The presentation of bacterial endocarditis is classified as subacute or acute [1]. While both forms share similar features, they differ regarding duration and rate of progression.

Subacute

Patients with this type experience an insidious onset of nonspecific symptoms such as low-grade fever, fatigue, anorexia, weight loss, malaise, night sweats, chills, and arthralgia. These may persist for weeks to months [2].

Acute

The clinical picture of acute bacterial endocarditis consists of a sudden onset of fever [3] along with a rapid and aggressive course [4]. Septic shock may occur in these critically ill individuals. The majority of patients will have a heart murmur.

Complications

Patients with bacterial endocarditis are at risk for congestive heart failure (CHF), stroke, various types of infection [2], myocardial infarction, etc.

Physical exam

Up to half of all patients will exhibit classic physical signs such as 1) petechiae, 2) splinter hemorrhages, 3) Osler's nodes, 4) Janeway lesions and 5) Roth's spots. The latter three are considered minor criteria used for diagnosis of bacterial endocarditis [5].

Notable vital sign findings include fever and tachycardia. The patient overall appears toxic and pale. Also, patients with CHF present with jugular vein distension and peripheral edema. Moreover, focal neurologic deficits occur in up to 40% of affected patients [6]. Delirium and other mental status changes may be evident. Additionally, conjunctival hemorrhage may also be apparent.

The cardiac exam is a crucial component of the physical assessment as auscultation typically reveals the presence of a murmur. This may either be new or an exacerbation of a preexisting murmur. Other abnormal heart and lung sounds may include gallops, rales, pericardial rub, and pleural friction rub.

• Splenomegaly

  Symptoms can include heart murmur, embolic phenomena, splenomegaly, bacteremia, extended fever, and heart failure. [medical-dictionary.thefreedictionary.com]

  […] murmurs Petechiae or round spots caused by bleeding into the skin Subungual haemorrhages or dark red linear lesions of the nail bed Tender subcutaneous nodules on the finger pads Lesions on the palms and soles Retinal haemorrhages with clear centres Splenomegaly [docdoc.com.sg]

  RESULTS--Group A--9 patients aged 8-58 years, 3 men, all them with cardiac murmurs, fever and anemia, 5 with splenomegaly. Hemocultures were done in 7 patients and positive in 1. [bases.bireme.br]

  There can been present splenomegaly, tachycardia, petechiae on the skin occur in about 10-15% of patients usually appear in groups 2-3 days and fade away and disappear without a trace, mucous membranes, then finding on the fundus, bleeding beneath the [remedyland.com]

  These minor criteria were splenomegaly (3), haematuria (4), clubbing (2), splinters (2), rash (1), petechiae (2), and purpura (1) (table 5). [doi.org]

• Fever

  Notable vital sign findings include fever and tachycardia. The patient overall appears toxic and pale. Also, patients with CHF present with jugular vein distension and peripheral edema. [symptoma.com]

  A 37-year-old man was admitted with fever, hemoptysis, and dyspnea. Admission examinations revealed severe renal failure requiring dialysis therapy. Chest radiograph showed extensive pulmonary reticulonodular infiltrates. [ncbi.nlm.nih.gov]

• Weight Loss

  The clinical presentation is one of fever, night sweats, weight loss, and weakness, with additional symptoms due to cardiac failure or embolism. Heart murmurs are common. [gpnotebook.co.uk]

  Subacute Patients with this type experience an insidious onset of nonspecific symptoms such as low-grade fever, fatigue, anorexia, weight loss, malaise, night sweats, chills, and arthralgia. These may persist for weeks to months. [symptoma.com]

  Other symptoms may include: poor appetite fatigue rapid breathing joint pain rash weight loss What are the causes of bacterial endocarditis? Bacterial endocarditis can occur when bacteria enter the body and grow on the heart lining. [childrenshospital.org]

  Long-term fever, weight loss, joint pain and muscle pain, fatigue and anemia. Heart murmur, petechiae, emboli phenomena. Blood culture is positive. [remedyland.com]

