The interval between the initiating bacteraemia and the onset of symptoms of endocarditis is estimated to be less than two weeks. The condition begins with complaints of fever, body ache, malaise, night sweats and chilly sensation. Occassionally embolic episode or heart failure maybe the first manifestation. Weight loss and anemia are seen later [7].

The patients are often elderly. They may complain of myalgia and arthalgia. A patient with fever and heart murmur should always be suspected of endocarditis.

• Splenomegaly

  PATIENT CONCERNS: A young woman, with a history of aortic stenosis, was admitted to our unit for a month of intermittent fever associated with a new diastolic heart murmur and splenomegaly. Laboratory tests were negative for infectious screening. [ncbi.nlm.nih.gov]

  Signs and symptoms of IE include petechiae, anorexia, high fever, heart failure, cardiac murmur, Osler's nodes, Janeway lesions, Roth Spots, and splenomegaly. [youtube.com]

  High body temperature, sudden and variable cardiac murmur, splenomegaly, Osler nodules by immunocomplex vasculitis, Janeway lesions, Roth spots at funduscopy may be seen. [atif.sobiad.com]

  In the second half of the 19 th century, renowned clinicians such as Jean-Martin Charcot (1825-1893) and Alfred Vulpian (1826-1887) understood that hyperthermia, chills and splenomegaly were symptoms of typhoid endocarditis, attributed to poisoning by [scielo.br]

  Signs and symptoms include fever, chills, sweating, malaise, weakness, anorexia, weight loss, splenomegaly, flu-like feeling, cardiac murmur, heart failure, petechia (red spots on the skin), Osler's nodes (subcutaneous nodules found on hands and feet) [en.wikipedia.org]

• Fever

  Diagnosis Endocarditis is suspected in a patient with a heart murmur and unexplained fever for at least one week, and in an intravenous drug abuser with a fever, even in the absence of hearing a murmur. [healthcentral.com]

  […] and fever Study: Eur Heart J. 1997 Jul;18(7):1149-56. [getthediagnosis.org]

  Surgery or dental procedures may cause such bacteria to get loose into the bloodstream, where they may start an infection in the endocardium. * rheumatic fever is a disease that causes fever, joint pain, and inflammation affecting many parts of the body [humanillnesses.com]

  Finally, diagnosis must be suspected in case of unexplained fever, inflammatory syndrome, or embolic event, especially in patients at risk. Conversely, in case of chronic Q fever, an immunodeficiency cause must be researched. Copyright © 2018. [ncbi.nlm.nih.gov]

• Pain

  Abdominal pain and nausea, vomiting, diarrhea, arthralgia, and myalgia. Overt Symptoms. Chest pain. Heart failure with dyspnea. Diagnostic tests. [micunursing.com]

  Clots may also cause abdominal pain, flank pain, or arterial insufficiency in an extremity. Damage from clots may be temporary or permanent. [rarediseases.org]

  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. [medlineplus.gov]

• Weight Loss

  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. [medlineplus.gov]

  Other symptoms may include night sweats, chills, headache and severe loss of appetite resulting in weight loss. Heart murmurs are present in over 85% of individuals with infective endocarditis, and 60% have enlarged spleens. [rarediseases.org]

  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]

• Fatigue

  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. [medlineplus.gov]

  The patient was evaluated for three weeks of lowgrade fever, generalized rash and fatigue, and found to have C. parapsilosis in the blood. [ncbi.nlm.nih.gov]

• Swelling

  To help manage swelling of inflamed tissues during acute rheumatic fever, medicines such as aspirin or corticosteroids may be needed. [nlm.nih.gov]

  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]

  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]

  You have new or increased swelling in your feet or ankles. You feel faint. When should I contact my healthcare provider? You have a fever. You lose your appetite or are unable to eat. You have increased fatigue and weakness. [drugs.com]

  Have swelling. Your abdomen, legs, or feet could all have swelling. Who’s at Risk? If you have a healthy heart, it’s unlikely that you’ll develop endocarditis. [webmd.com]

