Infective endocarditis

Lvia Jnoskuti

Definition
Bacterial or fungal
(chlamydial, rickettsial also occur)

Infection
Within the heart

Classification
Infective organism
(Gram pos., Gram neg, fungal, hemoculture negative IE)

Native valve , prosthetic valve

(early:within 12 month after operation, > 12 month after operation)

Population
(iv drug abusers, children, old patients)

Nosocomial
IE developing > 48 h prior to the onset of signs and symptoms
consistent with IE

Active at operation
(fever, positive hemoculture)

Recidive: 1 year after recovery

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Epidemiology
60/1 million inhabitants/year
Hungary:24/ 1 M / year
Predisposing lesions:
Prostetic valve and mitral valve prolapse
sclerosis,degenerative valve increasing incidence
Rheumatic valve disease decreasing incidence in
association with IE
Iv drug abusers have an unique propensity to
develope IE of the tricuspid valve
Mortality: 16-33%, early prosthetic valve IE 80%

Pathogenesis
Bacteria enters the blood stream
(oral or other source)

Lodge in the heart valves, that already may

bear platelet-fibrin thrombi
Bacteria proliferate freely-vegetation
develops

Complications of the disease

Emboli: brain, spleen, kidney,right sidedpulmonary
Valve destruction: regurgitation, obstruction
Extension: septum-AV block, fistulaspericardium (sinus Valsalva aneurysm
rupture into the pericardium)
IC vasculitis: arthritis, glom. nephritis,
Osler nodes, Roth spots, Latex positivity
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Peripheral manifestations of IE
Physical finding

Pathogenesis

Most common
organism

Petechiae(20-40%)red,
nonblanching lesions in crops on
conjuctivae, buccal mucosa, palate,
extremities

Vasculitis or
emboli

Streptococcus
Staphylococcus

Splinter hemorrhages(15%) linear

red streaks proximal in nailbed

Vasculitis or
emboli

Staphylococcus
Streptococcus

Osler s nodes(10-25%) 2-5mm

painful nodules on pads of fingers
or toes

Vasculitis

Streptococcus

Janeway lesions (<10%) macular

Emboli
red or hemorrhagic painless patches
on palm or soles)

Staphylococcus

Roth s spots (<5%) oval pale retinal Vasculitis

lesions surrounded by hemorrhage

Streptococcus

Janeway lesion

Osler nodul and Janeway lesion

Splinter hemorrhage

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Clinical features
Symptoms of IE starts within 2 weeks of
precipitating bacteremia
Malaise, night sweats, weight loss with
organism of low pathogenicity (viridans
streptococci)
Explosive onset with organims of high
pathogenicity ( Staphylococcus aureus)
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Symptoms
Fever

In almost all patients

Heart murmurs (new)

Up 99%

Splenomegaly

30 %

Petechiae, (Osler nodes, Janeway

etc.)

20-40%

Musculoskeletal complaints

Arthralgias, arthitis

Pulmonary emboli

In tricuspid valve IE

Clubbing

Duration longer than 6 weeks

Neurological( headache)

Brain abscesses,meningitis,arteritis

Congestive heart failure

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Renal disease

Nephritis 80%,infarction-50%,absc.

Diagnostic criteria (Duke)

Certain:
pathological criteria: surgical or autopsy findings,
clinical criteria: 2 major, 1 major+3 minor,
5 minor criteria

Possible: hemoculture positivity+ new heart

murmur, or known valve disease+vasculitis
Not possible: recovery in 4 days, negative
surgical, or autopsy findings
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Diagnostic criteria (Duke)

1.
2.
3.

1.
2.
3.
4.
5.
6.