• Chills

  Symptoms fever shaking chills swollen joints lameness spontaneous bleeding blindness behavioral and personality changes unstable gait seizures new or changing heart murmur Treatment Intensive therapy with injectable antibiotics can be effective if diagnosed [bigheartsfund.org]

  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]

  Symptoms: Early symptoms: Fatigue and weakness Intermittent fever, chills and excessive sweating, especially at night Weight loss Vague aches and pains Heart murmur Late symptoms: Severe chills and high fever Shortness of breath on exertion Swelling of [maxor.com]

• Fatigue

  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]

  Subacute Patients with this type experience an insidious onset of nonspecific symptoms such as low-grade fever, fatigue, anorexia, weight loss, malaise, night sweats, chills, and arthralgia. These may persist for weeks to months. [symptoma.com]

  These sometimes can: Be present for days before any other symptoms appear Come and go, or be more noticeable at nighttime You may also have fatigue, weakness, and aches and pains in the muscles or joints. [mountsinai.org]

• Anemia

  In 1939 Middleton and Burke 2 reported anemia, usually of [jamanetwork.com]

  Hemiplegia, persistent heart failure, anemia, bleeding fondness or uremia may be caused by the subacute bacterial endocarditis. [remedyland.com]

  These tests may reveal leukocytosis, anemia, elevated ESR, and positive RF. Also, urinalysis typically shows microscopic hematuria and may also depict red blood cell (RBC) casts. [symptoma.com]

  Staphylococcus epidermidis and Staphylococcus aureus "Bacteria FROM JANE" mnenomic Fever Roth spots Osler nodes Murmur Janeway lesions Anemia Nail-bed hemorrhage Emboli A particular organism causes endocarditis in patients with underlying colorectal carcinoma [quizlet.com]

• Cough

  Other symptoms include a cough, skin changes, and swelling in the arms, legs, or abdomen. Bacterial endocarditis is treated with antibiotics. If significant heart valve damage occurs, heart valve replacement surgery may be needed. [stanfordchildrens.org]

  Coughing up pink, foamy mucus. You passed out. You have symptoms of a stroke. These may include: Sudden numbness, tingling, weakness, or loss of movement in your face, arm, or leg, especially on only one side of your body. Sudden vision changes. [myhealth.alberta.ca]

  Symptoms may include: Flu-like symptoms, such as fever, chills, tiredness, aching muscles and joints, night sweats, and headaches Shortness of breath Cough Pale skin Bumps under the skin on the fingers and toes Spots on the palms of the hands and soles [stlouischildrens.org]

• Dyspnea

  She had signs of infection resistant to antibiotic therapy, secondary cachexia, and dyspnea. [ncbi.nlm.nih.gov]

  He was well, apart from episodes of dizziness and dyspnea after exercise during the previous 4 months. These episodes had started 1 week after the patient had undergone a dental treatment. Previous extensive investigations had been inconclusive. [nejm.org]

  […] and enterococci Early onset: S. epidermidis or S. aureus (most common) [1][2] Late-onset: S. epidermidis (most common) [1][2] Constitutional symptoms Fever and chills ( 90% of cases), tachycardia General malaise, weakness, night sweats, weight loss Dyspnea [amboss.com]

• Hemoptysis

  A 37-year-old man was admitted with fever, hemoptysis, and dyspnea. Admission examinations revealed severe renal failure requiring dialysis therapy. Chest radiograph showed extensive pulmonary reticulonodular infiltrates. [ncbi.nlm.nih.gov]

  Septic pulmonary emboli may cause cough, pleuritic chest pain, and sometimes hemoptysis. A murmur of tricuspid regurgitation is typical. [merckmanuals.com]

• Rales

  Other abnormal heart and lung sounds may include gallops, rales, pericardial rub, and pleural friction rub. [symptoma.com]