• Right Upper Quadrant Pain

  […] symptoms (eg, right upper quadrant pain, vomiting, postprandial distress, appendicitis-like symptoms). [emedicine.medscape.com]

  Syndromes similar to rheumatic fever, such as fever, dulled sensorium (as in typhoid), headaches Abdominal symptoms, such as right upper quadrant pain, vomiting, postprandial distress, appendicitis-like symptoms See Clinical Presentation for more detail [emedicine.com]

• Heart Failure

  Heart failure with dyspnea. Diagnostic tests. Chest X-ray Enlarged heart with evidence of heart failure Prominent blood vessels or fluid within the lungs. ECG Arrhythmias. ST-segment and T-wave abnormalities. [micunursing.com]

  failure, while 66.7% (906 patients) were categorized as having New York Heart Association class III of IV symptom status (greater degree of limitations/symptoms with physical activity). 839 (61.7%) of patients with heart failure underwent valvular surgery [medicalnewstoday.com]

  Acute aortic or mitral regurgitation with signs of heart failure. Heart failure unresponsive to medical therapy. Paravalvular extension. Valvular dehiscence, rupture, or fistula formation. New heart block. [acc.org]

  Morbidity Cardiac complications include heart failure, new valvular disease, valve ring abscess, myocardial disease or abscess, conduction abnormalities (including arrhythmia or heart block), and pericardial disease. [emedicine.medscape.com]

• Diastolic Murmur

  We detected 2/4th grade diastolic murmur along left sternal border. His blood analysis revealed hematocrit 45%, leucocytes 16500/ mm3, ESR 75 mm/h. [go.gale.com]

  On examination, she is afebrile but has a new harsh diastolic murmur and hepatomegaly. ECHO reveals a 1.5-cm vegetation on the aortic valve. She is admitted to the intensive care unit and given broad-spectrum antibiotics. [pedsinreview.aappublications.org]

• Arthralgia

  The patient also hasn't suffered any trauma, arthralgia, arthritis, headache, mandibular claudication or visual problems recently. [go.gale.com]

  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]

  Abdominal pain and nausea, vomiting, diarrhea, arthralgia, and myalgia. Overt Symptoms. Chest pain. Heart failure with dyspnea. Diagnostic tests. [micunursing.com]

  Vague musculoskeletal complaints are common - these include arthralgias in about a sixth of patients, and myalgias. As a consequence of severe valve involvement patients are often in heart failure. [anaesthetist.com]

• Sweating

  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]

  Symptoms The most common symptoms of endocarditis mimic the flu or other viral infections, including: Fever Chills Sweating, night sweats Lack of energy, weakness Paleness Aching joints and muscles Click to enlarge Other symptoms can include: Small areas [ottawaheart.ca]

  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]

  Other symptoms may include night sweats, chills, headache and severe loss of appetite resulting in weight loss. Heart murmurs are present in over 85% of individuals with infective endocarditis, and 60% have enlarged spleens. [rarediseases.org]

  Other symptoms include chills and sweating, feeling short of breath, and having pain in your joints. You may also notice red spots under your skin. [cardiosmart.org]

• 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]

  PMID 16330508 Janeway Lesion Sensitivity = 10% This sensitivity is for any cutaneous manifestation. These represent septic microemboli. [getthediagnosis.org]

  […] new valvular regurgitation Minor criteria predisposing heart condition or intravenous drug use fever: 38°C vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway [radiopaedia.org]

  lesions (painless hemorrhagic lesions on palms and soles) Nontender, erythematous and nodular Janeway lesions - http://simple-cardio.blogspot.com/2012/06/peripheral-signs-of-infective.... ● Glomerulonephritis ● Osler nodes (painful lesions on hand or [pedclerk.uchicago.edu]

  lesions ( painless hemorrhagic lesions on palms and soles) Nontender, erythematous and nodular Janeway lesions - http://simple-cardio.blogspot.com/2012/06/peripheral-signs-of-infective.... ● Glomerulonephritis ● Osler nodes ( painful lesions on hand [pedclerk.bsd.uchicago.edu]

