Clinical Features of Infective Endocarditis

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Clinical Features ofInfective Endocarditis

• Presented by Ri ???
• 2002/07/08

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Patient Data

• Name ???
• A 45 y/o male
• Denied previous systemic diseases

3
2002/02

• Bilateral ankle pain
• Treated as gouty arthritis but in vain

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2002/04

• Bilateral scapular pain (early April)
• Acute onset of epigastralgia, fever with chills
  for 3 days
• Dx Splenic infarction
• Tx Splenectomy on 04/17
• Patho septic embolic infarction
• Scapular pain and knee pain subsided

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2002/05

• Dyspnea
• Recurrent bilateral scapular pain
• New-onset left lower chest pain
• Superficial pain with tender point
• Persistent and dull
• Aggravated by food intake or inspiration
• Cold sweating at night

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2002/05

• Other symptoms
• Anorexia
• Body weight loss (5kg/1-2 mo.)
• Pedal edema
• Dry cough
• Easily abdominal distention
• Dx Bilateral pleural effusion
• Tx Oral diuretics

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2002/05

• Late May
• Fever
• Subsided under cefazolingentamicin
• Intermittent fever with dyspnea, anorexia,
  subscapular pain, chest pain still persists

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2002/06/04

• Severe dyspnea
• NTUH ER
• Leukocytosis with left shift
• Anemia
• CXR bilateral increased infiltration with
  cardiomegaly
• PRBC transfusion ? lung edema
• Dx CHF Tx IV Lasix

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2002/06/05

• Admitted to medical ward
• Progressive dyspnea with bilateral pleural
  effusion
• Intubation
• Transfer to MICU

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2002/06/05

• Cardiac echo aortic vegetation with severe AR
  and poor LV contractility
• Af improved under amiodarone
• Poor liver renal function
• Brain MRI multiple septic emboli
• Dx IE with sepsis

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2002/06/09

• OP AVR
• Indication uncontrolled sepsis with IE
• OP finding
• RCC, NCC perforation
• Subannular abscess cavity on LCC, RCC
• Multiple vegetation on LCC, RCC NCC

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Post-OP course

• Multiple organ failure
• Ventilator-dependent
• DNR
• Expired on 2002/07/03

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Infective Endocarditis (IE)

• Definition microbial infection of the
  endothelial lining of the heart
• Characteristic lesion vegetation
• ABE (acute) / SBE (subacute)
• Estimated incidence 1.6 to 6.0 / 100,000
  person-per year

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Clinical Manifestations

• Systemic infection
• Intravascular lesion
• Immunologic reaction to infection

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History (1)

• Symptoms develop insidiously and with great
  variability
• Flu-like illness systemic and immunologic
  reactions
• Fever, chills, rigor, night sweat
• General malaise, anorexia
• Weight loss
• Myalgia, arthralgia, back pain

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History (2)

• Intravascular lesion
• Left or right heart failure
• Symptoms of embolization
• Focal neurologic injury
• Chest pain
• Flank pain or RUQ pain
• Hematuria
• Ischemia of an extremity

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History (3)

• Symptoms of heart failure
• Valvular perforation
• Rupture of chordae tendineae
• Functional stenosis from obstruction by large
  vegetations
• Worsening of preexisted heart failure
• AMI due to coronary embolism

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PE Vascular Phenomena (1)

• Petechiae
• Common sites conjunctiva, hard palate, behind
  the ear, chest
• Splinter hemorrhage
• Linear subungual hemorrhage
• In 20 of patients with SBE
• In 5-8 of admitted patients without IE
• Of limited value when occurring alone

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PE Vascular Phenomena (2)

• Oslers node
• Painful, tender, erythematous nodules in the skin
  of the extremities
• Usually in the pulp of the fingers
• In 10-20 of patients with SBE
• In lt10 of patients with ABE

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PE Vascular Phenomena (3)

• Janeway lesion
• Small (lt5mm), flat, non-tender red spots
• Irregular in outline
• Non-hemorrhagic blench on pressure
• Found on the palms and soles
• In a few patients with SBE and ABE

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PE Vascular Phenomena (4)

• Ocular lesion
• Conjunctival petechiae important clue when
  unexplained fever and a heart murmur exist
• Retinal hemorrhage 10-25, variable in
  appearance
• Loss of vision
• Endopthalmitis Candida endocarditis

