Updated: 2/25/2018

Endocarditis

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Snapshot
  • A 50-year-old man presents to the emergency room for a fever that has persisted for several days. He denies any history of intravenous drug use or any congenital heart disease. Physical exam reveals nailbed splinter hemorrhages, Osler nodes on his fingers, and Janeway lesions on his palms and soles. Heart auscultation reveals a new murmur. An echocardiogram shows vegetations on the mitral valve, and blood cultures that were drawn 12 hours apart were positive for Streptococcus bovis. Antibiotic therapy is started and he is scheduled for a colonoscopy. 
Introduction
  • Clinical definition
    • inflammation of the heart valve, typically secondary to infection
  • Epidemiology
    • location
      • mitral valve > tricuspid valve
      • tricuspid valve disease is associated with intravenous (IV) drug use
        • Staphylococcus aureus, Pseudomonas, Candida
    • risk factors
      • rheumatic heart disease
      • IV drug use
      • immunosuppression
      • prosthetic heart valve
      • congenital heart disease
  • Etiology
    • acute endocarditis
      • Streptococcus pneumoniae
      • Streptococcus pyogenes
      • Neisseria gonorrhea
      • Staphylococcus aureus
        • IV drug users
        • large vegetations seen on valves
    • subacute bacterial endocarditis is characterized by slower onset and less severe symptoms
      • Streptococcus bovis (gallolyticus) 
        • in the setting of colon cancer
      • Enterococcus
        • in the setting of gastrointestinal/genitourinary procedures
      • Streptococcus viridans
        • often a complication of dental procedures
          • makes dextrans, which binds to fibrin-platelet aggregates on the heart valves
      • Staphylococcus epidermidis
        • often in the setting of prosthetic valves
      • Candida albicans
        • IV drug users
    • non-infectious endocarditis
      • Libman-Sacks endocarditis
        • from systemic lupus erythematosus
        • mitral or aortic valve involvement
      • marantic endocarditis
        • from metastatic cancer seeding to the valves
        • very poor prognosis
  • Pathogenesis
    • endothelial damage on the surface of the cardiac valve can cause a thrombus to form
      • factors include turbulent blood flow that can damage endothelium, or deposition of fibrin-platelet aggregate on damaged endothelium
      • bacteria can then adhere to thrombus
    • vegetations are caused by further depositions of fibrin and platelets
  • Prognosis
    • often presents as fever of unknown origin
    • endocarditis prophylaxis may be required before dental procedures
Presentation
  • Symptoms
    • persistent fevers (the most common symptom)
    • shortness of breath
    • systemic symptoms
      • weakness
      • fever
      • malaise
  • Physical exam
    • new murmur on auscultation
    • from emboli
      • Roth spots
        • retinal hemorrhages on funduscopy
      • Janeway lesions
        • erythematous and nontender macules on palms or soles
      • nail bed splinter hemorrhages
    • from immune complex deposition
      • Osler nodes
        • tender nodules on fingers or toes
      • glomerulonephritis
Imaging
  • Echocardiography
    • indication
      • for all patients
    • findings
      • vegetations on valves
Evaluation
  • Labs 
    • positive blood cultures drawn at least 12 hours apart or multiple positive cultures (at least 3 of 4) with the first and last drawn at least 1 hour apart
    • complete blood count
      • anemia
    • serum creatinine
      • to evaluate renal function (glomerulonephritis)
  • Making the diagnosis
    • based on clinical presentation and Duke criteria 
      • pathologic criteria
        • culture of organism
        • histologic evidence of endocarditis from vegetation or intracardiac abscess
      • clinical criteria: 1 of the following
        • 2 major criteria
        • 1 major and 3 minor criteria
        • 5 minor criteria
    • if blood cultures are negative but echocardiography shows endocarditis, consider 1 of the causes of Culture-Negative Endocardidtis (CNE)
      • Coxiella burnetii
      • Bartonella spp
      • HACEK organisms
        • Haemophilus
        • Aggregatibacter
        • Cardiobacterium
        • Eikenella
        • Kingella
Duke Criteria
Major Minor
  • Positive blood cultures from 2 separate blood cultures drawn > 12 hours apart, or 3 out of 4 blood cultures that are positive, with first and last samples drawn 1 hour apart
  • Abnormal echocardiogram with vegetation, abscess ,or partial dehiscence of prosthetic valve
  • Fever
  • Presence of risk factors, including intravenous drug use, structural heart disease, prosthetic heart valve, dental procedures, or history of endocarditis
  • Vascular phenomena, including Janeway lesions, emboli, mycotic aneurysm, and conjunctival hemorrhage
  • Immunologic phenomena, including glomerulonephritis, Osler nodes, and Roth spots
  • Positive blood cultures not meeting major criterion
  • Echocardiographic findings consistent with endocarditis but not meeting major criterion
 