• Petechiae

  Small red or purple spots composed of blood (petechiae) may cover the skin of the upper trunk. There may also be pale, oval spots on the retina of the eye (Roth’s spots) which may hemorrhage. [rarediseases.org]

  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]

  Signs and symptoms of IE include petechiae, anorexia, high fever, heart failure, cardiac murmur, Osler's nodes, Janeway lesions, Roth Spots, and splenomegaly. [youtube.com]

  […] from surgery or autopsy or on bacteriology (Gram's stain or culture) of valvular vegetation or peripheral embolus Probable: (a) persistently positive blood culture, plus one of: new regurgitant murmur; predisposing heart disease and vascular phenomena (petechiae [getthediagnosis.org]

• Roth's Spots

  […] or intravenous drug use fever: 38°C vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway lesions immunologic phenomena: glomerulonephritis Osler nodes Roth [radiopaedia.org]

  - http://en.wikipedia.org/wiki/Osler%27s_node ● Roth spots (retinal hemorrhages) Oval shaped, Roth spots, white centered hemorrhages present on the retina of a patient with infective endocarditis - http://simple-cardio.blogspot.com/2012/06/peripheral-signs-of-infective [pedclerk.uchicago.edu]

  Immunological phenomena: glomerulonephritis, Osler's nodes, Roth's spots and rheumatoid factor. [patient.info]

• Retinal Hemorrhage

  […] nodes (painful lesions on hand or fingertips) Osler's lesions found on the hand and fingers of a 43 year old male with subacute bacterial endocarditis. - http://en.wikipedia.org/wiki/Osler%27s_node ● Roth spots (retinal hemorrhages) Oval shaped, Roth [pedclerk.uchicago.edu]

  […] nodes ( painful lesions on hand or fingertips) Osler's lesions found on the hand and fingers of a 43 year old male with subacute bacterial endocarditis. - http://en.wikipedia.org/wiki/Osler%27s_node ● Roth spots (retinal hemorrhages) Oval shaped, Roth [pedclerk.bsd.uchicago.edu]

  Fundoscopic exam: Roth's spots - retinal hemorrhages with pale centers known. Development of a new cardiac murmur. [micunursing.com]

• Headache

  Serious cases can cause: Severe headaches Drowsiness Confusion Seizures Sudden fever Vomiting Diagnosis Diagnosis can include an echocardiogram. Treatment Treatment includes antibiotics and sometimes surgery. [hopkinsmedicine.org]

  You have a severe headache, stiff neck, and your eyes are sensitive to light. You have new or increased swelling in your feet or ankles. You feel faint. When should I contact my healthcare provider? You have a fever. [drugs.com]

  Other symptoms may include night sweats, chills, headache and severe loss of appetite resulting in weight loss. Heart murmurs are present in over 85% of individuals with infective endocarditis, and 60% have enlarged spleens. [rarediseases.org]

  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, scratchy throat or pain when swallowing Sinus drainage, nasal congestion, headaches [my.clevelandclinic.org]

  Symptoms of bacterial endocarditis may include fever, fatigue, loss of appetite, night sweats, chills, headaches, joint discomfort, and tiny pinpoint-sized hemorrhages on the chest and back, fingers, or toes. [healthcentral.com]

• Agitation

  Transesophageal echocardiography (TEE) with agitated saline injection test demonstrated shaggy vegetation at the coapting edge of both mitral leaflets and mitral regurgitation. [ncbi.nlm.nih.gov]

The cardinal features on examination are pyrexia, pallor, petechia, splenomegaly and clubbing of digits. Cardiac examination reveals murmur related to underlying heart disease and one may find change in character of murmurs due to development of endocarditis. Signs of heart failure may develop. The spleen is soft and non tender. Apart from the skin, petechia may be seen in the oral cavity, conjunctivae and even on the retina of the eye (Roth spots). Small flat erythematous non tender macules are seen mainly on the thenar and hypothenar eminences (Janeway lesions); these blanch with pressure. Splinter hemorrhages may develop. Embolic lesions such as hard painful, tender, subcutaneous swellings occur in the fingers, toes, palms and soles (Osler's nodes) occur. Hematuria is common. Arthritis of major joints is frequently seen.

