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Acute Bacterial Endocarditis

Infective endocarditis represents the infection of the endocardium, most commonly that of the valves or congenital heart defects, but the mural area, prosthetic valves or implantable devices may also be involved. Acute bacterial endocarditis usually has a fulminant course and leads to death if left untreated, whereas the subacute variant has a slower progression, leading to a variety of clinical signs. The most frequent bacterial etiologic agents of acute endocarditis are enterococci. The emergence of multi-drug resistant strains make treatment more difficult and prognosis more grim.


Presentation

Acute bacterial endocarditis patients are usually severely ill, with high fever, chills, poor appetite, weight loss and possible signs of embolism, acute heart failure or heart block. These may be patients who have previously been diagnosed with a congenital heart disease, individuals who recently underwent various procedures that can cause bacteremia or in whom bacteremia is the primary source. Fever may be absent in elderly or immunocompromised patients [1].

Clinical examination must be carefully performed and special attention must be paid to new murmurs or to a change in character of preexisting murmurs, suggestive of valvular dysfunction [2]. However, murmurs are absent in about 33% of acute bacterial endocarditis cases. Heart rate evaluation is also important because intramyocardial abscesses, especially those originating from the aortic valve [3], can involve the conduction system and cause heart block [4]. The patient may also exhibit acute heart failure symptoms [5], as well as signs of peripheral embolic phenomena, located in the central nervous system, lungs, kidneys, liver and spleen [6] Anterior mitral leaflet vegetations, especially if large and friable, are most likely to embolize [7], but the risk decreases after antibiotic treatment begins. Pulmonary embolism presents with chest pain, acute dyspnea and cough.

Peripheral signs of acute bacterial endocarditis are represented by Janeway lesions, located on the palms and soles and caused by vasculitis. The patient may also have articular or osseous pain, due to septic arthritis or osteomyelitis (most often vertebral). If consciousness level is decreased, the physician should suspect acute stroke or meningitis, that is usually purulent in acute endocarditis [8]. If an implantable device is present, it requires special attention [9]. Macroscopic hematuria may signify the presence of glomerulonephritis or embolic renal infarction.

