Endocarditis after Use of Tongue Scraper

Identifi cation of novel Hsp65 RFLPs for Mycobacterium leprae. To the Editor: Tongue scraping is advocated as a therapy for managing halitosis and as a technique for preventing dental caries by reducing bacterial counts in the mouth (1). The practice has been in existence for centuries (2). A Cochrane review has concluded that tongue cleaning is marginally and temporarily more effective than use of a toothbrush in reducing a measurable marker for halitosis, exhaled volatile sulfur compounds (3). The use of tongue scrapers may not be limited to those with clinical halitosis, as 10%–30% of Americans report bad breath (4), and websites offer to solve the problem of " your bad breath " for a price. We report the case of a woman in whom infective endocarditis followed the use of a tongue scraper. A 59-year-old woman with a known history of mitral valve prolapse with associated valvular regurgitation had onset of progressive malaise, fever , sweats, myalgia, and headache; the symptoms lasted 10 days. Two months previously she had begun cleaning her tongue with a plastic tongue scraper purchased at her local pharmacy. She had not undergone recent dental work. Her medical background included migraines , hypertension, mild quiescent psoriasis, and previous depression. Her medications were venlafaxine and candesartan. When seen at her local hospital, she reported severe headache and myalgia, with fever. The same day, she had a rigor at home and reported chest tightness and mild dyspnea. Physical examination showed no focal fi ndings other than the mitral valve prolapse. A provisional diagnosis of bacterial meningitis was made. Emergency treatment comprised intravenous dexamethasone, ceftriaxone, and benzylpenicillin. Cerebrospinal fl uid analysis performed shortly after showed no cells and normal glucose and protein levels. Culture of the cere-brospinal fl uid was negative. No further antimicrobial agents were administered. Multiple blood cultures were drawn but remained culture negative. Serologic tests for Q fever, Bartonella spp., and endemic rickettsiae were negative. She continued to be febrile. A transthoracic echocardiogram showed dilatation of the mitral valve annulus with bi-leafl et prolapse and vegetation attached to the anterolat-eral commissure. She was referred to a tertiary care center, and therapy with penicillin, fl ucloxacillin, and genta-micin was begun for culture-negative endocarditis. Transesophageal echo-cardiography and visual examination at the time of valve replacement con-fi rmed the presence of large valvular vegetations. After infected tissue was excised, a prosthetic mitral valve was placed. Extended culturing of …