  Other signs include the following: Stiff neck Delirium Paralysis, hemiparesis, aphasia Conjunctival hemorrhage Pallor Gallops Rales Cardiac arrhythmia Pericardial rub Pleural friction rub Subacute infective endocarditis Approximately 3-15% of patients [emedicine.medscape.com]

• Loss of Appetite

  These may include: Fever Chills Fatigue Weakness Discomfort Unexplained weight loss Poor appetite Muscle aches Joint pain Coughing Shortness of breath Little red dots on the skin, inside the mouth, and/or under the nails Bumps on the fingers and toes [health.cvs.com]

  Other symptoms are loss of appetite, unexplained weight loss, new rashes (both painful and painless), headache, backache, joint pain, confusion, shortness of breath, or sudden weakness in the face or limbs suggestive of a stroke. [ahajournals.org]

  […] away if you have any of the following: Tiredness that persists for 2 to 3 days Decreased exercise tolerance Chest pain or shortness of breath Fever over 100.4 F ( 38.0 C) Sweats Severe abdominal or flank pain Bloody urine Return of symptoms such as loss [saintlukeskc.org]

• Heart Disease

  Author information 1 1Department of Congenital Heart Diseases and Pediatric Cardiology,Silesian Center for Heart Diseases,Medical University of Silesia,Zabrze,Poland. 2 2Department of Transplantology and Cardiac Surgery,Silesian Center for Heart Diseases [ncbi.nlm.nih.gov]

  This infection can occur in any person (infant, child or adult) who has heart disease present at birth (congenital heart disease), or can occur in people without heart disease. [cincinnatichildrens.org]

  This infection can occur in any person (infant, child, or adult) who has heart disease present at birth (congenital heart disease), or can occur in people without heart disease. [chw.org]

• Heart Murmur

  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]

  Symptoms can include heart murmur, embolic phenomena, splenomegaly, bacteremia, extended fever, and heart failure. [medical-dictionary.thefreedictionary.com]

  About 90 percent of patients will have heart murmurs, but murmurs may be absent in patients with right-sided heart infections. A changing murmur is common only in acute endocarditis. [healthcentral.com]

  Symptoms fever shaking chills swollen joints lameness spontaneous bleeding blindness behavioral and personality changes unstable gait seizures new or changing heart murmur Treatment Intensive therapy with injectable antibiotics can be effective if diagnosed [bigheartsfund.org]

• Chest Pain

  pain Fatigue Fever that doesn't go away Fever Numbness Weakness Weight loss without change in diet Prevention The American Heart Association recommends preventive antibiotics for people at risk for infectious endocarditis, such as those with: Certain [mountsinai.org]

  When to call your healthcare provider Call your healthcare provider right away if you have any of the following: Tiredness that persists for 2 to 3 days Decreased exercise tolerance Chest pain or shortness of breath Fever over 100.4 F ( 38.0 C) Sweats [saintlukeskc.org]

  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 Fatigue Fever that doesn't go away in two or three days Fever Numbness Weakness Weight loss without change in diet The American Heart Association recommends preventive antibiotics for people at risk for infectious endocarditis, such as those with [nlm.nih.gov]

• Tachycardia

  Notable vital sign findings include fever and tachycardia. The patient overall appears toxic and pale. Also, patients with CHF present with jugular vein distension and peripheral edema. [symptoma.com]

  Neonates with endocarditis may also have feeding problems, respiratory distress, or tachycardia. [emedicine.medscape.com]

  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]

  Bacterial endocarditis should be considered in horses with clinical signs of weight loss, fever, cardiac murmur and tachycardia. [cbmr.ku.dk]

  An electrocardiogram revealed sinusal tachycardia. Thoracic radiography and abdominal ultrasonography examinations were normal. Lumbar radiography showed a lytic lesion in the L4 vertebral body. [scielo.br]

• Systolic Murmur

  On physical exam, you appreciate a faint systolic murmur. Before any lab tests or other imaging have been done, you obtain the following echo: Post navigation [web.archive.org]

