Intentional ingestion of foreign objects, a form of self-injurious behavior, is rarely discussed in the medical literature but often requires extensive evaluation, management, and resources. It can be especially problematic for gastroenterologists, who are often consulted for removal of the foreign body. Pica is the psychiatric diagnosis for intentional ingestion of nonnutritive objects and is most commonly seen in prison inmates and those diagnosed with intellectual disability or psychiatric illness. This case report presents a challenging case of pica, highlighting the complexity involved in diagnosis and the need for early psychiatric intervention. It also aims to provide a general review of the literature and practical recommendations to assist with managing this form of self-injurious behavior in the inpatient setting. Collaborative efforts among specialties in addition to primary prevention are vital to successful management of these patients.

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Patient: Male, 34-year-old Final Diagnosis: Infective endocarditis of the tricuspid valve Symptoms: Lethargy • weakness Medication: — Clinical Procedure: Tricuspid valve repair • tricuspid valve replacement Specialty: Anesthesiology • Cardiac Surgery • Infectious Diseases • Psychiatry Objective: Unusual clinical course Background: Intravenous drug use is an epidemic in the United States. One of the complications of intravenous drug use can be infective endocarditis. The treatment for this disease is a combination of intravenous antibiotics, cardiac surgery consultation, and multidisciplinary psychiatric care. Despite surgical intervention, recurrence of disease is common. In the setting of recurrent infective endocarditis in the setting of intravenous drug use, the ethics of redo cardiac surgery has not been well-established. Case Report: A 34-year-old man with history of intravenous drug use presented on 3 separate occasions with infective endocarditis resulting in 3 tricuspid valve surgeries within fewer than 7 months. He said he had not injected drugs since before his first operation, he was considered to have a strong social support system, and he completed his postoperative antibiotic regimens each time. However, prior to his last operation, the patient had a urine drug screen positive for opiates without recorded prescribed opioids. Pathology reports from the 3 intraoperative specimens showed different pathogens each time. An extensive interprofessional discussion ensued. Conclusions: Infective endocarditis in the setting of intravenous drug use and its treatments continue to be a point of ethical and medical discussion for all professionals involved with the care of these patients. This case could be used as an example of individualized decision-making, with rigorous ethical and medical discussion factoring into each decision for cardiac surgery. The ongoing treatment for patients with recurrent endocarditis in the setting of intravenous drug use requires more research and guidelines to help medical professionals better care for this patient population.

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