Fever
  • Typically the presentation is silent, with persistent fever and positive blood cultures being the only consistent findings. Fibrin-platelet vegetations on the valvular endocardium are thought to be seeded during bacteremic episodes.[ncbi.nlm.nih.gov]
  • A 38-year-old man presented with sore throat, fever, rash and arthritis. Laboratory findings showed that both erythrocyte sedimentation rate and ferritin had increased.[ncbi.nlm.nih.gov]
  • Acute bacterial endocarditis patients are usually severely ill, with high fever, chills, poor appetite, weight loss and possible signs of embolism, acute heart failure or heart block.[symptoma.com]
  • The patient presented with fevers, fatigue, abdominal pain and renal failure and was found to have acute left-sided staphylococcal endocarditis. He subsequently developed small bowel perforation and purpuric rash.[ncbi.nlm.nih.gov]
  • Both ME and IE may present with fever and a heart murmur with or without embolic phenomenon. Leukocytosis and elevated erythrocyte sedimentation rate suggest the diagnosis of IE.[ncbi.nlm.nih.gov]
Chills
  • Acute bacterial endocarditis patients are usually severely ill, with high fever, chills, poor appetite, weight loss and possible signs of embolism, acute heart failure or heart block.[symptoma.com]
  • On post-procedure day 5, he experienced mental confusion, chills and fever. Upon readmission, he was in severe sepsis with a left central facial palsy and bilateral absence of radial pulses.[link.springer.com]
  • Patients with right-sided ABE present with symptoms of fever and chills, and symptoms and signs of pulmonary emboli. In the patient presented, the PICC line was removed and high-dose cefazolin therapy, 2 g (IV) every 8 hours, was initiated.[ncbi.nlm.nih.gov]
  • Acute Bacterial Endocarditis Patients with acute or recent infection High temperature with chills, sweating, weakness Sudden changes or appearance of new murmurs The emergence embolism, petechiae and toxic effects General intoxication, an enlarged spleen[remedyland.com]
  • Other symptoms include chills, weakness, cough, trouble breathing, headaches, aching joints, and loss of appetite. Emboli may also cause a variety of symptoms, depending on their location.[medical-dictionary.thefreedictionary.com]
Weight Loss
  • Symptoms can be as non-specific as fever, fatigue, weight loss, new rashes (either painful or painless), headaches, backaches, joint pains and confusion; hence the disease remains a diagnostic and therapeutic challenge.[books.google.de]
  • Acute bacterial endocarditis patients are usually severely ill, with high fever, chills, poor appetite, weight loss and possible signs of embolism, acute heart failure or heart block.[symptoma.com]
  • Long-term fever, weight loss, joint pain and muscle pain, fatigue and anemia. Heart murmur, petechiae, emboli phenomena. Blood culture is positive.[remedyland.com]
  • Symptoms you might notice include fever, shortness of breath, fluid buildup in your arms or legs, tiny red spots on your skin, and weight loss.[icdlist.com]
  • Patients may experience such general symptoms as fevers, chills, fatigue, weight loss, muscle aches, and sweating. These general, nonspecific, symptoms can make it hard both for the patient and the doctor to recognize endocarditis.[diagnose-me.com]
Anemia
  • Hemiplegia, persistent heart failure, anemia, bleeding fondness or uremia may be caused by the subacute bacterial endocarditis.[remedyland.com]
  • As follows: CBC ; Hb%, TC, DC, ESR (normochromic normocytic anemia, neutrophil leukocytosis, high ESR may be present). Serum CRP (increased. It is more reliable than ESR in monitoring progress).[prepareformedicalexams.blogspot.com]
  • The symptoms of chronic IE may be such things as fatigue, mild fever (99 –101 F), a moderately fast heart rate, weight loss, sweating, a low red blood cell count (anemia) and can take place over as much as a period of months.[heart.org]
Malaise
  • In addition, the patient reported a mild febrile illness with malaise and dysuria during the 3 weeks prior to presentation. Figure 1.[retinalphysician.com]
  • For example, fever, malaise, weakness, and shortness of breath are common symptoms of endocarditis.[medicinenet.com]
  • For the last 2 months, the patient also experiences malaise, generalized weakness, arthralgia, myalgia, anorexia and substantial loss of weight. There is no history of unconsciousness, hematuria or loin pain (differentiates from embolic phenomena).[prepareformedicalexams.blogspot.com]
  • This form of endocarditis develops rapidly, with fever, malaise, and other signs of systemic infection coupled with abnormal cardiac function and… Read More formation of antigen-antibody complexes In immune system disorder: Type III hypersensitivity …[britannica.com]
  • Following symptoms can be present: sweating at night, chills, malaise, fatigue, anorexia, weight loss, vague muscle pain, redness and swelling of joints, sudden changes in the eyes, hemiplegia caused by cerebral embolism, pain abdomen, thorax, changes[remedyland.com]
Dyspnea
  • Pulmonary embolism presents with chest pain, acute dyspnea and cough. Peripheral signs of acute bacterial endocarditis are represented by Janeway lesions, located on the palms and soles and caused by vasculitis.[symptoma.com]
  • There is no history suggestive of orthopnea or paroxysmal nocturnal dyspnea. For the last 2 months, the patient also experiences malaise, generalized weakness, arthralgia, myalgia, anorexia and substantial loss of weight.[prepareformedicalexams.blogspot.com]
  • The sudden dyspnea with acute AR appeared and aortic valve replacement was performed immediately. In case of unknown etiology of fever, an echocardiographic examination is suggested for the diagnosis of IE.[ci.nii.ac.jp]
  • ., dyspnea, orthopnea, crackles, dependent edema, changes in the heart murmur, and a postsystolic gallop), cerebral emboli (e.g., paralysis, aphasias, changes in mental status), and embolization to the kidney (e.g., decreased urine output, hematuria);[medical-dictionary.thefreedictionary.com]
Heart Disease
  • Other previously reported cases of this functional delay of the left branch were secondary to arteriosclerotic heart disease.[ncbi.nlm.nih.gov]