Differential
  • Osteomyelitis
    • distinguishing factor
      • although this can present as fever of unknown origin, it typically lacks other findings of endocarditis and will not have vegetations on echocardiography
Treatment
  • Management approach
    • choice of antibiotics ultimately depend on causative agent and susceptibility as well as the presence of prosthetic material in the heart
    • all antibiotics should be given intravenously
  • Medical
    • vancomycin plus ceftriaxone or gentamicin
      • indications
        • for patients with no prosthetic valve
        • empiric antibiotic therapy
    • vancomycin plus gentamicin and rifampin
      • indications
        • for patients with prosthetic valve
        • empiric antibiotic therapy
  • Operative
    • surgical valve replacement
      • indications
        • heart failure
        • patients who are refractory to medical therapy
        • abscess formation
        • conduction disturbance
Complications
  • Cardiac complications
    • perivalvular abscess
    • arrhythmias
    • heart failure
  • Neurologic complications
    • stroke
 

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(M1.CV.13.125) A 35-year-old woman with a medical history significant for asthma, hypertension, and occasional IV drug use comes to the emergency department with fever. On physical exam, there are findings depicted in figure A, for which the patient cannot account. What test will be most helpful to establish the diagnosis? Tested Concept

QID: 100641
FIGURES:
1

Echocardiography

73%

(11/15)

2

Chest X-ray

0%

(0/15)

3

Pulmonary function tests

0%

(0/15)

4

Electrocardiogram (EKG)

7%

(1/15)

5

CT pulmonary angiography

7%

(1/15)

M 2 A

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(M1.CV.13.134) A 25-year-old man presents to the emergency room with shortness of breath. He has no past medical history and takes no medications. On physical exam, vital signs are temperature 38.1° C, heart rate 110/min, blood pressure 118/76 mm Hg, respiratory rate 22/min, and oxygen saturation 98% on room air. He appears malnourished and has poor dentition. Physical exam also reveals the markings along the cubital fossa as shown in Figure A and a low frequency pansystolic murmur best heard on the lower left sternal border. The murmur increases with inspiration and decreases with expiration and Valsalva maneuver. The patient is treated for his illness but later presents with hematuria, hypertension, and an elevated creatinine. What is the most likely cause of this patient's subsequent renal disease? Tested Concept

QID: 100650
FIGURES:
1

Dilation and blunting of the renal calyces with cortical thinning

5%

(8/153)

2

Immune complex deposition

38%

(58/153)

3

Vascular damage to renal vessels secondary to benign nephrosclerosis

16%

(24/153)

4

Hereditary nephritis caused by a mutation in glomerular basement membrane

5%

(8/153)

5

Renal papillary necrosis secondary to infarctions of the medulla

25%

(39/153)

M 1 C

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(M1.CV.13.44) A 58-year-old man presents to the doctor with recurring fevers, night sweats and malaise. On exam he is found to have a mid systolic click. His dermatologic exam is notable for painless skin lesions shown in Figure A. Which of the following heart conditions most likely predisposed him to his current condition? Tested Concept

QID: 100560
FIGURES:
1

Bicuspid aortic valve

9%

(2/23)

2

Aortic stenosis

4%

(1/23)

3

Mitral stenosis

0%

(0/23)

4

Mitral valve prolapse

39%

(9/23)

5

Rheumatic heart disease

48%

(11/23)

M 2 E

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(M1.CV.13.45) A 32-year-old African American woman presents to her family physician complaining of fevers, fatigue, weight loss, joint pains, night sweats and a rash on her face that extends over the bridge of her nose. She has also had multiple sores in her mouth over the past few weeks. She recently had a root canal procedure done without complications. She has no significant past medical history but has recently had a urinary tract infection. She denies tobacco, alcohol, and illicit drug use. Laboratory evaluation reveals hemolytic anemia. If she were found to have a cardiac lesion, what would be the most likely pathogenetic cause? Tested Concept

QID: 100561
1

Bacteremia secondary to a recent dental procedure

33%

(7/21)

2

Aberrant flow causing platelet-fibrin thrombus formation secondary to hypercoagulability and malignancy

0%

(0/21)

3

Bacteremia secondary to a urinary tract infection

5%

(1/21)

4

Immune complex deposition and subsequent inflammation

52%

(11/21)

5

Left atrial mass causing a ball valve-type outflow obstruction

5%

(1/21)

M 2 E

Select Answer to see Preferred Response

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