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PE Signs of Embolization

• Decreased or absent arterial pulse
• Focal neurologic signs
• Infarctions of spleen, kidney or bowel mimicking
  an acute abdomen
• AMI

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PE Splenomegaly

• In 25 of patients with ABE
• In 50 of patients with SBE
• Spleen usually soft and only slightly tender
  unless embolic infarction exists

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PE Cardiac Examination

• Tachycardia due to fever or CHF
• Arrhythmias
• Heart murmur
• Triad of fever, anemia, and a new murmur
• Up to 15 of patients do not have a murmur when
  first seen

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Complications (1)

• Heart failure critical influence on prognosis
• Embolization
• In 12-40 of patients with SBE
• In 40-60 of patients with ABE
• Conduction abnormalities
• Associate with a worse prognosis
• Indicative of surgical intervention

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Complications (2)

• Neurologic deficits
• In 29-50 of all IE patients
• 10-15 as initial complaint
• Brain infarction
• Meningeal reaction
• Cerebritis due to septic emboli

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Complications (3)

• Mycotic aneurysm 3-15
• Common sites (usually multiple)
• Proximal aorta
• Visceral arteries
• Limb arteries
• Arteries to the brain
• May continue to enlarge after extinction of
  microbes

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Lab CBC

• Anemia
• Mild to moderate
• Normocytic normochromic
• Leukocytosis not reliable

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Lab Other Routine Tests

• Elevated ESR 90
• Elevated CRP 96
• Urinalysis
• Microscopic hematuria or proteinuria gt50
• RBC casts heavy proteinuria glomerulonephritis
• Gross hematuria renal infarction

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Lab Serology

• Positive RF
• In gt50 of patients with SBE
• Rarely in patients with ABE
• Specific serological test important for Dx of IE
  caused by Coxiella and Bartonella (rare)

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Lab Blood Culture

• B/C should be done in all patients with
  undiagnosed fever and a heart murmur
• B/C x3 on the first day
• Aerobic anaerobic
• Additional B/C x2 on day 3 if necessary (when
  diagnosis is likely but B/C yielded negative
  results)

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ECG

• Repeated or even continuous ECG monitoring
• Frequent APC or VPC
• Prolonged PR interval
• Myocardial infarction

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Echocardiography

• Positive echo findings Positive B/C Diagnosis
  of IE
• Not cost-effective
• Unclear value of predicting the outcome

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Image Study CXR

• Provide evidence of early CHF
• Valvular calcification
• Multiple small, patchy infiltrates in the lungs
  of an IDU with fever septic emboli from
  right-sided IE(IDUIV drug user)

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Image Study CT/MRI

• For defining the cause of focal neurologic
  lesions
• Cerebral emboli

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Image Study Cardiac Cath

• Indication
• In patients gt40 y/o (for possible concurrent CAD)
• When surgical intervention is considered
• CO (CI)
• Heart chamber pressure
• Degree of AR

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Differential Diagnosis ABE

• Sepsis
• Pneumonia
• Meningitis
• Brain abscess
• Stroke
• Malaria
• Acute pericarditis

• Vasculitis
• DIC

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Differential Diagnosis SBE

• As FUO
• Rheumatic fever
• Osteomyelitis
• Tuberculosis
• Meningitis
• Abdominal infection
• Glomerulonephritis

• Myocardial infarction
• Stroke
• Connective tissue diseases
• Occult malignancy
• Chronic heart failure
• Pericarditis

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Diagnostic Criteria

• Definite IE
• Pathologic criteria
• Clinical criteria see the following slides
• Possible IE
• Rejected
• Firm alternative diagnosis
• Resolution of S/S with antibiotics ? 4 days
• No pathologic evidence at surgery or autopsy

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Clinical Criteria

• 2 major
• 1 major 3 minor
• 5 minor

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Major Criteria

• Positive blood culture for IE
• Typical microorganism for IE from B/C x2
• Persistently positive B/C
• Positive echocardiogram for IE
• Oscillating intracardiac mass
• Abscess
• New partial dehiscence of prosthetic valve,
  orNew valvular regurgitation

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Minor Criteria

• Predisposing heart condition or IDU
• Fever ? 38C
• Vascular phenomena
• Immunologic phenomena
• Microbiologic evidence
• Echocardiogram Not meeting major criteria

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Reference Textbook

• Hursts THE HEART, 10th edition. McGraw-Hill,
  2001.

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Thanks for your attention!