Major:
positive hemoculture ( typical agent and 2 tests positivity)
positive echocardiography (vegetation, abscess)
new regurgitation murmur
Minor:
predisposing heart disease
fever
vascular symptoms
immune phenomenons
echocardiographically possible, but not certain
microbiologically possible, but not certain

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Differential diagnosis
Missleading clinical presentations:
Young adult with stroke
Adult with confusion( but fever, murmur)
Blood cultures are negative:
Acute rheumatic fever
Multiple pulm. embolism
Atrial myxoma
SLE-Libman Sacks endocarditis
malignancy
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Indications of TEE in IE
1.Suspected prosthetic valve IE
2.Suspected native valve IE, but TTE is
uncertain, or certain, but patient has high
risk (large vegetation)

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Syndromes suggesting specific

bacteria causing IE
Indolent course:
viridans streptococci, streptococcus bovis (colon cc),
Streptococcus faecalis

Aggressive course:
staphylococcus aureus, str. pneumoniae, str.pyogenes,
neisseria gonorrhoea

Drug users:
staphylo.aureus, pseudomonas, candida

Frequent major emboli:

haemophilus sp., bacterioides sp, Candida sp.
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Native valve endocarditis

Most people (60-80%) have an identifiable
predisposing cardiac lesion
Rheumatic heart disease
Congenital heart disease (bicuspic aortic valve, M
valve prolapse with regurg., HOCM, Marfane with
AI)
Aortic sclerosis, calcified mitral anulus,
ventricular aneurysms
Diabetes mell-accel.artscler+infections
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Native valve endocarditis/

Microbiology
Streptococci (50-70%) cure rate 90%
Enterococci (10%)
cure rate 75-90%
Staphylococci (25%) cure rate 60-70%

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Native valve endocarditis/mortality

30%
Poorer prognosis
Old or very young
Aortic, versus mitral valve
Left sided versus right sided
Large vegetations (more than 10mm)
Delay of diagnosis
Staphylococcus
Enterococci (10%)
cure rate 75-90%
Staphylococci (25%) cure rate 60-70%
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Prostetic valve endocarditis/5-15%

of all IE cases
Cardiac valve
replacement

Early-<12month

Late->12month

Bacteria

Staph.epiderm.
Staph.aureus
diphteroids
75%

Strept.viridans

Vancomycin+
gentamycin(Ripha
mpicin)
Surgical treatment

Penicillin+
gentamycin

Mortality
Therapy

40%

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Endocarditis in iv drug abusers

Male/female ratio 3:1

Right sided predilection
Staphylococcal 60%, polymicroorganism 5%
Migratory pneumonia
(multiple septic pulm. emboli)

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IE in children
Rare 34/1 million inhab./year
Rheumatic heart disease, congenital heart
disease
Str viridans

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Therapy
Early antibiotic treatment with bactericid
AB
Duration of iv treatment 4-6 weeks
No anticoagulation (but in prosthetic valve
cases it is necessary)
No steroid

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Empiric therapy
Native valve endocarditis
4x3gr Ampicillin/sulbactam or
A/clavulanate
with 3mg/kg/die Gentamycin
Ampicillin intolerance:
30mg/kg/die Vancomycin+ Gentamycin +
Ciprofloxacine (800mg/die iv)
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Empiric therapy
Early prostetic valve IE (< 12 month)
Vancomycin 6 weeks+Gentamycin (2
weeks) iv+ Rifampcin 1200mg/die pos(2
weeks)
Late prostetic valve IE (>12 month)
As in native IE

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Treatment
Streptococcus viridans-10-20 ME penicillin or
Ceftriaxon 2 gr/day
Enterococcal-Ampicillin 4x3gr/die +Gentamycin
1,5mg/kg/die
Staphylococcal-Oxacillin 12g/die+Gentamycin
Methicillin resistant species or at penicillin allergie
2x1gr Vancomycin+ Gentamycin/die

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Surgery
Absolute indications:
Refractory heart failure
Myocardial, paravalvular abscess
Ineffective therapy
Repeated relapses
Relative indications:multiple embolic
episodes
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Endocarditis profilaxis
recommended
Prosthetic cardiac valves
Previous IE
Congenital malformations
A. Cyanotic CHD without surgical correction, or
with residual defects, or palliative shunts
B.For 6 month after complete surgical repaire
C.After surgical correction with residual defects