Anemia is almost universal and is normochromic normocytic due to bone marrow depression. Leucocyte count is mildly elevated. High ESR is always present. Urine examination reveals albuminuria and microscopic hematuria. Liver biochemistry is often disturbed mainly an increased alkaline phosphate. Serum immunoglobulins are increased but total complement and C3 complement are decreased owing to immune complex formation. Blood culture is positive in almost two third of the cases.

Transesophageal approach is used in echocardiography to visualize vegetations but smaller sized ones can be missed. This is the greatest sensitivity for detection of vegetations. Vegetation may persist despite treatment. Chest X-ray to demonstrate heart failure or emboli in the right sided endocarditis.

• Pseudomonas

  Pseudomonas aeruginosa was isolated from his blood. Pseudomonas aeruginosa is a rare cause of endocarditis. Patient revealed that he injected drugs intravenously with tap water. [ncbi.nlm.nih.gov]

  A high correlation between the use of the street drugs pentazocine and tripelennamine and pseudomonas endocarditis has been noted [ 57 ]. [academic.oup.com]

  The indications for valve replacement in patients with endocarditis are: Congestive heart failure from valvular regurgitation Failure of antibiotic therapy to successfully suppress the infection or infection with difficult to treat organisms (fungal, Pseudomonas [healio.com]

  All had blood culture positive – 3 for staphylococcus auerus 1 for pseudomonas. None had vegetations on the first echocardiographic examination. Transesophageal echcardiography (TEE) also failed to detect a vegetation or abscess. [drsvenkatesan.wordpress.com]

  […] antibiotic therapy has been given An infection on a new prosthetic valve, supported by positive blood cultures and an echocardiogram showing vegetation on the valve Certain types of difficult to treat bacteria such as non-candida fungal endocarditis or pseudomonas [my.clevelandclinic.org]

Any underlying infection should be treated [8]. The endocarditis is treated with antibiotics chosen on the results of the blood culture. The treatment should continue for 4 to 6 weeks. The microbes in the vegetation being deep seated and surrounded by a fibrin mesh in the relatively poorly vascularised vegetation masses. Hence antibiotics should be administered in large doses. In addition to drug therapy patient should be given complete bed rest, properly regulated fluids, electrolytes and diet and other medications as dictated by an individual case like digoxin, diuretics and ACE inhibitors for heart failure. Most cases show good response to treatment and four weeks of treatment suffice even for virulent organisms [9].

Surgery is required if the following conditions occur:

• Extensive damage of a valve
• Early infection of prosthetic material
• Worsening renal failure
• Embolization
• Progressive cardiac failure

This generally depends on the complications which develop, if left untreated endocarditis can be fatal. Heart failure is the single most important complication responsible for high morbidity and mortality.

Mortality rates for treated endocarditis range from 16 to 27%. Factors associated with mortality include age above 65 years of age [6], additional underlying debilitating medical disorders, and development of congestive heart failure and major embolic complications mainly of the central nervous system. Mortality rates also depend upon infecting organisms being much lower with Streptococcus and quite high with Staphylococcus.

Relapse maybe seen within the first two months of cessation of therapy and blood cultures commonly involve same organisms, indicating that the vegetation was not adequately sterilized during previous drug therapy.