  • The subacute bacterial endocarditis is usually a rheumatic or congenital heart disease.[remedyland.com]
  • The prevalence of infective endocarditis is between 1.7 and 4 people per 100,000, and is most commonly found in people who have underlying heart disease.[books.google.de]
  • He has been suffering from some valvular heart disease for several years. There is no family history of such illness. He used to take frusemide, propranolol and vitamins prescribed by the local physicians.[prepareformedicalexams.blogspot.com]
  • These may be patients who have previously been diagnosed with a congenital heart disease, individuals who recently underwent various procedures that can cause bacteremia or in whom bacteremia is the primary source.[symptoma.com]
Heart Murmur
  • Both ME and IE may present with fever and a heart murmur with or without embolic phenomenon. Leukocytosis and elevated erythrocyte sedimentation rate suggest the diagnosis of IE.[ncbi.nlm.nih.gov]
  • Heart murmurs can be considered irrelevant when it comes to infections tricuspidalis valves and valvular pulmonary artery. However, with repeated pulmonary infarction due to pneumonia, heart murmurs can be very characteristic signs.[remedyland.com]
  • At this time the patient revealed that she had been diagnosed with a heart murmur and had undergone dental work 4 weeks prior to presentation for which she had taken antibiotic with clindamycin.[retinalphysician.com]
  • Listening to the patient's chest with a stethoscope, the doctor may also hear a heart murmur. A heart murmur may indicate abnormal flow of blood through one of the heart chambers or valves.[medical-dictionary.thefreedictionary.com]
  • With a stethoscope, a doctor can listen to your chest for the distinct sound of a new heart murmur or a change in the sound of an old heart murmur. Heart murmurs are caused by the sound of faulty heart valves and by certain defects in your heart.[texasheart.org]
Chest Pain
  • Pulmonary embolism presents with chest pain, acute dyspnea and cough. Peripheral signs of acute bacterial endocarditis are represented by Janeway lesions, located on the palms and soles and caused by vasculitis.[symptoma.com]
  • He also complains of central chest pain, sharp in nature without any radiation, does not aggravate by cough or movement of the chest.[prepareformedicalexams.blogspot.com]
  • Symptoms may include : Symptoms include fever, chest pain, and fatigue. a high temperature, or fever a new or different heart murmur muscle pain bleeding under the fingernails or toenails broken blood vessels in the eyes or skin chest pain coughing headache[medicalnewstoday.com]
  • The symptoms may include fever, lethargy, shortness of breath, chest pain or palpitations. These symptoms require prompt assessment and investigation by a physician.[dermnetnz.org]
  • pain when you breathe Swelling in your feet, legs or abdomen Endocarditis can also cause symptoms that are more uncommon.[mayoclinic.org]
Tachycardia
  • Heart murmur is present in approximately 80-90% of patients, and in subacute bacterial endocarditis is more frequent up to 95% and it is accompanied by tachycardia and other signs of aggravated heart failure.[remedyland.com]
  • ECG Non-specific, but electrocardiographic abnormalities common and may include: prolongation of the PR interval with progressive degrees of AV block sinus tachycardia right atrial enlargement bundle branch blocks left or right ventricular strain pattern[radiopaedia.org]
  • Löffler's endocarditis, Löffler's parietal fibroplastic endocarditis endocarditis associated with eosinophilia, marked by fibroplastic thickening of the endocardium, resulting in congestive heart failure, persistent tachycardia, hepatomegaly, splenomegaly[medical-dictionary.thefreedictionary.com]
  • There may also be a rapid heartbeat (tachycardia). Individuals with prosthetic valvular endocarditis may develop abscesses on or near the valves. Bacteria may also grow in the heart and obstruct the flow of blood through it.[rarediseases.org]
  • Furthermore, 2 patients presented with ventricular tachycardia during ACS. At least 7 patients had elevated enzymatic markers of myocardial necrosis, although the values ranged widely.[revespcardiol.org]
Systolic Murmur
  • In addition to the general symptoms of infective endocarditis, there may be a heart murmur from blood flowing backward through a defective valve (regurgitative murmur) or a murmur suggestive of blood outflow obstruction (systolic murmur).[rarediseases.org]
Janeway Lesion
  • Peripheral signs of acute bacterial endocarditis are represented by Janeway lesions, located on the palms and soles and caused by vasculitis.[symptoma.com]
  • O/e his blood pressure 140/90 mm Hg, Pulse 136/min, temperature 37.5, respiratory rate 22/min, janeway lesion, splinter hemorrhages, clubbing, Osler nodes, conjunctival hemorrhages.[omicsonline.org]
  • What are Osler nodes and Janeway lesions? Osler nodes and Janeway lesions are two rare but well-known skin manifestations of bacterial endocarditis.[dermnetnz.org]
  • 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.[medbullets.com]
Splinter Hemorrhage
  • O/e his blood pressure 140/90 mm Hg, Pulse 136/min, temperature 37.5, respiratory rate 22/min, janeway lesion, splinter hemorrhages, clubbing, Osler nodes, conjunctival hemorrhages.[omicsonline.org]
  • The following positive findings were elicited from the minimal exam the girl allowed: · Fingers showed splinter hemorrhages and tender nodes on fingers.[pjms.com.pk]
  • hemorrhages Petechiae (embolic or vasculitic) Clubbing: in long standing disease Eyes: Roth spots (boat shaped hemorrhages with pale centers, in retina) and conjunctival splinter hemorrhages Neurological: Confusion, hemiplegia and sensory dysfunction[pathologyoutlines.com]
  • Doctors may also look for small, dark lines under your fingernails that look like wood splinters (called splinter hemorrhages) or burst blood vessels in the retina of your eyes (called Roth’s spots).[texasheart.org]
Cesarean Section
  • In the presence of severe congestive heart failure, the patient underwent cesarean section and delivered a health 2020-g male infant; 36 hours later the aortic valve was successfully replaced with a no. 21 Byork-Shiley prosthesis.[ncbi.nlm.nih.gov]

