Endocarditis is an inflammatory disease involving the inner lining ( endocardium Endocardium The innermost layer of the heart, comprised of endothelial cells. Heart: Anatomy) of the heart, most commonly affecting the cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) valves. Both infectious Infectious Febrile Infant and noninfectious Noninfectious Febrile Infant etiologies lead to vegetations on the valve leaflets. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship may present with nonspecific symptoms such as fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever and fatigue Fatigue The state of weariness following a period of exertion, mental or physical, characterized by a decreased capacity for work and reduced efficiency to respond to stimuli. Fibromyalgia. Important clinical exam findings include a new or changed heart murmur and common extra- cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) signs, such as Osler nodes, Janeway lesions, splinter hemorrhages, and Roth spots. The diagnosis is based on clinical findings, blood cultures Cultures Klebsiella, and echocardiography Echocardiography Ultrasonic recording of the size, motion, and composition of the heart and surrounding tissues. The standard approach is transthoracic. Tricuspid Valve Atresia (TVA) showing valvular vegetations. Management includes intravenous antibiotics for infectious Infectious Febrile Infant cases, addressing the underlying etiology for noninfectious Noninfectious Febrile Infant cases, and surgical repair when necessary.
Last updated: 20 Feb, 2022
Infective endocarditis:
Noninfective endocarditis:
Infective endocarditis may be caused by numerous organisms; the list below is not exhaustive.
The following are risk factors for IE:
Pathology specimens from a patient with chronic bovine
fibrous
Fibrous
Fibrocystic Change calcified endocarditis:
a: gross pathology showing extensive
fibrosis
Fibrosis
Any pathological condition where fibrous connective tissue invades any organ, usually as a consequence of inflammation or other injury.
Bronchiolitis Obliterans and thickening of the stroma (*) and widespread superficial calcification (arrows)
b: histopathology of the lesion, showing extensive
fibrosis
Fibrosis
Any pathological condition where fibrous connective tissue invades any organ, usually as a consequence of inflammation or other injury.
Bronchiolitis Obliterans (*) and areas of calcification (arrows)
Vegetations of the
aortic valve
Aortic valve
The valve between the left ventricle and the ascending aorta which prevents backflow into the left ventricle.
Heart: Anatomy at autopsy:
a: The macroscopic appearance of the
aortic valve
Aortic valve
The valve between the left ventricle and the ascending aorta which prevents backflow into the left ventricle.
Heart: Anatomy demonstrates 2 vegetations of 4
mm
MM
Multiple myeloma (MM) is a malignant condition of plasma cells (activated B lymphocytes) primarily seen in the elderly. Monoclonal proliferation of plasma cells results in cytokine-driven osteoclastic activity and excessive secretion of IgG antibodies.
Multiple Myeloma and 5
mm
MM
Multiple myeloma (MM) is a malignant condition of plasma cells (activated B lymphocytes) primarily seen in the elderly. Monoclonal proliferation of plasma cells results in cytokine-driven osteoclastic activity and excessive secretion of IgG antibodies.
Multiple Myeloma in diameter.
b: Histologic evaluation shows that the vegetations consist of
fibrin
Fibrin
A protein derived from fibrinogen in the presence of thrombin, which forms part of the blood clot.
Rapidly Progressive Glomerulonephritis without bacterial colonies, consistent with noninfective endocarditis.
Verrucous vegetations seen in
Libman-Sacks endocarditis
Libman-Sacks Endocarditis
Systemic Lupus Erythematosus of the
mitral valve
Mitral valve
The valve between the left atrium and left ventricle of the heart.
Heart: Anatomy:
The
sterile
Sterile
Basic Procedures vegetations typically have a wart-like morphology. The vegetations can be found near the edge of the leaflets along the line of closure, both on the atrial and ventricular sides of the leaflets, and can even be found on the chordae and the
endocardium
Endocardium
The innermost layer of the heart, comprised of endothelial cells.
Heart: Anatomy. In this case, several microthrombi are present on the free edge of the leaflet and on the chordae.
Infective endocarditis can be further classified based on the clinical course, type of valve, and location.
Acute infectious Infectious Febrile Infant endocarditis:
Subacute infectious Infectious Febrile Infant endocarditis (endocarditis lenta):
Native valve endocarditis:
Prosthetic valve Prosthetic Valve Soft Tissue Abscess endocarditis:
Left-sided endocarditis:
Right-sided endocarditis (most common in IV drug use):
Presentation Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor and course depend on the etiology, location of vegetations, and severity.
The following are more frequently seen in IE than NIE:
The following are potential findings in IE:
Osler node on the 4th digit of the left hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy
Image: “Osler’s node on the fourth digit of the left hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy” by Yang ML, Chen YH, Chen TC, Lin WR, Lin CY, Lu PL. License: CC BY 2.0Janeway lesion on the toe in a patient with infective endocarditis
Image: “Janeway lesion on patient’s left toe” by Case Reports in Infectious Infectious Febrile Infant Diseases. License: CC BY 4.0Janeway lesion showing as painless, macular, hemorrhagic, irregularly-shaped lesions on patient’s palm:
Two pronounced lesions are seen at thumb and middle finger. Subungual splinter hemorrhages (arrowhead) are seen at the
nail bed
Nail bed
Skin: Structure and Functions of thumb.
