Endocarditis

usually results from

infection of the cusp of a heart valve,
although any part of the endocardium or
any prosthetic material inserted into the
heart may be invoived.a.
Etiology.
A variety of organisms may cause
endocarditis, although bacteria account
for almost all cases. The specific agent of
endocarditis depends on which cardiac
structures are affected. (1)
Infection
of normal valves, which is rare, is
usually associated with intravenous drug
use. S. aureus is the most common
pathogen.(2)
Infection
of
previously damaged valves usually is
due to viridans streptococci.Other agents
of endocarditis in this setting are
enterococci, S. aureus, and various small
gram-negative rods comprising part of the
normal oral flora.(3) Infection
of
prosthetic valves involves staphylococci
(both coagulase positive and coagulase
negative) as the most common agents of
early-onset diseas ocurring < 2 months
postoperatively). Streptococci are the
most common agent of late-onset disease
(occurring > 2 months postoperatively) h.
Clinical features. Signs and symptoms
vary widely.Ii)
Common findings
include fever, which is almost universal,
and a heart murmur. Endocarditis is one
of the most common causes of fever of
unknown origin.2 Less commonly,
embolic disease such as stroke or splenic
artery embolism infarction is evident.
Most emboli are small and may give rise
to uncommon but diagnostically helpful
physical findings including Roths spots.
Osiers nodes Janeway lesions, and
conjunctival hemorrhage. (3) A variety
of constitutional symptoms such as
myalgia, back pain , confusion or fatigue
may occur.c.
Laboratory
diagnosis (1) Blood cultures are critical
and are positive in more than 90% of
cases of endocarditis. (Previous use of
antibiotics may lower this figure.)
Because of the continiuos bacteremia of
endocarditis, virtually all cultures are
positive, and necessary to obtain more
than three or four cultures. (2) For
patients
with
culture-negative
endocarditis, there is little incremental
value in collecting several additional
blood samples for culture. Sometimes, the
micoc -ogy laboratory can enhance
isolation by using special culture
techniques. (3)
Immune complexes
may cause a glomerulonephritis, which
is characterized by elevated serum
creatinine, hematuria, and casts in the
urine, or rheumatologic manifestations

such as sterile arthritis. The role of

immune complexes in other aspects of
endocarditis is not well understood. (4)
Moderate anemia is associated with
endocarditis that has been present for
more than 2 weeks.d. Therapy.
Treatment has been carefully studied.
When endocarditis is untreated, it is
almost uniformly fatal. In general,
prosthetic valve disease is more difficult
to treat medically or surgically (1)
Antibiotic therapy alone provides an
excellent chance of cure for streptococcal
disease on a native valve and for
staphylococcal disease on the tricuspid
valve. The key is to provide an adequate
dosage for a long enough period of time,
usually 26 weeks, depending on the
organism.(2)
In medical failures,
valve replacement may be a necessary
adjunct to antibiotic.Therapy: Other
indications for valve surgery include (a)
Fungal endocarditis (an absolute
indication) (b)
Congestive
heart
failure (CHF)
(c)Recurrent major emboli (d) Inability
to provide a full course of antibiotic
therapy (e) Inability to sterilize the blood
after 1014 days