Workup

While evaluating an acute bacterial endocarditis patient, all efforts should be made to identify the etiological agent. A minimum of three blood cultures should be obtained, preferably while the patient is febrile. Blood workup should also include determination of the inflammatory markers and rheumatoid factor. Leukocytosis is usually present. Baseline workup should also include creatinine, urea, blood urea nitrogen, glycemia, and electrolytes.,

The electrocardiogram is able to highlight rhythm and conduction abnormalities if present. The chest radiography is used to mark out concomitant pulmonary infection or pulmonary embolic pyogenic abscesses.

The definitive diagnosis is established following echocardiography, both transthoracic and transesophageal if needed [5]. Emphysema, obesity and valve prosthesis make transthoracic diagnosis more difficult [10]. A vegetation is described as an oscillating mass, usually attached to a valve, but may also be appended to implanted material or ventricular wall. This method is able to describe the size, motility, and consequences of the pathological process, such as leaflet perforation or pillar rupture, dehiscence of a prosthetic valve [11], abscess [12], aneurysm or fistula formation [13].

Computer tomography and magnetic resonance imaging are adjunct methods for acute bacterial endocarditis diagnosis, not widely used in clinical practice, except for selected cases [14].

Urinalysis may demonstrate the presence of hematuria, indicative for immunologically mediated glomerulonephritis or renal infarction. Proteinuria may also be present.

Blood Culture Positive
  • Diagnosis 5.1 Clinical features 5.2 Laboratory findings 5.3 Imaging techniques 5.3.1 Echocardiography 5.3.2 Multislice computed tomography 5.3.3 Magnetic resonance imaging 5.3.4 Nuclear imaging 5.4 Microbiological diagnosis 5.4.1 Blood culturepositive[escardio.org]

