Endocarditis Summary



Who?

Infectious:

• Pre-existing valvular disease

• Prosthetic valve

• Congenital heart disease

• IV substance use

• IV catheter

• Recent dental procedure

• Cardiac implantable electronic devices (CIED)

Non-Infectious (NTBE):

• Malignancy (Marantic, verrucous)

	• Lung, Pancreas, Gastric & Ovarian CA

	• Involves aortic and mitral regurgitation

• Autoimmune (SLE Libman Sacks)

• Atrial myxoma

• Hypercoagulable (APLAS)



Microbiology:

Blood cultures are positive in 90% of IE cases

Culture (+):

	Acute:

	• S. Aureus

	• S. Epidermidis

	• S. Pyogenes

	• Enterococci

	Subacute:

	• S. Viridans (Sanguinis, Mitis, Oralis, Mutans)

	• S. Bovis, S. gallolyticus

	• HACEK, H. Parainfluenza

	• H. Influenza

	Prosthetic Valve Endocarditis:

	• Staphylococcus aureus

	• Coagulase-negative staphylococci

Culture (-):

	• Bartonella

	• Brucella

	• Coxiella Burnetii

	• Streptobacillus Moniliformis

	• Tropheryma Whipplei

	• Aspergillus

	• Cryptococcus, Histoplasma



What?

Generalized:

• Chills, night sweats, fever

• Malaise, fatigue, weight loss

• Myalgias

Cardiac:

• New cardiac murmur

• Valvular insufficiency

• New-onset Heart Failure

• Dyspnea

Vascular:

• Systemic emboli: Cerebral > Splenic, pulmonary

• Janeway lesions

• Mycotic aneurysm

• Splinter hemorrhages

• Petechiae

Immunologic:

• Osler nodes

• Roth’s spots

• Glomerulonephritis



Septic Emboli Cause Injury By:

• Early embolic/ischemic insult due to vascular occlusion that may lead to infarction

• Infectious insult that leads to inflammation and possible abscess formation

• Other vegetations can also embolize: Marantic (NTBE)



Differential Diagnosis:

• Rheumatic valvular disease

• Degenerative valvular disease

• Vasculitis

• Nonbacterial thrombotic endocarditis

• Fibroelastoma

• Lambl’s excrescences

• Paradoxical emboli via ASD

• Metastatic disease and tumor embolism



Endocarditis Diagnosis?

• Blood cultures

• 2D Echo TTE

	• TTE nondiagnostic + ↑ Suspicion -> TEE

• Duke Criteria

• ↑ ESR, CRP

• EKG: Conduction abnormalities (suggests perivalvular abscess)

• Leukocytosis, anemia, and hematuria, + RF



Endocarditis Rx?

• IV Antibiotics

• Surgery

• Marantic:

	• Treat underlying cause + Systemic anticoagulation



Pearls?

• Left sided > Right sided

• IV Substance use: R > L Tricuspid

• Marantic: Emboli > Regurgitation

• Colon CA: S. Bovis, gallolyticus, clostridium septicum

• S. Viridans



Surgery:

• Valvular dysfunction -> symptomatic heart failure

• Left sided IE: heart block, annular or aortic abscess, or destructive lesion

• Complications: Abscess, destructive penetrating lesions, heart block

• Persistent bacteremia/fevers > than 5 to 7 days after onset of appropriate antimicrobial therapy

• >10-mm left sided vegetations to prevent emboli

• S. aureus prosthetic valve endocarditis



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