Edit concept Question Editor Create issue ticket

Subacute Bacterial Endocarditis

Subacute bacterial endocarditis (SBE) is the microbial infection of the endocardium with an indolent nature. It has the potential to disseminate by means of septic emboli.


Presentation

Although subacute bacterial endocarditis (SBE) develops insidiously and has a slow progression over weeks to months, it is often aggressive. Usually, no evident portal of entry or source of infection can be found. The most common causative microorganism is streptococci (especially viridans, anaerobic, enterococci, microaerophilic, and non-enterococcal group D streptococci). SBE is less commonly caused by staphylococcus epidermidis and staphylococcus aureus. SBE is generally developed on abnormal valves after asymptomatic bacteremia resulting from gastrointestinal, genitourinary, or periodontal infections.

The initial symptoms are vague, including night sweats, malaise, fatigability, weight loss, anorexia, myalgia, dyspnea, and low-grade fever (< 39°C) [1]. Arthralgias and chills are possible. Valvular insufficiency features may be the first clue. Early in the course of the disease, ≤ 15% of patients have a murmur or fever but all eventually develop both. On physical examination, normal findings can be observed or fever, pallor, tachycardia, and change in a murmur or a new regurgitant type may be detected.

Approximately 35% of cases show CNS effects like transient ischemic attacks, stroke, or brain abscesses and subarachnoid hemorrhage due to mycotic aneurysm rupture. Potential renal emboli can result in flank pain. Splenomegaly and clubbing of fingers and toes may occur because of prolonged infection.

The four peripheral signs of endocarditis include:

  • Roth spots: Retinal emboli that appear as oval or round hemorrhagic lesions on the retina with white centers on fundoscopic examination. Roth spots are also found in hypertension, vasculitis, diabetes mellitus, and intracranial hemorrhages [2]. Other ocular manifestations are retinal hemorrhages and infectious vitritis in embolic disease [3].
  • Osler nodes: Painful subcutaneous and erythematous nodules on the digits tips. Osler nodes are one of the classic signs in late-phase SBE. However, they can be found in other conditions such as bacteremia, systemic lupus erythematosus, and disseminated gonococcal infection. Adequate intravenous antibiotics can resolve Osler nodes within 3 days [4].
  • Janeway lesions: Small, erythematous, non-tender, or hemorrhagic macular lesions. They do not have an immunological origin and are present on the palms and soles [5].
  • Splinter hemorrhages: Small vertical blood clots under nails. They can also be observed in scleroderma, systemic lupus erythematosus, rheumatoid arthritis, and trauma [6].
Splenomegaly
  • Fever, anaemia, splenomegaly and positive blood cultures for Gram-negative bacteria were found on admission. The fever resolved with antibiotic therapy on the third hospital day but he then developed hemiplegia and multifocal seizures.[ncbi.nlm.nih.gov]
  • Findings compatible with both SBE and marantic endocarditis due to a B-cell lymphoproliferative disorder included an elevated ESR, and splenomegaly. Blood cultures eventually became positive during hospitalization.[ncbi.nlm.nih.gov]
  • Splenomegaly and clubbing of fingers and toes may occur because of prolonged infection.[symptoma.com]
  • It is characterized by a slow, quiet onset with fever, heart murmur, splenomegaly, and development of clumps of abnormal tissue, called vegetations, around an intracardiac prosthesis or on the cusps of a valve.[medical-dictionary.thefreedictionary.com]
  • 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]
Fever
  • Fever, anaemia, splenomegaly and positive blood cultures for Gram-negative bacteria were found on admission. The fever resolved with antibiotic therapy on the third hospital day but he then developed hemiplegia and multifocal seizures.[ncbi.nlm.nih.gov]
  • Its symptoms and signs are varied, and include fever, heart murmur, peripheral embolism, and heart failure.[ncbi.nlm.nih.gov]
  • Early in the course of the disease, 15% of patients have a murmur or fever but all eventually develop both.[symptoma.com]
  • Abstract Serum antibodies reactive with streptococcal peptidoglycan-polysaccharide complexes (PG-PS) have been estimated by enzyme-linked immunosorbent assay in patients with acute rheumatic fever (ARF), tuberculosis (TB) and subacute bacterial endocarditis[ncbi.nlm.nih.gov]
  • Abstract Pyomyositis is a pyogenic infection of the skeletal muscles causing myalgia and fever in patients. Hematogenous seeding engendered by persistent bacteremia and septic embolism is usually the underlying cause of the disease.[ncbi.nlm.nih.gov]
Weight Loss
  • The diagnosis of subacute bacterial endocarditis (SBE) is suggested by a history of an indolent process characterized by fever, fatigue, anorexia, and unexplained weight loss.[ncbi.nlm.nih.gov]
  • Because of a persistently increased erythrocyte sedimentation rate and associated weight loss, blood cultures were obtained, all of which grew Streptococcus constellatus. A transesophageal echocardiogram revealed mitral valve vegetation.[ncbi.nlm.nih.gov]
  • 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]
  • The initial symptoms are vague, including night sweats, malaise, fatigability, weight loss, anorexia, myalgia, dyspnea, and low-grade fever ( 39 C). Arthralgias and chills are possible. Valvular insufficiency features may be the first clue.[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]
Chills
  • Arthralgias and chills are possible. Valvular insufficiency features may be the first clue. Early in the course of the disease, 15% of patients have a murmur or fever but all eventually develop both.[symptoma.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]
  • Infective Endocarditis SYMPTOMS Weakness Fatigue Weight loss Fever Chills Night sweats Anorexia Arthralgia 7. Infective Endocarditis SIGNS Petechial Hemorrhages Linear Hemorrhages Osler Nodes Janeway Lesions Retinal Hemorrhages Heart Murmur 8.[slideshare.net]
  • 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]
Fatigue
  • The diagnosis of subacute bacterial endocarditis (SBE) is suggested by a history of an indolent process characterized by fever, fatigue, anorexia, and unexplained weight loss.[ncbi.nlm.nih.gov]
  • Long-term fever, weight loss, joint pain and muscle pain, fatigue and anemia. Heart murmur, petechiae, emboli phenomena. Blood culture is positive.[remedyland.com]
  • Infective Endocarditis SYMPTOMS Weakness Fatigue Weight loss Fever Chills Night sweats Anorexia Arthralgia 7. Infective Endocarditis SIGNS Petechial Hemorrhages Linear Hemorrhages Osler Nodes Janeway Lesions Retinal Hemorrhages Heart Murmur 8.[slideshare.net]
  • Acute bacterial endocarditis usually begins suddenly with a high fever, fast heart rate, fatigue, and rapid and extensive heart valve damage.[merckmanuals.com]
Malaise
  • The initial symptoms are vague, including night sweats, malaise, fatigability, weight loss, anorexia, myalgia, dyspnea, and low-grade fever ( 39 C). Arthralgias and chills are possible. Valvular insufficiency features may be the first clue.[symptoma.com]
  • In addition, the patient reported a mild febrile illness with malaise and dysuria during the 3 weeks prior to presentation. Figure 1.[retinalphysician.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]
Clubbed Finger
  • Obliteration in clubbed fingers of the diamond-shaped window normally produced when the dorsal surfaces of the corresponding finger of each hand are opposed (Schamroth sign) may useful for the identification of clubbing. [13] Causes Clubbing can be idiopathic[emedicine.medscape.com]
Colic
  • A patient with enterococcal endocarditis sustained separate intra-abdominal hemorrhages, 24 hours apart, from aneurysms of the middle colic and left colic arteries.[ncbi.nlm.nih.gov]
Heart Disease
  • AbP is given to patients with known rheumatic or other valvular heart disease by 98.9% of responders and to patients with known prosthetic heart valves by 81.5%.[ncbi.nlm.nih.gov]