  Cardiovascular examination revealed an ejection click and a systolic murmur that radiated to the carotids. Neurological examination demonstrated left facial weakness and Medical Research Council (MRC) grade 4/5 power in left upper and lower limbs. [academic.oup.com]

  On the eighth hospital day, a grade 2 systolic murmur was present in the mitral area. [scielo.br]

• Roth's Spots

  Little black bags, ophthalmoscopy, and the Roth spot. Tex Heart Inst J 2013 ; 40 : 115 – 6. 2. Litten's sign (Roth's spots) in bacterial endocarditis. Arch Ophthalmol 1994 ; 112 : 683 – 4. 3. [academic.oup.com]

  Physical exam Up to half of all patients will exhibit classic physical signs such as 1) petechiae, 2) splinter hemorrhages, 3) Osler's nodes, 4) Janeway lesions and 5) Roth's spots. [symptoma.com]

  Staphylococcus epidermidis and Staphylococcus aureus "Bacteria FROM JANE" mnenomic Fever Roth spots Osler nodes Murmur Janeway lesions Anemia Nail-bed hemorrhage Emboli A particular organism causes endocarditis in patients with underlying colorectal carcinoma [quizlet.com]

  The presence of white-centered hemorrhages (Roth spots) should prompt the consideration of possible infective endocarditis. A comparison of Panel A and Panel B (3 days apart) shows how quickly such spots can change. [nejm.org]

  This finding is known as Roth spots. There may be small, pinpoint areas of bleeding on the surface of the eye or the eyelids. [mountsinai.org]

• 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]

• Night Sweats

  The clinical presentation is one of fever, night sweats, weight loss, and weakness, with additional symptoms due to cardiac failure or embolism. Heart murmurs are common. [gpnotebook.co.uk]

  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]

  Subacute Patients with this type experience an insidious onset of nonspecific symptoms such as low-grade fever, fatigue, anorexia, weight loss, malaise, night sweats, chills, and arthralgia. These may persist for weeks to months. [symptoma.com]

• Janeway Lesion

  Janeway lesions are seen in people with acute bacterial endocarditis. They appear as flat, painless, red to bluish-red spots on the palms and soles. Janeway lesions are seen in people with acute bacterial endocarditis. [mountsinai.org]

  Physical exam Up to half of all patients will exhibit classic physical signs such as 1) petechiae, 2) splinter hemorrhages, 3) Osler's nodes, 4) Janeway lesions and 5) Roth's spots. [symptoma.com]

  Cutaneous manifestations include petechiae, Osler nodes, Janeway lesions, and splinter hemorrhages. Neurologic syndromes include cerebral embolism, infarction, and intracerebral hemorrhage and stroke. [emedicine.medscape.com]

  Osler’s nodes and Janeway lesions. The Australasian journal of dermatology. 2007; 48(4):251-5. [PMID: 17956487] Marrie TJ. Osler’s nodes and Janeway lesions. The American journal of medicine. 2008; 121(2):105-6. [rebelem.com]

• 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]

  Physical exam Up to half of all patients will exhibit classic physical signs such as 1) petechiae, 2) splinter hemorrhages, 3) Osler's nodes, 4) Janeway lesions and 5) Roth's spots. [symptoma.com]

  Cutaneous manifestations include petechiae, Osler nodes, Janeway lesions, and splinter hemorrhages. Neurologic syndromes include cerebral embolism, infarction, and intracerebral hemorrhage and stroke. [emedicine.medscape.com]

  In addition, the musculoskeletal symptoms preceded the infective endocarditis (IE) by about 1 month, which occurred together with other symptoms, e.g. mycotic aneurysms and petechiae. [scielo.br]

• Splinter Hemorrhage

  Physical exam Up to half of all patients will exhibit classic physical signs such as 1) petechiae, 2) splinter hemorrhages, 3) Osler's nodes, 4) Janeway lesions and 5) Roth's spots. [symptoma.com]