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IE profilaxis is not recommended

Isolated sec. atrial septal defect
Surgical repair without residua beyond 6
month of ASD-II,VSD, or patent duct.art.
ACBG
Mitral valve prolapse without regurg.
Previous rheumatic fever without valvular
dysfunction
Cardiac pacemakers and impl. defibrillators
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IE profilaxis for patients undergoing dental or

upper resp. procedures
1 hour before the procedure 2 gr Amoxicillin
orally
Penicillin allergic patients: Clindamycin
600mg, or 500mg Claritromycin, or
Azitromycin orally

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B.A. 34 year old man

Case report 1.

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Past history
Patient 6 years old - tonsillectomie
Patient 8 years old - rheumatic fever ( migratory
ankle and knee arthritis, AST ) Penicillin
therapy for years
Patient 34 years old, when recurrent dentological
interventions were done
Two month after this intervention, 3 weeks before
admission, he got

weekness,
afternoons fever,
arthralgias,
recurrent transient visual loss.

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Physical examination

Pale, maculopapular rash on the chest

No lymph node enlargement
No pulmonary abnormalities
Diastolic murmur in the II.III. right intercostal
space
Pulse 96/min ,RR 130/60
Negative abdomen
Fever: 38,5
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Lab values
Urin sediment: 40-50 rbc, 4-5wbc
Sediment rate 90mm/h Ht 0,34 HB 9,5 wbc
10000 Se 83% Se protein 73 ELFO
gammaglob 21% IC, RF negative
ECG: Sinus tachycardia QRS left deviation.

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Imagine methods

Chest X-ray:neg
Abd. US: cystae renis.l.u.
Fundus: neg.
Cardiac US: bicusp. aortic valve with
vegetation, AI-III.
TEE: large, moblie vegetation, with cusp
fenestration
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TTE

37

Therapy
Hemocultures (nutritionally varinat Streptococcus,
sensitive to Penicillin, gentamycin)
Penicillin 4x5M unit/day + Tobramycin
160mg/day
Constant fever.
Cardiac surgery: arteficial aortic valve
implantation.
After 12 years patient has no complaines, he is a
dancer, can work without problems.
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D.T-59 year old man

Case report 2.

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Past history
Tonsillectomie in his childhood.
In 1994, in his age 59, in March 3 days fever without any
concomittant symptoms
In April: transient dizziness and double-vision. Neurological,
ophtalmological and rheumatological examinations were performed.
Dg. Spondylosos cerv.
In May: sudden left leg spasm-pain
Phys. examination:out of soft aortic systolic murmur, normal.
Lab values: normal sed. rate, urin, blood smear
Imagine methods: chest Xray, arterial and venous Doppler, carotis
Doppler negative
Dg.Myalgia cruris
He travelled to the USA, where he got fever and cough
In June: admission to our hospital because of 3 weeks fever and
weakness
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Results and history

Physical: pale, pulmonary rales, loud diastolic murmur above the aorta.
2cm liver enlargement. Temp: 37,1
Lab: Sed.rate 60mm/h Ht 0,36 wbc 9,9 IC positive
Chest X ray: pulmonary congestion
TTE: vegetation on the aortic valve, AI-II-III
TEE: bicuspid aotic valve, 9mm large veg on it.
Hemoculture (was negative)
Therapy 20Me penicillin-160mg Tobramycine
After 2 weeks of therapy recurrent fever-TTE control: vegetation
became larger
Surgery: artefic. valve implanation.
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J.L. 82 year old man

Case report 3.

42

History
Treated because of NHL in Central Institute
of Oncology.
For 4 weeks he has had fever. No
explanation of it was found. Weekness,
dyspnoe at 20 m walk.
TTE was requested.

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TTE

44

Results and history

Physical: pale, no lymph nodes, Loud systolic
murmur at the apex, radiated to the axillary line.
Palpable spleen.
Lab: CRP 58 Ht 0,28 wbc 2,8 Se 78% Urin sed.
Neg.
Hemoculture neg
Augmentin, later Imipenem therapy for 5 weeksno fever, no dyspnoe.
TEE controll: no vegetation on mitral valve.
MI-III. Good left ventricular function.
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P.A. 44 year old woman

Case report 4.

