolic murmur along the parasternal line and mild congestive rales in both lower lung fields were detected&#46; Secondary myocarditis was diagnosed&#46; Serum CD4&#43; cell count was 651&#47;mm<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a>&#44; and antiviral therapy for HIV was not initiated&#46; In order to assess the effect of antibiotic therapy&#44; blood and urine cultures were re-evaluated&#46; On day 8 bacteria were not detected in urine culture&#44; but <span class="elsevierStyleItalic">S&#46; epidermidis</span> was detected in blood cultures&#46; Antibiotic therapy was changed to a combination of oxacillin and gentamicin &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; On day 20 the echocardiogram showed significantly decreasing EF &#40;10&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The ECG showed sinus rhythm and inverted T waves in leads I&#44; aVL&#44; V5&#44; and V6&#46; An elevated D-dimer level &#40;2&#46;25 &#956;g&#47;ml&#41; was detected&#46; Repeat chest X-ray showed progression of pleuritic lesions on the right &#40;hydrothorax&#41;&#44; the right lung being almost completely covered with liquid&#44; and the mediastinum displaced to the left&#44; covering the lower left lung field&#46; While still in a critical condition&#44; the patient was given vancomycin &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#44; which led to regression of the abnormalities&#44; bacteria being undetectable in blood culture&#46; On day 44 the ECG showed sinus rhythm&#44; and there was reversal of T-wave inversion in leads I&#44; aVL&#44; and V5-V6&#46; On the chest X-ray the hydrothorax had disappeared&#46; After treatment with vancomycin&#44; echocardiography revealed a significant recovery of EF &#40;from 10&#37; to 50&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#44; 48 days of treatment&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">S&#46; aureus</span> is the causative agent in the majority of IE cases in IDUs&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a> It is the most common pathogen in isolated TV endocarditis&#44; accounting for 50&#37;&#8211;60&#37; of cases among IDUs&#46; However&#44; in our case&#44; <span class="elsevierStyleItalic">S&#46; aureus</span> affected not only the TV&#59; vegetations also appeared on the aortic valve &#40;AoV&#41;&#46; Less common infectious agents include methicillin-resistant <span class="elsevierStyleItalic">S&#46; aureus</span> &#40;MRSA&#41;&#44; <span class="elsevierStyleItalic">Streptococcus bovis</span> and other streptococci species&#44; and fungi&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Because material is injected intravenously&#44; the first valves to screen particulate matter would be on the right side of the heart&#46; In the present case the patient was addicted to heroin for 10 years&#46; The question arises&#58; why did the patient only develop infective endocarditis to after so many years&#63; Some authors argue that since cocaine has a shorter half-life than heroin it requires more frequent dosing&#44; increasing the bacterial load and incidence of endocarditis&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a> According to the literature&#44; if infective endocarditis affects the TV&#44; the prognosis is much more favorable than when it damages the MV or AoV&#46; In the present case the TV was the most seriously damaged valve&#44; but vegetations 6&#8211;7 mm in length were also observed on the noncoronary and right coronary leaflets of the AoV&#44; leading to complications involving both sides of the heart&#46; A study by Chambers et al&#46; comparing the clinical presentation of IE among intravenous drug addicts and nonaddicts showed that intravenous drug addicts were younger and had less underlying diseases than nonaddicts&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a> In the case presented the patient survived&#44; but according to data in the literature&#44; no other intravenous drug user with so many complications and such a severe condition has survived&#46; There are few clinical studies that analyze the influence of HIV infection in IDUs with IE&#46; Two studies showed that the risk of IE for those infected with HIV is increasing&#46; It is associated with decreased CD4&#43; cell counts&#44; and among HIV-infected patients with CD4&#43; cell counts of less than 200 cells&#47;&#956;l or with AIDS criteria&#44; the mortality rate is much higher&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">6&#44;8</span></a> In the present case&#44; despite the patient&#39;s diagnosis of HIV infection seven years previously&#44; there was no significant immunosuppression &#40;CD4&#43; count 651 cells&#47;&#956;l&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Diagnosis of IE is based on the Duke criteria&#44; which are divided into major and minor criteria&#46; A clinical diagnosis of IE requires two major&#44; one major and three minor&#44; or five minor criteria&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a> In the case presented&#44; vegetations and regurgitation were detected on transthoracic echocardiography and blood cultures were positive for a typical organism&#44; <span class="elsevierStyleItalic">S&#46; aureus</span> &#40;two major criteria&#41;&#44; and the patient was an intravenous drug user &#40;one minor criterion&#41;&#46; Due to the presence of two major Duke criteria&#44; a clinical diagnosis was made of infective endocarditis&#46; The key echocardiographic finding in right-sided endocarditis is that of vegetation&#40;s&#41; in association with the TV or rarely the pulmonary valve&#46; Tricuspid vegetations are often large&#44; in excess of 