  Cutaneous manifestations include petechiae, Osler nodes, Janeway lesions, and splinter hemorrhages. Neurologic syndromes include cerebral embolism, infarction, and intracerebral hemorrhage and stroke. [emedicine.medscape.com]

  He was afebrile but had a pansystolic murmur and a solitary splinter hemorrhage on the right thumb. Echocardiography revealed moderate-to-severe mitral-valve regurgitation, with thickening and signs of vegetations. The ejection fraction was 65%. [nejm.org]

  Other signs can include: Small areas of bleeding under the nails ( splinter hemorrhages ) Red, painless skin spots on the palms and soles (Janeway lesions) Red, painful nodes in the pads of the fingers and toes (Osler nodes) Shortness of breath with activity [mountsinai.org]

  Splinter hemorrhages of the nails: a systematic review of clinical features and associated conditions. International journal of dermatology. 2016; 55(12):1304-1310. [PMID: 27420914] Li JS, Sexton DJ, Mick N. [rebelem.com]

• Eczema

  Pyoderma form when the organism colonises, and subsequently invades (especially when occlusive dressings are used), exfoliative lesions, venous stasis ulcers or eczema. These have a characteristic moth-eaten appearance and erythematous border. [web.archive.org]

• Arthralgia

  Subacute Patients with this type experience an insidious onset of nonspecific symptoms such as low-grade fever, fatigue, anorexia, weight loss, malaise, night sweats, chills, and arthralgia. These may persist for weeks to months. [symptoma.com]

  Churchill et al reported on 192 patients with a diagnosis of bacterial infective endocarditis, 29 (15%) of whom had only musculoskeletal involvement as the first symptom of IE and their symptoms included: arthralgia (38%), arthritis (31%), lumbar pain [scielo.br]

  The diagnosis of acute interstitial nephritis is usually based on the clinical presentation (fever, skin rash, acute arthralgia), and laboratory findings (eosinophilia and abnormal urinalysis findings of eosinophiluria, proteinuria, hematuria, sterile [antimicrobe.org]

  It can be associated with chills, night sweats, anorexia, weight loss, loss of appetite, malaise, headache, myalgias, arthralgias, abdominal pain, dyspnea, cough, and pleuritic pain. Cardiac murmurs are observed in about 85% of patients. [ncbi.nlm.nih.gov]

• Myalgia

  It can be associated with chills, night sweats, anorexia, weight loss, loss of appetite, malaise, headache, myalgias, arthralgias, abdominal pain, dyspnea, cough, and pleuritic pain. Cardiac murmurs are observed in about 85% of patients. [ncbi.nlm.nih.gov]

  He was admitted to the hospital due to intense diffuse myalgia, left ankle arthritis, and abdominal pain. He did not have a history of cardiac or general disease and reported no intravenous drug abuse. [doi.org]

  SymptomsAcute– High grade fever andchills– SOB– Arthralgias/ myalgias– Abdominal pain– Pleuritic chest pain– Back painSub acute– Low grade fever– Anorexia– Weight loss– Fatigue– Arthralgias/ myalgias– Abdominal pain– N/VThe onset of symptoms is usually [slideshare.net]

  […] aureus (most common) [1][2] Late-onset: S. epidermidis (most common) [1][2] Constitutional symptoms Fever and chills ( 90% of cases), tachycardia General malaise, weakness, night sweats, weight loss Dyspnea;, cough, pleuritic chest pain Arthralgias, myalgias [amboss.com]

• Back Pain

  Back pain, may be severe Heart murmur Weight loss Late stages: Severe chills and high fever Shortness of breath on exertion Swelling of the feet, legs and abdomen Rapid or irregular heartbeat Acute bacterial endocarditis (ABE) has similar symptoms, but [diagnose-me.com]

  Secondary phenomena could include focal neurologic complaints due to an embolic stroke or back pain associated with vertebral osteomyelitis. As many as 20% of cases present with focal neurologic complaints and stroke syndromes. [emedicine.medscape.com]