Signs of IE can be remembered with the mnemonic “FROM JANE”:
System embolization Embolization A method of hemostasis utilizing various agents such as gelfoam, silastic, metal, glass, or plastic pellets, autologous clot, fat, and muscle as emboli. It has been used in the treatment of spinal cord and intracranial arteriovenous malformations, renal arteriovenous fistulas, gastrointestinal bleeding, epistaxis, hypersplenism, certain highly vascular tumors, traumatic rupture of blood vessels, and control of operative hemorrhage. Gastrointestinal Bleeding may occur in both IE and NIE. Often, an embolic event is the only presenting evidence of NIE.
Depiction of transesophageal
echocardiography
Echocardiography
Ultrasonic recording of the size, motion, and composition of the heart and surrounding tissues. The standard approach is transthoracic.
Tricuspid Valve Atresia (TVA):
Patients
Patients
Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.
Clinician–Patient Relationship are generally sedated for this procedure. The echo
transducer
Transducer
A device placed on the patient’s body to visualize a target
Ultrasound (Sonography) is lowered into the
esophagus
Esophagus
The esophagus is a muscular tube-shaped organ of around 25 centimeters in length that connects the pharynx to the stomach. The organ extends from approximately the 6th cervical vertebra to the 11th thoracic vertebra and can be divided grossly into 3 parts: the cervical part, the thoracic part, and the abdominal part.
Esophagus: Anatomy, which places it right next to the left side of the heart.
Transesophageal
echocardiography
Echocardiography
Ultrasonic recording of the size, motion, and composition of the heart and surrounding tissues. The standard approach is transthoracic.
Tricuspid Valve Atresia (TVA) images demonstrating vegetations on the
mitral valve
Mitral valve
The valve between the left atrium and left ventricle of the heart.
Heart: Anatomy in a patient with noninfective endocarditis due to
malignancy
Malignancy
Hemothorax.
The solid arrow is pointing to a vegetation on the anterior leaflet, and the dotted arrow is pointing to a vegetation on the posterior leaflet.
Ao:
aorta
Aorta
The main trunk of the systemic arteries.
Mediastinum and Great Vessels: Anatomy; LA: left atrium; LV: left ventricle
Transesophageal echocardiography Echocardiography Ultrasonic recording of the size, motion, and composition of the heart and surrounding tissues. The standard approach is transthoracic. Tricuspid Valve Atresia (TVA) image demonstrating a large pedunculated vegetation within the ascending aorta Ascending aorta Mediastinum and Great Vessels: Anatomy arising from the commissure of the right and noncoronary cusp of the aortic valve Aortic valve The valve between the left ventricle and the ascending aorta which prevents backflow into the left ventricle. Heart: Anatomy with a calcified base consistent with endocarditis
Image: “Lomentospora prolificans endocarditis–case report and literature review” by Kelly M, Stevens R, Konecny P. License: CC BY 4.0, cropped by Lecturio.Transesophageal echocardiography Echocardiography Ultrasonic recording of the size, motion, and composition of the heart and surrounding tissues. The standard approach is transthoracic. Tricuspid Valve Atresia (TVA) image showing 2 vegetations (red arrows) on the mitral valve Mitral valve The valve between the left atrium and left ventricle of the heart. Heart: Anatomy in a patient with endocarditis
Image: “ Pseudomonas Pseudomonas Pseudomonas is a non-lactose-fermenting, gram-negative bacillus that produces pyocyanin, which gives it a characteristic blue-green color. Pseudomonas is found ubiquitously in the environment, as well as in moist reservoirs, such as hospital sinks and respiratory equipment. Pseudomonas mendocina native valve infective endocarditis: a case report” by Journal of Medical Case Reports. License: CC BY 4.0Laboratory findings:
Imaging:
An ECG ECG An electrocardiogram (ECG) is a graphic representation of the electrical activity of the heart plotted against time. Adhesive electrodes are affixed to the skin surface allowing measurement of cardiac impulses from many angles. The ECG provides 3-dimensional information about the conduction system of the heart, the myocardium, and other cardiac structures. Electrocardiogram (ECG) showing atrioventricular dissociation Dissociation Defense Mechanisms in a patient with S. viridans endocarditis
Image: “Timing for pacing after acquired conduction disease in the setting of endocarditis” by Brancheau D, Degheim G, Machado C. License: CC BY 3.0The Duke diagnostic criteria is a set of clinical criteria that can aid in the diagnosis of IE.
Prompt initiation of IV antibiotics is necessary if the patient is acutely ill.
Intraoperative vegetation findings on the aortic valve Aortic valve The valve between the left ventricle and the ascending aorta which prevents backflow into the left ventricle. Heart: Anatomy in a patient with endocarditis
Image: “A rare case of Candida Candida Candida is a genus of dimorphic, opportunistic fungi. Candida albicans is part of the normal human flora and is the most common cause of candidiasis. The clinical presentation varies and can include localized mucocutaneous infections (e.g., oropharyngeal, esophageal, intertriginous, and vulvovaginal candidiasis) and invasive disease (e.g., candidemia, intraabdominal abscess, pericarditis, and meningitis). Candida/Candidiasis parapsilosis endocarditis in a young healthy woman” by Pelemiš, M., et al AL Amyloidosis. License: CC BY 2.0