  • Abstract Systemic necrotizing vasculitis involving cerebral blood vessels is described in a 30-year-old man with rheumatic heart disease and subacute bacterial endocarditis.[ncbi.nlm.nih.gov]
  • Also discussed is the relationship of acute rheumatic fever and its sequela, rheumatic heart disease, to predisposing people to SBE and possible genetic factors. The well-known case of Alfred S.[ncbi.nlm.nih.gov]
  • Abstract We report the case of a 31-year-old woman with no history of heart disease. She came to the hospital with fever, dyspnea, palpitation, and edema of the lower extremities.[ncbi.nlm.nih.gov]
  • The subacute bacterial endocarditis is usually a rheumatic or congenital heart disease.[remedyland.com]
Heart Murmur
  • Its symptoms and signs are varied, and include fever, heart murmur, peripheral embolism, and heart failure.[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]
  • Heart murmurs are common. Also a focal renal infarction, focal nephritis or diffuse glomerulonephritis is very common, resulting in microscopic haematuria and proteinuria. The onset of the illness may be difficult to date.[gpnotebook.co.uk]
  • 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]
Tachycardia
  • On physical examination, normal findings can be observed or fever, pallor, tachycardia, and change in a murmur or a new regurgitant type may be detected.[symptoma.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]
  • 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]
  • […] glomerulonephritis ; , Osler nodes Therapeutic consequences Lack of valve vascularization requires antibiotic treatment for several weeks References: [14] [15] [6] [16] Clinical features Course of disease Constitutional symptoms Fever and chills ( 90% of cases) , tachycardia[amboss.com]
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]
Diastolic Murmur
  • murmur ; loudest at the left sternal border Signs of progressive heart failure ( e.g., dyspnea , edema ) Signs of acute cardiac decompensation ( pulmonary edema ) Arrhythmias Extracardiac manifestations These manifestations are mainly caused by bacterial[amboss.com]
Janeway Lesion
  • A case is reported with splinter hemorrhages and Janeway lesions, resulting from an infected radial artery catheter.[ncbi.nlm.nih.gov]
  • Janeway lesions: Small, erythematous, non-tender, or hemorrhagic macular lesions. They do not have an immunological origin and are present on the palms and soles. Splinter hemorrhages: Small vertical blood clots under nails.[symptoma.com]
  • See also bacterial endocarditis, endocarditis, Janeway lesion. observations The infected vegetations may separate from the valve or prosthesis and form emboli.[medical-dictionary.thefreedictionary.com]
  • On physical exam, there may be conjunctival hemorrhages, splinter hemorrhages, Janeway lesions (nontender hemorrhagic macules and papules on the palms), Osler nodes (painful erythematous nodules located on the fingertips), or Roth spots (pale lesions[visualdx.com]
  • Infective Endocarditis SIGNS Petechial Hemorrhages Linear Hemorrhages Osler Nodes Janeway Lesions Retinal Hemorrhages Heart Murmur 8. Infective Endocarditis Outcome Fatal 10-70% of cases 9.[slideshare.net]
Splinter Hemorrhage
  • Abstract SBE manifests many skin findings including petechiae, splinter hemorrhages of the nails, Osler's and laneway lesions, clubbing of the fingers, and findings suggestive of angiitis.[ncbi.nlm.nih.gov]
  • Abstract Classical lesions associated with subacute bacterial endocarditis include petechiae, splinter hemorrhages, Osler's modes and Janaway lesions.[ncbi.nlm.nih.gov]
  • A case is reported with splinter hemorrhages and Janeway lesions, resulting from an infected radial artery catheter.[ncbi.nlm.nih.gov]
  • Splinter hemorrhages: Small vertical blood clots under nails. They can also be observed in scleroderma, systemic lupus erythematosus, rheumatoid arthritis, and trauma.[symptoma.com]
  • Osler's nodes, petechiae, Roth's spots, and splinter hemorrhages under the fingernails are common manifestations of blood-borne metastases of these emboli.[medical-dictionary.thefreedictionary.com]
Petechiae
  • Abstract SBE manifests many skin findings including petechiae, splinter hemorrhages of the nails, Osler's and laneway lesions, clubbing of the fingers, and findings suggestive of angiitis.[ncbi.nlm.nih.gov]
  • Abstract Classical lesions associated with subacute bacterial endocarditis include petechiae, splinter hemorrhages, Osler's modes and Janaway lesions.[ncbi.nlm.nih.gov]
  • 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]
  • […] developed dehiscence of a prosthetic valve New valvular regurgitation Minor criteria Predisposing cardiac disease Intravenous drug abuse Fever 38 C Vascular phenomena: arterial embolism, pulmonary septic embolism, mycotic aneurysm, intracranial hemorrhage, petechiae[symptoma.com]
  • Osler's nodes, petechiae, Roth's spots, and splinter hemorrhages under the fingernails are common manifestations of blood-borne metastases of these emboli.[medical-dictionary.thefreedictionary.com]
Palpable Purpura
  • Abstract The case of a patient who had palpable purpura on his lower extremities due to Lactobacillus-caused subacute bacterial endocarditis is reported. Histologic examination of the purpuric lesions demonstrated a leukocytoclastic angiitis.[ncbi.nlm.nih.gov]
  • Physical examination revealed palpable purpura, mild hypertension, hepatosplenomegaly, and a holosystolic cardiac murmur (Levine 2/6). Echocardiography showed tricuspid valve vegetations with moderate to severe regurgitation.[ncbi.nlm.nih.gov]
  • Palpable purpura may also be seen. Imaging may reveal septic pulmonary infarcts, mycotic aneurysms, and stroke.[visualdx.com]
Retinal Hemorrhage
  • Other ocular manifestations are retinal hemorrhages and infectious vitritis in embolic disease. Osler nodes: Painful subcutaneous and erythematous nodules on the digits tips. Osler nodes are one of the classic signs in late-phase SBE.[symptoma.com]
  • hemorrhage and a vitreous inflammatory response leading to a mild decrease in VA.[retinalphysician.com]
  • Infective Endocarditis SIGNS Petechial Hemorrhages Linear Hemorrhages Osler Nodes Janeway Lesions Retinal Hemorrhages Heart Murmur 8. Infective Endocarditis Outcome Fatal 10-70% of cases 9.[slideshare.net]