2 cm&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> In the case presented&#44; transesophageal echocardiography was not performed&#44; since transthoracic echocardiography showed vegetations on the TV and AoV&#44; the largest being 29 mm&#46; Diagnosis of IE takes into consideration such indicators as increased ESR and C-reactive protein&#44; splenic enlargement and microscopic hematuria&#46; In our case&#44; CRP of 38 mg&#47;l&#44; ESR of 45 mm&#47;h and hematuria &#40;800&#47;ml&#41; were detected&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Most patients have a benign presentation and the main concern for treatment will be the choice of appropriate antibiotics&#46; This essentially depends on the likely microorganisms&#44; the valves involved and the types of injected drugs the patient has used&#46; In our case only treatment with vancomycin was effective&#44; after which the patient&#39;s condition began to improve rapidly&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusions</span><p id="par0130" class="elsevierStylePara elsevierViewall">A severe and exceptional clinical case was presented&#46; The patient was an intravenous drug user&#44; had IE&#44; was HIV-infected&#44; and had damaged TV and AoV&#46; Heart&#44; respiratory and renal failure were rapidly progressing&#46; Despite additional complications&#44; the patient&#39;s condition improved significantly after administration of vancomycin&#44; with a significant recovery of EF &#40;from 10&#37; to 50&#37;&#41;&#46; Although the patient was given ceftriaxone&#44; oxacillin and gentamicin&#44; only vancomycin produced a good result&#46; It is important to note that even in a patient with a such severe condition&#44; immunosuppression was not detected &#40;CD4&#43; count 651 cells&#47;&#956;l&#41;&#46; The patient was relatively young&#44; and was therefore more likely to survive&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Protection of human and animal subjects</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Confidentiality of data</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Right to privacy and informed consent</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; The corresponding author is in possession of this document&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflict of interest</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "identificador" => "sec0025"
          "titulo" => "Ethical disclosures"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Protection of human and animal subjects"
            ]
            1 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Confidentiality of data"
            ]
            2 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Right to privacy and informed consent"
            ]
          ]
        ]
        8 => array:2 [
          "identificador" => "sec0045"
          "titulo" => "Conflict of interest"
        ]
        9 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2014-11-27"
    "fechaAceptado" => "2015-03-08"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec814944"
          "palabras" => array:4 [
            0 => "Infective endocarditis"
            1 => "HIV"
            2 => "Intravenous drug use"
            3 => "Tricuspid valve"
          ]
        ]
      ]
      "pt" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palavras-chave"
          "identificador" => "xpalclavsec814945"
          "palabras" => array:4 [
            0 => "Endocardite infecciosa"
            1 => "VIH"
            2 => "Utiliza&#231;&#227;o de f&#225;rmaco intravenoso"
            3 => "V&#225;lvula tric&#250;spide"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Infective endocarditis is a common complication among injecting drug users&#46; Disease risk among these patients is increased by the spread of HIV infection&#46; In the following article&#44; we discuss the exceptional clinical presentation of a 28-year-old patient who used intravenous drugs &#40;heroin&#41; for 10 years&#44; had been infected with HIV for seven years and as a complication had developed <span class="elsevierStyleItalic">Staphylococcus aureus</span> infective endocarditis&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The patient came to the hospital in serious condition&#44; complaining of bodily pain&#44; swelling of the legs and general weakness&#46; During hospitalization&#44; besides infective endocarditis&#44; she was also diagnosed with anemia&#44; toxic hepatitis&#44; renal failure&#44; ascites&#44; sepsis&#44; and pneumonia&#46; A completely disrupted tricuspid valve&#44; damaged aortic valve&#44; and fibrosis of the mitral valve were detected&#46; Echocardiographic and radiologic data showed that the patient&#39;s condition continued to deteriorate day by day&#44; with significant progression of heart failure&#44; ejection fraction decreasing from 45&#37; to 10&#37;&#44; and development of myocarditis&#44; hydrothorax and pericarditis&#46; However&#44; this progressive worsening of the patient&#39;s condition ceased when vancomycin was administered&#46; To the authors&#8217; knowledge&#44; this is the first such case described in the literature in which significant improvement was observed despite the patient&#39;s complex condition with associated complications&#46;</p></span>"
      ]