Endocarditis can be classified into infective and non-infective endocarditis. Infective endocarditis is caused by many organisms which can be bacterial, viral or fungal. Presently, the main causative agents are bacteria the three most common being:

• Streptococcus viridians: These organisms are part of bacterial flora of the pharynx and upper respiratory tract and infection may follow a dental extraction, cleaning, tonsillectomy or bronchoscope.
• Enterococcus faecalis: Is found in perianal and faecal bacterial flora. Common in the elderly with infections related to the genitourinary area.
• Staphylococcus aureus: This organism is responsible for 50% of acute cases. Patients with central venous catheters used for parenteral feeding or temporary pacemaker electrode catheters are prone to this infection. Cellulitis and skin abscesses are often originating found in drug addicts who mainline.

Other organisms such as fungal agents like Aspergillus species and Candida albicans [3] are common in intravenous drug addicts, alcoholics and patients with prosthetic heart valves. Prosthetic valve endocarditis risk is greatest during initial 6 months of surgery.

Another type of endocarditis known as native valve endocarditis (NVP) also occurs post surgery [4]. Mitral valve prolapse has emerged as a prominent predisposing structural cardiac abnormality largely confined to patients with both prolapse and mitral regurgitation murmur. In patients with RHD, endocarditis occurs more commonly on the mitral valve, the next common site being the aortic valve. Amongst adults, the most common predisposing congenital conditions are patent ductus arteriosus, ventricular septal defect and bicuspid aortic valve.

Since the widespread availability of antibiotics, the disease pattern has drastically changed [5]. The mean age of patients has raised from 30 years to 50 years. Male to female ratio has increased. Incidence of infection due to Staphylococcus aureus and fungi has increased especially amongst drug abusers. The incidence of infective endocarditis has rasied amongst operated cardiac cases probably due to increased longevity of patients. The incidence of concomitant HIV infection and endocarditis has also increased. The middle aged and elderly are more prone to infective endocarditis (IE). In contrast, the disease is uncommon in children less than 2 years of age. It is more common in males with the ratio being 4:1, mainly because of increasing incidence of IV drug abuse.

The most marked diagnostic pathological feature of endocarditis is the development of vegetation which is either sessile or a polypoidal mass which is mobile and situated on the heart leaflets or defects.

Infection generally occurs along the edges of the heart valves, more commonly on the left side. The bacteria enter into the circulation by way of untreated or partially treated septic focus or by diagnostic or therapeutic instrumentation or along with indwelling canola or intravenous catheters used for long time. The lesion of infective endocarditis is a mass of fibrin, platelets and infecting organism known as vegetation. The chance of an organism sticking to a vegetation is increased because of clumping together of bacteria caused by agglutinating antibodies. They can develop because of repeated infection with the bacterium over a period of time. The vegetation may embolise to central nervous system leading to hemiplegic, meningitis, intracerebral haemorrhage, and encephalopathy and at a later date rupture of my mycotic aneurysms leading to haemorrhage.

The extracardiac manifestations result either from embolization or from deposition of immune complexes. The latter thought to be responsible for arthalgia, Roth spots, focal glomerulonephritis and acute vasculitis.

Those at risk of developing infective endocarditis should receive antibiotic therapy before undergoing a procedure likely to result in bacteraemia [10]. Since it is a condition associated with high morbidly and mortality it is worthwhile giving antibiotic prophylaxis to patients undergoing dental or invasive diagnostic or therapeutic procedures since they all are associated with transient bacteraemia. The form of prevention depends upon on the procedure and on the likelihood of endocarditis. High risk patients are those with prosthetic heart valve or a previous history of endocarditis.

Endocarditis is an inflammation of the endocardium or vascular endothelium of the heart. This condition may occur sometimes as a fulminating or acute infection but runs an insidious course and is generally known as subacute bacterial endocarditis (SBE) [1]. Endocarditis occurs most commonly on rheumatic (RHD) or congenitally abnormal valves as well as mitral valve prolapse and calcified aortic valve disease. It can occur in congenital conditions such as ventricular septal defect or persistent ductus arteriosus. Prosthetic valves or prosthetic vascular material may similarly be infected and thus, there is a rising incidence of this condition in developing countries.