Workup

The diagnosis of endocarditis is challenging since the presentation varies from case to case. The symptoms of SBE can take several weeks or months to develop while some patients show symptoms acutely after a few days [7].

Laboratory studies may show anemia, leukocytosis, elevated erythrocyte sedimentation rate (ESR), and microscopic hematuria. Although, bacterial endocarditis can be present in the absence of these findings [8].

If endocarditis is suspected, three sets of blood cultures (20 mL each) must be obtained from a separate new venipuncture site within 24 hours.

Echocardiography should be performed. Transthoracic echocardiography (TTE) is usually preferred since it is less costly and non-invasive compared to transesophageal echocardiography (TEE).

The definite diagnosis of infective endocarditis is done when microorganisms are cultured or observed histologically after being obtained from endocardial vegetations during embolectomy, cardiac surgery, or autopsy. Since this is not always possible, diagnostic criteria called revised Duke's criteria has been established with a specificity and sensitivity of more than 90%.

For a definite clinical diagnosis: 2 major criteria are needed, or 1 major and 3 minor criteria, or 5 minor criteria.
For a potential clinical diagnosis: 1 major criterion and 1 minor criterion are needed, or 3 minor criteria.

Major criteria

  1. 2 positive blood cultures for typical microorganisms causing endocarditis
  2. 3 positive blood cultures for microorganisms that are consistent with endocarditis
  3. Serologic evidence of Coxiella burnetii infection (or 1 positive blood culture)
  4. Evidence of endocardial involvement on echocardiography:
  • Oscillating intracardiac vegetative mass on a valve, or on the supporting structures, in the path of regurgitant jets, or on implanted material without other anatomic explanation
  • Cardiac abscess
  • Newly developed dehiscence of a prosthetic valve
  • New valvular regurgitation

Minor criteria

  1. Predisposing cardiac disease
  2. Intravenous drug abuse
  3. Fever ≥38° C
  4. Vascular phenomena: arterial embolism, pulmonary septic embolism, mycotic aneurysm, intracranial hemorrhage, petechiae on the conjunctiva, Janeway lesions
  5. Immunologic phenomena: glomerulonephritis, Osler nodes, Roth spots, positive rheumatoid factor
  6. Microbiological evidence of infection that is consistent with but not meeting major criteria
  7. Serologic evidence of infection with organisms consistent with causing endocarditis
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
  • 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

  • […] endocarditis. 3 The present report, which deals with the apparently successful treatment of 7 consecutive examples of subacute bacterial endocarditis, employs variations on previous technics.[doi.org]
  • The amnesia completely resolved after treatment with intravenous penicillin for subacute bacterial endocarditis secondary to a viridans streptococcus.[ncbi.nlm.nih.gov]
  • The importance of alertness to the possibility of SBE in cases of disease manifesting itself as an immunological disorder, thus achieving early diagnosis and early antimicrobial treatment, is stressed.[ncbi.nlm.nih.gov]
  • A synoptic table is presented of 19 reported cases of infection caused by A. actinomycetemcomitans not connected with actinomycosis, with particular regard to their clinical features, treatment, and outcome.[ncbi.nlm.nih.gov]

Prognosis

  • Aortic insufficiency has the hardest prognosis and requires appropriate surgical intervention. Worst prognosis have embolism which affect the brain.[remedyland.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]
  • Each problem is presented on a two-page spread in boxes with consistent headings including introduction; etiology, pathophysiology and risk factors; patient presentation; differential diagnosis; diagnostic evaluation; treatment and management; and prognosis[books.google.com]
  • Prognosis and Predictive Factors The overall mortality of infectious endocarditis is approximately 20-25%, and it is increased with advanced patient age, left-sided disease, methicillin-resistant S aureus (MRSA) infection, and chronic renal failure .[emedicine.medscape.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]

Etiology

  • Streptococcus viridans is the usual etiologic agent of sbe.[icd9data.com]
  • A clear, comprehensive introduction to disease, Pathophysiology, 5th Edition explores the etiology, pathogenesis, clinical manifestations, and treatment of disorders.[books.google.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]
  • Each problem is presented on a two-page spread in boxes with consistent headings including introduction; etiology, pathophysiology and risk factors; patient presentation; differential diagnosis; diagnostic evaluation; treatment and management; and prognosis[books.google.com]
  • Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology.[icd10coded.com]