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History
No previous illness
In 2008.Aug. she got fever and chills.
Because of cough and dyspnoe she was admitted
to the Institute of Pulmonolgy.
Physical examination : systolic murmur at the
apex, diastolic murmur above the aorta was heard
Chest X ray showed pneumonia
TTE: showed aortic and mitral valve vegetations
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TEE

48

Results and history

Hemoculture was positive
(staphylococcus aureus)

Vancomycin therapy started

Because hemodinamic insufficiency aortic
and mitral arteficial valve was implanted.
5 weeks post op. antibiotic therapy.
CRP normal, patient is well.
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SZ-M 65 year old man

Case report 5.

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Past history
5 years ago working in Cyprus has had a severe
pneumonia. Since he has been weak, and has had
dyspnoe at exertion.He has been treated with
bronchodilatators on Pulmonology, with the
diagnosis of COPD.
In Dec. 2006. CLL and AIHA was diagnosed.
Medrol and Cytoxan therapy have induced
complet remission.
Present therapy: Symbicort, Spiriva, Berodual,
Verospiron, Lokren, Medrol, Cytoxan
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Complaines
On 15. January 2007. he got chest pain,
radiating to the right shoulder, the pain
increased with breathing. He got fever 40 C,
with cough and dyspnoe.
Physical examination showed diffuse
pulmonary wheezels. Diminished heart
sounds. Blood pressure 150/70 , pulse rate
100/min. Palpable spleen.
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Examinations
Labor: Ht 0,31 wbc 13,950 thrcyta 80 000 Ly 78%
DDimer 2,2 SGOT 76 GPT 90 LDH 340 SAP 58
CRP 135
pO2 68 pCO2 27 O2 sat 96% with oxygen
Pulmonary scintigraphy: Multiple segmental,
bilateral perfusion defects.
Chest X ray: negative
TTE: for the detection of acute right heart
enlargement and pulmonary hypertension
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Echocardiography/ the surprise

TTE:10mm vegetation on the noncoron
cusp of the aortic valve. A vegetation on the
septal cusp of the mitral valve. AI-I. MI-II.
Pulm systolic pressure 36HGmm
TEE: Aortic, and mitral valve vegetation.
Normal pulmonary and tricuspid valves.

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55

History
Hemoculture: Enterococcus sp.
Therapy:4x3gr Ampicillin 3x80mg
gentamycin.
No fever after 2 weeks , CRP 25,9

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V.Cs. 27 year old women

Case report 6.

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Anamnesis.
Marfan sy, 2 years ago luxatio lentis( Her
mother had Marfan sy)
On the 18.07.2006. Mitral valve and aortic
valve and aorta asc. conduit,biological was
performed.
Since 2 days, chills and fever 38-40 C. No
cough, no dyspnoe, no dysuria.
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Physical examination:
Tall stature, arachnodactyly, joint
hyperflexibility, ectopia lentis. 1/6 systolic
murmur p.max at the aortic region. Blood
pressure100/70 P 88/min

59

Labor
We: 14 CRP 37 -26-28 Ht 0,33 thrcyta 96 wbc
4004 SGOT 103 GPT 121 Urine sediment:15-20
wbc
Next day: CRP 43 SGOT 94 GPT 137
Hemoculture
Chest Xray: neg.
Abdominal US: negative
TTE: aortic non coron cusp is thicker. Small AI.
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History

Every day chills and fever

TEE no vegetation was found.
One week later procalcitonin 20,3
wbc 11 000 CRP 132
TEE :vegetation on the aortic valve and on
the septal cusp of the mitral valve, the
suspition of a paravalvular abscess.
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V.Cs. 29 years old female