  Back pain (15% of patients) may have origin in immune complex deposition in disc spaces. Investigations[4] Nonspecific signs of infection - eg, elevated CRP or ESR, leukocytosis, anaemia and microscopic haematuria. [patient.info]

  Complaints of low back pain, pain in the joints (arthralgia) or in one or more muscles (myalgia) are common. These symptoms usually appear early in the disease, occasionally as the only initial symptoms. [rarediseases.org]

• Low Back Pain

  Complaints of low back pain, pain in the joints (arthralgia) or in one or more muscles (myalgia) are common. These symptoms usually appear early in the disease, occasionally as the only initial symptoms. [rarediseases.org]

• Hematuria

  Also, urinalysis typically shows microscopic hematuria and may also depict red blood cell (RBC) casts. [symptoma.com]

  Microscopic hematuria is seen in about 50% of cases. Gross hematuria indicates the presence of focal or diffuse glomerulonephritis or possible embolic renal infarction. [antimicrobe.org]

  However, renal insufficiency resulting from immune complex–mediated glomerulonephritis occurs in less than 15% of patients with endocarditis and may cause hematuria and, rarely, azotemia. [emedicine.medscape.com]

  2005) S. aureus, Candida, HACEK organisms, and Abiotrophia Vegetation size 10 mm Vegetation mobility Mitral valve involvement Renal emboli Emboli to kidneys can lead to abscess formation, ischemia, and infarction, presenting as flank pain, pyuria, or hematuria [rebelem.com]

  Urinalysis may demonstrate proteinuria, microscopic hematuria, and/or pyuria.[5] Treatment / Management Empiric antibiotic therapy should cover Staphylococcus (methicillin-susceptible and resistant), Streptococcus, and Enterococcus. [ncbi.nlm.nih.gov]

• Stroke

  We report the case of a patient who presented with multifocal left middle cerebral artery stroke in the setting of Enterococcus faecalis endocarditis and was found to have near-occlusive ipsilateral carotid artery stenosis in stroke workup. [ncbi.nlm.nih.gov]

  […] risk of stroke. [medicalxpress.com]

  Symptoms include stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. Renal embolism and infarction occur in patients with bacterial endocarditis. [emedicine.medscape.com]

• Headache

  A sudden, severe headache that is different from past headaches. Call your doctor or nurse call line now or seek immediate medical care if: You have a new or higher fever. [myhealth.alberta.ca]

  BE patients (32-77 years) presented multiple (n 3) or single ischemic strokes (n 2) or encephalopathy and headache (n 2). [ncbi.nlm.nih.gov]

  Symptoms may include: Flu-like symptoms, such as fever, chills, tiredness, aching muscles and joints, night sweats, and headaches Shortness of breath Cough Pale skin Bumps under the skin on the fingers and toes Spots on the palms of the hands and soles [stlouischildrens.org]

• Confusion

  Endocarditis is generally preventable with simple measures, but the implementation of these measures is often confusing for the parents of thechild, the physician, and the dentist. Hopefully this brief article will decrease some of that confusion. [csun.edu]

  Sudden confusion or trouble understanding simple statements. Sudden problems with walking or balance. A sudden, severe headache that is different from past headaches. [myhealth.alberta.ca]

  Other symptoms are loss of appetite, unexplained weight loss, new rashes (both painful and painless), headache, backache, joint pain, confusion, shortness of breath, or sudden weakness in the face or limbs suggestive of a stroke. [ahajournals.org]

• Altered Mental Status

  38 yo female presents with altered mental status. The patient was found down at home, and no further history is known. EMS intubated on scene. [ultrasoundoftheweek.com]

The clinical assessment should include a detailed history of the patient and the inquiry about risk factors such as congenital heart defects, history of the rheumatic disease, and the presence of prosthetic valves [7] as well as intravenous drug use (IVDU) [8].