      "pt" => array:2 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A endocardite infecciosa &#233; uma complica&#231;&#227;o comum entre os consumidores de drogas injet&#225;veis&#46; O risco desta doen&#231;a nestes pacientes aumenta com a propaga&#231;&#227;o da infe&#231;&#227;o do VIH&#46; Neste artigo&#44; discute-se a apresenta&#231;&#227;o cl&#237;nica de uma jovem doente que consumiu drogas intravenosas &#40;hero&#237;na&#41; durante dez anos e que h&#225; sete anos que est&#225; infetada pelo VIH&#46; Para al&#233;m disso&#44; desenvolveu endocardite infecciosa causada por <span class="elsevierStyleItalic">Staphylococcus aureus</span>&#46; De 28 anos de idade apresentou-se no hospital em estado grave&#44; queixando-se de dores no corpo&#44; pernas inchadas e de um estado geral de fraqueza&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Durante o internamento&#44; para al&#233;m da endocardite infecciosa&#44; foi-lhe tamb&#233;m diagnosticado &#8211; anemia&#44; hepatite t&#243;xica&#44; insufici&#234;ncia renal&#44; ascite&#44; sepsis e pneumonia&#46; Foram tamb&#233;m detetadas interrup&#231;&#227;o total da v&#225;lvula tric&#250;spide&#44; v&#225;lvula a&#243;rtica danificada e fibrose da v&#225;lvula mitral&#46; De acordo com a avalia&#231;&#227;o ecocardiogr&#225;fica e dados radiol&#243;gicos&#44; a situa&#231;&#227;o da doente continuou a deteriorar-se&#58; a insufici&#234;ncia card&#237;aca progrediu significativamente&#44; a fra&#231;&#227;o de eje&#231;&#227;o diminuiu de 45&#37; para 10&#37; e desenvolveram-se miocardite&#44; hidrot&#243;rax e pericardite&#46; No entanto&#44; apesar da situa&#231;&#227;o grave da doente progredir de modo cont&#237;nuo&#44; houve uma melhoria assim que lhe foi administrada vancomicina&#46; De acordo com os autores&#44; este ser&#225; o primeiro caso cl&#237;nico descrito na literatura que revelou uma melhoria significativa apesar da situa&#231;&#227;o complexa da doente com demais complica&#231;&#245;es&#46;</p></span>"
      ]
    ]
    "nomenclatura" => array:1 [
      0 => array:3 [
        "identificador" => "nom0005"
        "titulo" => "<span class="elsevierStyleSectionTitle" id="sect0025">List of abbreviations</span>"
        "listaDefinicion" => array:1 [
          0 => array:1 [
            "definicion" => array:16 [
              0 => array:2 [
                "termino" => "AoV"
                "descripcion" => "<p id="par0005" class="elsevierStylePara elsevierViewall">aortic valve</p>"
              ]
              1 => array:2 [
                "termino" => "CHF"
                "descripcion" => "<p id="par0010" class="elsevierStylePara elsevierViewall">congestive heart failure</p>"
              ]
              2 => array:2 [
                "termino" => "CRP"
                "descripcion" => "<p id="par0015" class="elsevierStylePara elsevierViewall">C-reactive protein</p>"
              ]
              3 => array:2 [
                "termino" => "EF"
                "descripcion" => "<p id="par0020" class="elsevierStylePara elsevierViewall">ejection fraction</p>"
              ]
              4 => array:2 [
                "termino" => "ESR"
                "descripcion" => "<p id="par0025" class="elsevierStylePara elsevierViewall">erythrocyte sedimentation rate</p>"
              ]
              5 => array:2 [
                "termino" => "HF"
                "descripcion" => "<p id="par0030" class="elsevierStylePara elsevierViewall">heart failure</p>"
              ]
              6 => array:2 [
                "termino" => "ICU"
                "descripcion" => "<p id="par0035" class="elsevierStylePara elsevierViewall">intensive care unit</p>"
              ]
              7 => array:2 [
                "termino" => "IDUs"
                "descripcion" => "<p id="par0040" class="elsevierStylePara elsevierViewall">intravenous drug users</p>"
              ]
              8 => array:2 [
                "termino" => "IE"
                "descripcion" => "<p id="par0045" class="elsevierStylePara elsevierViewall">infective endocarditis</p>"
              ]
              9 => array:2 [
                "termino" => "LV"
                "descripcion" => "<p id="par0050" class="elsevierStylePara elsevierViewall">left ventricle&#47;left ventricular</p>"
              ]
              10 => array:2 [
                "termino" => "MRSA"
                "descripcion" => "<p id="par0055" class="elsevierStylePara elsevierViewall">methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span></p>"
              ]
              11 => array:2 [
                "termino" => "MV"
                "descripcion" => "<p id="par0060" class="elsevierStylePara elsevierViewall">mitral valve</p>"
              ]
              12 => array:2 [
                "termino" => "RBC"
                "descripcion" => "<p id="par0065" class="elsevierStylePara elsevierViewall">red blood cells</p>"
              ]
              13 => array:2 [
                "termino" => "RC"
                "descripcion" => "<p id="par0070" class="elsevierStylePara elsevierViewall">right coronary</p>"
              ]
              14 => array:2 [
                "termino" => "RV"
                "descripcion" => "<p id="par0075" class="elsevierStylePara elsevierViewall">right ventricle&#47;right ventricular</p>"
              ]
              15 => array:2 [
                "termino" => "TV"
                "descripcion" => "<p id="par0080" class="elsevierStylePara elsevierViewall">tricuspid valve</p>"
              ]
            ]
          ]
        ]
      ]
    ]
    "multimedia" => array:2 [