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History
Early prosthetic valve endocarditis?
Therapy: Vancomycin-Gentamycin
wbc 8,7 procalcitonin 10,3 CRP 63, but
fever on every day
Hemoculture:haemophilus parainfluenzae
Therapy: 2 gr Ceftriaxone
Fever on every day: 2x2 gr
Ceftriaxone/day
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History
01.20-26 . Continous fever during this
therapy.
Abdominal US: abscess?- negative
TTE. The mitral vegetation disappeared, but
the aortic valve vegetation is the same.
Consultation with surgeon-operation is
possible only, if there is no inflammation.
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Present situation
From 26.01 no fever.
CRP 11 fvs 7,6
We are waiting for complete
remission(calcification of the vegetation)
(Operation has a very high risk)

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A patient with migratory

pneumonia
Lvia Jnoskuti
3rd Dept. of Medicine Semmelweis
University
Budapest, Hungary
66

History 1
65 year old woman,
with hypertension and diabetes mellitus type 2.
Recurrent urinary tract infections for 3 years
In February 2005
she got acute renal failure during acute pyelonephritis,
hemodialysis was performed
At the end of March 2005
hemodialysis was stopped because
patients renal function has normalized
In summer 2005
recurrent short fevers, due to urinary tract infections,
which were treated by antibiotics
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History 2
In September 2005
fever, right sided pneumonia, hydrothorax
(bacteriology negative)
In November 2005
fever, left sided pneumonia, hydrothorax,
later spleen abscess
blood culture positive: Enterococcus faecalis
After splenectomy, and 4 weeks Clindamycinamoxicillin therapy;
patients condition stabilized, became free of fever
68

Question
What is the pathomechanism of the
migratory pneumonias and the splenic
abscess?
1. Urosepsis
2. Right sided endocarditis and sepsis
3. Left sided endocarditis and sepsis

69

TEE on 22. December 2005.

Aortic , mitral and pulmonary valves are normal
Tricuspid valve endocarditis was detected
On the lateral cusp
echodens 1,5 cm large mobile vegetation
On the septal cusp
echodens 0,5 cm large mobile vegetation

No PFO
TI III. Pulmonary systolic pressure 35Hgmm

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TEE dec.22.

71

TEE dec.22.

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History 3
After 8 weeks of AB therapy in January 2006
No change on TEE control
Calcified vegetations on the tricuspid valves
No embolic phenomenons
No inflammatory labor signs
Consultant heart surgeon suggested observation
Control on April 2006
No fever
Because of TI III-IV, diuretic therapy was
intensified

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New risk factors of IE

IV. Drug abusers

Intensive care settings
Hemodialysis
Elderly age
Degenerative valve diseases
Cirrhosis hepatis, diabetes mellitus
Skin infections
Gastrointestinal tumors
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Endocarditis of tricuspid valve

Clinical characteristics: migratory pneumonias
Frequent among iv drug abusers.
Incidence 2-5% per year ( tricuspid valve is the most frequently
affected (60-70%),followed by the mitral and aortic valves( 20-30%)

The most common etiological agent is

Staphylococcus aureus, being usually sensitive to methicillin

The prognosis of right side IE is generally good,

Overall mortality is <5%, and with surgery <2%

Mortality of HIVinfected iv drug abusers is higher

one year survival 65%, 5 year survival 35%.
Miro J.M. Cardiology Clinics 21 (2) 164-84 2003.
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Infectious tricuspid valve endocarditis in a

chronic hemodialysis patient
67-year old male with chr. Renal failure, complained of
fever up to 38 degrees C after hemodialysis.
Blood culture negative, CRP high
TEE:13x25 mm large vegetation on the tricuspid valve
He got a bioprosthetic valve
Extensive vegetation was found in each cusps of the
tricuspid valve.
9 month after surgery; no signs of reccurence were
obsereved
Yoshida Japanese Journal of Thoracic Surgery 59(3):235-7 2006.
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Message
Think of right sided endocarditis in the case of
migratory pneumonia.
By effective and ongoing therapy, further
complications may be prevented and the
illness may be cured.

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