The clinical presentation, history, and physical exam findings should raise suspicion for bacterial endocarditis. Further testing is necessary as described below. Also, the clinician must follow the Duke diagnostic criteria for endocarditis to establish the diagnosis [5].

Laboratory tests

The American Heart Association (AHA) recommends obtaining at least three blood cultures, of which the initial and final sets are drawn at least one hour apart [5]. Furthermore, the samples should be retrieved from 3 different venipuncture sites. Very importantly, initiation of empiric antibiotic treatment should be postponed until after cultures are provided.

The workup further includes a complete blood count (CBC), complete metabolic panel (CMP), erythrocyte sedimentation rate (ESR), complement panel, coagulation studies, and rheumatoid factor (RF). These tests may reveal leukocytosis, anemia, elevated ESR, and positive RF. Also, urinalysis typically shows microscopic hematuria and may also depict red blood cell (RBC) casts.

Imaging

The AHA also recommends the use of echocardiography to investigate the presence of valvular vegetations and annular abscess [5] and to evaluate the valvular and heart function overall. Specifically, transthoracic echocardiography (TTE) is the initial imaging modality performed in most individuals while transesophageal echocardiogram (TEE) is the study of choice for those with a cardiac implantable electronic device (CIED) [9] or prosthetic valves [5].

Note that a patient with manifestations suggestive of cerebral emboli should be evaluated with a head computed tomography (CT) scan [10] or magnetic resonance imaging (MRI) [5].

• Elevated Sedimentation Rate

  Blood tests show signs of inflammation such as an elevated sedimentation rate,while anemia and blood cells in the urine are often present. The most important diagnostic test for endocarditis involves a positive blood culture. [csun.edu]

• Blood Culture Positive

  Duke Criteria - Major Criteria Positive blood culture* Positive echocardiogram (vegetation, paravalvular abscess, or valve dehiscence after surgery). While transesophageal echo recommended in adults, transthoracic echo is fine in children. [pedclerk.bsd.uchicago.edu]

  Whipple’s endocarditis: review of the literature and comparisons with Q fever, Bartonella infection, and blood-culture positive endocarditis. Clin Infect Dis 2001 ; 33 : 1309 –16. La Scola B, Raoult D. [doi.org]

  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]

  In cases of blood culture-positive endocarditis, results of valve cultures may cause unnecessary confusion if valve cultures generate discrepant (i.e., falsely positive) results. [jcm.asm.org]

1. Mylonakis E, Calderwood SB. Medical progress: infective endocarditis in adults. N Engl J Med. 2001;345(18):1318-1330.
2. Giessel BE, Clint J, Koenig CJ, and Blake RL Jr. Management of Bacterial Endocarditis. Am Fam Physician. 2000; 61(6):1725-1732.
3. Crawford MH, Durack DT. Clinical presentation of infective endocarditis. Cardiol Clin. 2003; 21(2):159-66, v.
4. McDonald JR. Acute Infective Endocarditis. Infect Dis Clin North Am. 2009;23(3):643-664.
5. Baddour LM, Wilson WR, Bayer AS, et al. Infective Endocarditis in Adults: Diagnosis, AntimicrobialTherapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation. 2015; 132(15):1435-86.
6. Epaulard O, Roch N, Potton L, Pavese P, Brion JP, Stahl JP. Infective endocarditis-related stroke: diagnostic delay and prognostic factors. Scand J Infect Dis. 2009; 41(8):558-62.
7. Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis. Recommendations by the American Heart Association. JAMA. 1997;277(22):1794–801.
8. Berlin JA, Abrutyn E, Strom BL, et al. Incidence of infective endocarditis in the Delaware Valley, 1988–1990. Am J Cardiol. 1995;76(12):933–6.
9. Baddour LM, Epstein AE, Erickson CC, 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. Roe MT, Abramson MA, Li J, Heinle SK, et al. Clinical information determines the impact of transesophageal echocardiography on the diagnosis of infective endocarditis by the duke criteria. Am Heart J. 2000; 139(6):945-51.