Treatment

  • Among 82 patients who underwent surgical treatment for acute endocarditis over a 10-year period, 15 (18.2%) had extensive destruction of the anulus necessitating special reconstructive techniques for treatment.[ncbi.nlm.nih.gov]
  • Treatment usually involves prolonged administration of intravenous antibiotics. In rare circumstances, valvular resection and replacement may be indicated.[ncbi.nlm.nih.gov]
  • The patient markedly improved after treatment with prednisone 1 mg. kg-1. This controlled and then progressively reduced the disease; the drug was then withdrawn.[ncbi.nlm.nih.gov]
  • Vigorous methods of diagnosis and specific treatment are recommended.[ncbi.nlm.nih.gov]
  • The emergence of multi-drug resistant strains make treatment more difficult and prognosis more grim.[symptoma.com]

Prognosis

  • Aortic insufficiency has the hardest prognosis and requires appropriate surgical intervention. Worst prognosis have embolism which affect the brain.[remedyland.com]
  • The emergence of multi-drug resistant strains make treatment more difficult and prognosis more grim.[symptoma.com]
  • Patients with right-sided endocarditis have a better prognosis than patients with other forms of the disease. Treatment Many patients recover after treatment with prolonged courses of parenteral antibiotics.[medical-dictionary.thefreedictionary.com]
  • Outcome after discharge: follow-up and long-term prognosis 11.1 Recurrences: relapses and reinfections 11.2 Short-term follow-up 11.3 Long-term prognosis 12.[escardio.org]
  • […] endocarditis; HACEK endocarditis; Bloodstream infection Overview Historical Perspective Classification Pathophysiology Causes Differentiating Endocarditis for other Disorders Risk Factors Epidemiology and Demographics Natural History, Complications, and Prognosis[wikidoc.org]

Etiology

  • The etiology and diagnosis of this complication are discussed.[ncbi.nlm.nih.gov]
  • The most frequent bacterial etiologic agents of acute endocarditis are enterococci. The emergence of multi-drug resistant strains make treatment more difficult and prognosis more grim.[symptoma.com]
  • Significant impact on health outcomes is the etiology of infective endocarditis. Only about 50% of patients feel good five years after a cure of bacterial endocarditis.[remedyland.com]
  • […] and multiple body system manifestations due to the underlying etiology.[icd10data.com]
  • Wilensky et al used the term Simultaneous Quadrilateral Gangrene in a 1953 study, and cited endocarditis as a major concern amongst other etiologies. 12 The term acronecrosis was suggested by Walter Pagel, defined as cyanosis followed by necrosis of extreme[pjms.com.pk]

Epidemiology

  • Prosthetic valve endocarditis; Endocardial infection; Native valve endocarditis; HACEK endocarditis; Bloodstream infection Overview Historical Perspective Classification Pathophysiology Causes Differentiating Endocarditis for other Disorders Risk Factors Epidemiology[wikidoc.org]
  • 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[medbullets.com]
  • Epidemiology IE occurs worldwide.[patient.info]
  • The aim of this study was to describe the epidemiological, clinical, microbiological, and echocardiographic characteristics of patients with ACS caused by endocarditis, as well as the course of ACS, and to propose a treatment plan for these patients.[revespcardiol.org]
Sex distribution
Age distribution

Pathophysiology

  • Intravenous drug abuse endocarditis; Intravenous drug abuse infective endocarditis; Prosthetic valve endocarditis; Endocardial infection; Native valve endocarditis; HACEK endocarditis; Bloodstream infection Overview Historical Perspective Classification Pathophysiology[wikidoc.org]
  • Pathoanatomic, pathophysiologic and clinical correlations in endocarditis. New Eng J Med 1974; 291(21): 1122-6. 11. Blumer G. Subacute bacterial endocarditis. Medicine 1923; 2: 105-70. 12. Wilensky ND, Milton M, Moldovan A, Gherardi GJ.[pjms.com.pk]
  • Management of specific situations 12.1 Prosthetic valve endocarditis 12.1.1 Definition and pathophysiology 12.1.2 Diagnosis 12.1.3 Prognosis and treatment 12.2 Infective endocarditis affecting cardiac implantable electronic devices 12.2.1 Introduction[escardio.org]
  • […] defibrillator, IVDA (right sided endocarditis), indwelling catheter Congenital heart disease: small ventricular septal defect, bicuspid aortic valve, coarctation of aorta, patent ductus arteriosus Uncommon with large VSD, mitral stenosis, atrial septal defect Pathophysiology[pathologyoutlines.com]
  • Rifampicin-associated acute renal failure: pathophysiologic, immunologic, and clinical features. Am J Kidney Dis 1998;31:108-15. [PubMed] 1 1. Lomaestro BM. Fluoroquinolone-induced renal failure. Drug Saf 2000;2: 479-85. [PubMed] 12.[antimicrobe.org]