It is classified into infective and non-infective endocarditis depending upon the etiological agent. Virulent organisms may infect healthy valves especially when the victim is debilitated or immunologically incompetent. The characteristic lesion is a variable sized amorphous mass of platelets and fibrin in which many microorganisms and scanty inflammatory cells are enmeshed [2].

The symptoms range from fever, weakness, tiredness and dyspnoea or maybe nonspecific. The treatment consists of a course of antibiotics mainly given intravenously and over a period of 4 to 6 weeks. Surgery may be required in case of damage to heart valves. The intensity and period of disease depends upon the type of organism involved.

Endocarditis is inflammation of the innermost lining of the heart which is mainly caused due to an infectious agent. The human heart consists of heart chambers and valves which can get inflamed and infected. It can affect any part of the heart from the muscles of the heart, the valves which prevent backward flow of blood or the inner lining of the heart. It occurs more in people who have a hereditary or a problem in the heart since birth, damaged heart valves or some heart valve surgery or a previous history of endocarditis. Commonest organisms which cause endocarditis are bacterial other being fungus. These microbes can enter the body through the blood stream either by an unclean injection use, some dental procedures or any other operations related to the airways, urinary tract and skin.

The clinical presentation mainly is a slow and gradual onset with fever, chills and night sweats. Tiredness, weakness and body pain may also be present. Small areas of sudden bleeding under the nails, red spots on the palms and soles and difficulty in breathing may also occur. Immediate medical attention should be given as if left untreated it can be fatal.

A thorough examination will reveal a murmur or a change in the heart murmur which will help your physician to conclude the diagnosis. Other tests required would be a blood culture, a complete blood count and a transesophageal echocardiogram. Immediate antibiotic therapy with hospitalization will be required. At least 4 to 6 weeks of drug therapy will be required. Surgery maybe required if the heart valves are damaged, cardiac failure setting in or there is severe spread to other vital organs. Prompt treatment reduces the morbidly and prevents more grave complications such as cardiac failure, brain involvement and stroke. To prevent these conditions certain high risk patients should take antibiotic therapy prior to any surgeries especially individuals with birth heart defects, heart valve problems or past history of this condition.

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2. Karchmer AW. Infective endocarditis. In: Harrison's Principles of Internal Medicine. 16th ed. McGraw-Hill; 2005:731-40.
3. Baddley JW, Benjamin DK Jr, Patel M, Miró J, et al. Candida infective endocarditis. Eur J Clin Microbiol Infect Dis. Jul 2008;27(7):519-29.
4. Chu VH, Woods CW, Miro JM, Hoen B, Cabell CH, Pappas PA, et al. Emergence of coagulase-negative staphylococci as a cause of native valve endocarditis. Clin Infect Dis. Jan 15 2008;46(2):232-42.
5. Hill EE, Herijgers P, Claus P, Vanderschueren S, Herregods MC, Peetermans WE. Infective endocarditis: changing epidemiology and predictors of 6-month mortality: a prospective cohort study. Eur Heart J. Jan 2007;28(2):196-203.
6. Mendiratta P, Tilford JM, Prodhan P, Cleves MA, Wei JY. Trends in hospital discharge disposition for elderly patients with infective endocarditis: 1993 to 2003. J Am Geriatr Soc. May 2009;57(5):877-81.
7. Crawford MH, Durack DT. Clinical presentation of infective endocarditis. Cardiol Clin. May 2003;21(2):159-66, v.
8. Thuny F, Grisoli D, Collart F, Habib G, Raoult D. Management of infective endocarditis: challenges and perspectives. Lancet. Mar 10 2012;379(9819):965-75.
9. Cunha BA, Gill MV, Lazar JM. Acute infective endocarditis. Diagnostic and therapeutic approach. Infect Dis Clin North Am. Dec 1996;10(4):811-34.
10. Dajani AS, Taubert KA, Wilson W, Bolger AF, Bayer A, Ferrieri P, et al. Prevention of bacterial endocarditis. Recommendations by the American Heart Association. JAMA. Jun 11 1997;277(22):1794-801.