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

  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]

  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]

• 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]

  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]

  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]

• Chills

  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 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]

  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]

• 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]

  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]

  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]

• 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]

• 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]

  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]

  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]

  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]

  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]

  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]

  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]

• Sweating

  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]

  Call your doctor if you have any of these signs of an infection: Fever over 100 F(38.4 C) Sweats or chills, particularly night sweats Skin rash Pain, tenderness, redness or swelling Wound or cut that won't heal Red, warm or draining sore Sore throat, [my.clevelandclinic.org]

  The symptoms of acute IE usually begin with fever (102 –104 F), chills, fast heart rate, fatigue, night sweats, aching joints and muscles, persistent cough or swelling in the feet, legs or abdomen. [heart.org]

  Clinical History: Mr …, 28-year-old, student, normotensive, nondiabetic, nonsmoker, presented with fever for 1 month, which is low grade, continued, sometimes associated with chills and rigor, also with profuse sweating, subsides only with paracetamol [prepareformedicalexams.blogspot.com]

  Other symptoms that can occur with endocarditis are chills, night sweats, fatigue, joint and muscle aches, and swelling of the legs, abdomen, and feet due to fluid accumulation (edema). [medicinenet.com]

• 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]

• Petechiae

  In these cases, the changes are masked and as the first warning sign, suddenly embolism, then petechiae, unexpected heart failure, altered murmur or high temperature can occur. [remedyland.com]

  Emboli may also cause petechiae, tiny purple or red spots on the skin, resulting from hemorrhages under the skin's surface. Tiny hemorrhages resembling splinters may also appear under the fingernails or toenails. [medical-dictionary.thefreedictionary.com]

  Petechiae These are small (1-2mm) purple spots, caused by a minute haemorrhage. They can be caused by loads of things. [almostadoctor.co.uk]

  Most patients with infective endocarditis have a heart murmur (most commonly preexisting), and patients may have petechiae on the skin, conjunctivae, or oral mucosa, as well as splenomegaly and other peripheral manifestations. [histopathology-india.net]

  […] existing murmur (a regurgitant murmur may disappear or worsen) Skin lesions Osler nodes: tender lesions found on finger pulps and thenar / hypothenar eminences Janeway lesions: transient, nontender macular papules on palms or soles Splinter hemorrhages Petechiae [pathologyoutlines.com]

• Conjunctival Petechiae

  petechiae Janeway lesions Immunologic phenomena: Glomerulonephritis Osler nodes Roth spots Rheumatoid factor Microbiologic evidence of infection consistent with but not meeting major criteria Serologic evidence of infection with organisms consistent [merckmanuals.com]

• 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]

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 culture–positive [escardio.org]

  positive for infectious organisms Blood cultures that are positive for microorganisms, which are taken 12 hours apart 3 blood cultures positive on separate occasions that are taken at least 1 hour apart Abnormalities in echocardiogram showing either a [dovemed.com]

  IV drug user, congenital heart condition, prosthetic valve Unusual echo, but not with findings stated above Immunological factors present; Roth spots, Osler’s nodes, glomerulonephritis, rheumatoid factor Blood cultures positive, but major criteria not [almostadoctor.co.uk]

  The criteria combine the clinical, microbiologic, pathologic, and echocardiographic characteristics of a specific case [2] : Major blood culture criteria for IE include the following: Two blood cultures positive for organisms typically found in patients [emedicine.medscape.com]

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.