All but two were male‚ and 10 died.

Meel and Essop work at Chris Hani Baragwanath Hospital in Soweto‚ and say in the July edition of the South African Medical Journal that they expect to see cases of infective endocarditis increase in tandem with the popularity of injecting nyaope‚ also known as whoonga.

The drug - a cocktail of antiretrovirals‚ heroin‚ tik‚ cocaine‚ cannabis and even rat poison - was initially smoked‚ and its core users are young‚ unemployed black men from poor backgrounds.

“Because of the social stigma associated with drug abuse and addiction to drug‚ most of the patients [in this study] presented late to the hospital‚” said Meel and Essop.

Most of them had been misdiagnosed elsewhere with pulmonary tuberculosis or pneumonia‚ and the cardiologists said it was vital for doctors to maintain “a high degree of suspicion” so treatment could be initiated before heart failure became inevitable.

Three-quarters of the endocarditis patients were HIV-positive‚ but Meel and Essop said a bigger problem was the fact that 58% also had hepatitis C. In addition to long-term risks such as liver cirrhosis and cancer‚ this made surgery more risky.

“In addition‚ significant costs are associated with the treatment of hepatitis C infection‚ often in non-compliant patients‚ who frequently have other concurrent opportunistic infections associated with HIV.”

Meel and Essop said most of the 58 patients who did not die responded to antibiotics or refused surgery. Three patients had “destroyed” heart valves replaced.