Epidemiology

  • Conventions Publication Fees Ethics Resources and Policies About the Journal About IAI Editor in Chief Editorial Board For Reviewers For the Media For Librarians For Advertisers Alerts RSS FAQ Subscribe Members Institutions Pathogenic Mechanisms, Ecology, and Epidemiology[iai.asm.org]
  • […] abscess formation • Mycotic aneurysm: : A term applied to fungal or bacterial infection within the wall of a vessel • Mycotic endocarditis: : Endocarditis caused by fungus Objectives After completing this article, readers should be able to: Discuss the epidemiology[pedsinreview.aappublications.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[step1.medbullets.com]
  • He has since completed further training in emergency medicine, clinical toxicology, clinical epidemiology and health professional education.[lifeinthefastlane.com]
  • Epidemiology IE occurs worldwide.[patient.info]
Sex distribution
Age distribution

Pathophysiology

  • […] clarify complex pathophysiological concepts.[books.google.com]
  • Each problem is presented on a two-page spread in boxes with consistent headings including introduction; etiology, pathophysiology and risk factors; patient presentation; differential diagnosis; diagnostic evaluation; treatment and management; and prognosis[books.google.com]
  • 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]
  • ., UTIs , spondylodiscitis ) References: [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] Pathophysiology Pathogenesis : localized infection or contamination bacteremia bacterial colonization and possible formation of thrombi on valve leaflets[amboss.com]
  • […] that amount in an urban population with a high rate of intravenous drug abuse (IVDA). [3] Endocarditis accounts for about 0.75 admissions per 1000 per year in large community hospitals. [4] See the following articles for more information: Etiology and Pathophysiology[emedicine.medscape.com]

Prevention

  • So, I don’t recommend antibiotic prophylaxis to prevent prosthetic joint infections.[tcmp.med.ubc.ca]
  • A high suspicion of potential complications can prevent morbidity and mortality.[ncbi.nlm.nih.gov]
  • The authors also outline current recommendations for surgical intervention as heart valve replacement surgery was warranted in the patient to prevent fatal outcome.[ncbi.nlm.nih.gov]
  • Unnecessary immunosuppression can be prevented with full investigation of such patients, including both immunofluorescence and ELISA.[ncbi.nlm.nih.gov]

References

Article

  1. Mylonakis E, Calderwood SB. Infective endocarditis in adults. N Engl J Med. 2001;345:1318–30. doi: 10.1056/NEJMra010082.
  2. Fred HL. Little black bags, ophthalmoscopy, and the Roth spot. Tex Heart Inst J. 2013;40:115–6.
  3. Habib G, Hoen B, Tornos P, et al. Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009): The task force on the prevention, diagnosis, and treatment of Infective Endocarditis of the European society of Cardiology (ESC). Eur Heart J. 2009;30(19):2369-413.
  4. Jackson TL, Eykyn SJ, Graham EM, Stanford MR. Endogenous bacterial endophthalmitis: a 17-year prospective series and review of 267 reported cases. Surv Ophthalmol. 2003;48:403–23. doi: 10.1016/S0039-6257(03)00054-7.
  5. Farrior JB, Silverman ME. A consideration of the differences between a Janeway’s lesion and an Osler’s node in infectious endocarditis. Chest. 1976;70:239–43. doi: 10.1378/chest.70.2.239.
  6. Robertson JC, Braune ML. Splinter haemorrhages, pitting, and other findings in fingernails of healthy adults. Br Med J. 1974;4:279–81. doi: 10.1136/bmj.4.5939.279.
  7. Luttenberger K, DiNapoli M. Subacute bacterial Endocarditis. J.Nurse Pract. 2011;36(3):31–38. doi:10.1097/01.npr.0000393971.15598.0c.
  8. Cunha BA, Gill MV, Lazar JM. Acute infective endocarditis. Diagnostic and therapeutic approach. Infect Dis Clin North Am. 1996;10:811–34.

Ask Question

5000 Characters left Format the text using: # Heading, **bold**, _italic_. HTML code is not allowed.
By publishing this question you agree to the TOS and Privacy policy.
• Use a precise title for your question.
• Ask a specific question and provide age, sex, symptoms, type and duration of treatment.
• Respect your own and other people's privacy, never post full names or contact information.
• Inappropriate questions will be deleted.
• In urgent cases contact a physician, visit a hospital or call an emergency service!
Last updated: 2018-06-21 18:48