Prevention

  • Rapidly find the answers you need with separate sections on diseases and disorders, differential diagnosis, clinical algorithms, laboratory results, and clinical preventive services, plus an at-a-glance format that uses cross-references, outlines, bullets[books.google.de]
  • Conclusion: This patient has a very rare presentation of Acute Infective Endocarditis, in this case we exactly do not know the source of Staphylococcus aureus but it could be due to poor dental hygiene, early diagnosis and appropriate treatment can prevent[omicsonline.org]
  • The symptomatology and excellent visual outcome speak against a diagnosis of bacterial endophthalmitis although the patient was treated with ciprofloxacin prior to this examination, which may have prevented a more obvious presentation of endophthalmitis[retinalphysician.com]
  • Treatment peak and trough drug levels are checked (e.g. when aminoglycoside or vancomycin is given) to maintain therapeutic levels and prevent toxicity.[medical-dictionary.thefreedictionary.com]
  • […] of systemic embolism 8.3.1 Embolic events in infective endocarditis 8.3.2 Predicting the risk of embolism 8.3.3 Indications and timing of surgery to prevent embolism in infective endocarditis 9.[escardio.org]

References

Article

  1. Perez de Isla L, Zamorano J, Lennie V, et al. Negative blood culture infective endocarditis in the elderly: long-term follow-up. Gerontology 2007;53:245–249.
  2. Sexton D, Spelman D. Current best practices and guidelines: Assessment and management of complications in infective endocarditis. Cardiol Clin. 2003;21:273–282.
  3. Graupner C, Vilacosta I, San Román JA, et al. Periannular extension of infective endocarditis. J Am Coll Cardiol. 2002;39:1204–1211.
  4. Anguera I, Mire J, Cabell C, et al. Clinical characteristics and outcome of aortic endocarditis with periannular abscess in the International Collaboration on Endocarditis Merged Database. Am J Cardiol. 2005;96:976–981.
  5. Bashore T, Cabell C, Fowler V. Jr Update on infective endocarditis. Curr Probl Cardiol. 2006;4:274–352.
  6. Thuny F, Disalvo G, Belliard O, et al. Risk of embolism and death in infective endocarditis: Prognostic value of echocardiography, a prospective multicenter study. Circulation. 2005;112:69–75.
  7. Mylonakis E, Calderwood S. Infective endocarditis in adults. N Engl J Med. 2001;345:1318–1330.
  8. Crawford M, Durack D. Clinical presentation of infective endocarditis. Cardiol Clin. 2003;21(2):159-166.
  9. Baddour L, Epstein A, Erickson C, et al. Update on cardiovascular implantable electronic device infections and their management: a scientific statement from the American Heart Association. Circulation. 2010;121(3):458-77.
  10. Baddour L, Wilson W, Bayer A, et al. Infective endocarditis: Diagnosis, antimicrobial therapy, and management of complications. A statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council of Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association. Circulation. 2005;6:e394–e434.
  11. Li J, Sexton D, Mick N, et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis. 2000;30:633–638.
  12. Choussat R, Thomas D, Isnard R, et al. Perivalvular abscesses associated with endocarditis; clinical features and prognostic factors of overall survival in a series of 233 cases. Perivalvular Abscesses French Multicentre Study. Eur Heart J. 1999;20(3):232-241.
  13. Sachdev M, Peterson GE, Jollis JG. Imaging techniques for diagnosis of infective endocarditis. Infect Dis Clin North Am. 2002;16:319–337.
  14. Feuchtner G, Stolzmann P, Dichtl W, et al. Multislice computed tomography in infective endocarditis. J Am Coll Cardiol. 2009;53:436–444.

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Last updated: 2018-06-21 19:51