      0 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">AoV&#58; aortic valve&#59; EF&#58; ejection fraction&#59; IS&#58; interventricular septum&#59; LV&#58; left ventricle&#47;left ventricular&#59; LVESD&#58; left ventricular end-systolic diameter&#59; LVPW&#58; left ventricular posterior wall&#59; MMI&#58; myocardial mass index&#59; MV&#58; mitral valve&#59; PV&#58; pulmonary valve&#59; RA&#58; right atrial&#59; RC&#58; right coronary&#59; RV&#58; right ventricle&#47;right ventricular&#59; TV&#58; tricuspid valve&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Before antibiotic therapy<br>&#40;day 8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">After treatment with ampicillin &#43; ceftriaxone &#40;day 11&#41;</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">After treatment with oxacillin &#43; gentamicin<br>&#40;day 20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">After treatment with vancomycin<br>&#40;day 48&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">EF 27&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">EF 45&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">EF 20&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">EF 10&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">EF 50&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vegetations on TV and right atrium&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Large florid vegetations on TV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vegetations on TV leaflets &#40;largest 29 mm&#41;&#44; vegetations on AoV and RC leaflet &#40;up to 6-7 mm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vegetations on AoV and MV not visible&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Regurgitation&#58; grade 3&#8211;4 TV&#44; grade 1 MV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade 4 TV regurgitation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Regurgitation&#58; grade 2 PV&#44; grade 1 MV&#44; grade 4 TV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pericardial effusion&#58; 12&#46;6 mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pericardial effusion&#58; 16 mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pericardial effusion&#58; 12&#8211;14 mm &#40;no tamponade&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pericardial effusion&#58; 5 mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Grade 4 TV leakage&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade 4 TV leakage&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade 4 TV leakage&#44; grade 1 AoV leakage&#44; grade 1 MV leakage&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ascending aorta&#58;<br>28 mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ascending aorta&#58;<br>22 mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Significant RV and RA volume overload&#44; RV dilatation&#44; dyskinetic IS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LV concentric hypertrophy&#44; dilatation of right heart chambers dominant&#59; LVESD&#58; 35 mm&#59; IS&#58; 15 mm&#59; LVPW&#58; 14 mm&#59; MMI&#58; 132 g&#47;m<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LV non-dilated&#44; poor systolic function&#59; RV poor systolic function&#59; MV leaflets fibrosed&#59; LVESD&#58; 39 mm&#44; IS&#58; 9 mm&#44; LVPW&#58; 11 mm&#44; MMI&#58; 69 g&#47;m<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Recovery of LV systolic function&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Evolution of echocardiographic changes according to antibiotic therapy&#46;</p>"
        ]
      ]
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        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">iv&#58; intravenous&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Combination of antibiotics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Daily dosage&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Duration &#40;days&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total dose &#40;g&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ampicillin&#44; ceftriaxone iv on days 9-11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;0 g&#215;4<br>1&#46;0 g&#215;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24<br>6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ceftriaxone iv only on days 12&#8211;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><br>1&#46;0 g&#215;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><br>5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><br>10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Oxacillin iv&#59; gentamicin iv on days 18&#8211;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;0 g&#215;4<br>0&#46;160 g&#215;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24<br>0&#46;48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vancomycin iv on days 21&#8211;48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 g&#215;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => "xTab1374672.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Details of antimicrobial treatment&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:11 [
            0 => array:3 [
              "identificador" => "bib0060"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Infective endocarditis in intravenous drug abusers&#58; an update"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "C&#46; Sousa"
                            1 => "C&#46; Botelho"
                            2 => "D&#46; Rodrigues"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur J Clin Microbiol Infect Dis"
                        "fecha" => "2012"
                        "volumen" => "9"
                        "paginaInicial" => "2905"
                        "paginaFinal" => "2910"
                        "itemHostRev" => array:3 [
                          "pii" => "S0090429511006108"
                          "estado" => "S300"
                          "issn" => "00904295"
                        ]
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Revista Portuguesa de Cardiologia (English edition)
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