Infective EndocarditisInfective Endocarditis

Goals for TodayGoals for Today

Recognize the risk factors, signs, and Recognize the risk factors, signs, and symptoms of infectious endocarditis.symptoms of infectious endocarditis.Understand the many approaches to Understand the many approaches to diagnosing infectious endocarditis.diagnosing infectious endocarditis.Appreciate the necessity of rapid treatment.Appreciate the necessity of rapid treatment.Anticipate possible complications.Anticipate possible complications.Bring it all together with an actual patient Bring it all together with an actual patient case!case!

DefinitionDefinition

Infectious Endocarditis (IE):Infectious Endocarditis (IE): an infection of an infection of the heart’s endocardial surfacethe heart’s endocardial surface

Classified into Classified into fourfour groups: groups: – Native Valve IENative Valve IE– Prosthetic Valve IEProsthetic Valve IE– Intravenous drug abuse (IVDA) IEIntravenous drug abuse (IVDA) IE– Nosocomial IENosocomial IE

Further ClassificationFurther Classification

AcuteAcute– Affects normal heart Affects normal heart

valvesvalves– Rapidly destructiveRapidly destructive– Metastatic fociMetastatic foci– Commonly Staph.Commonly Staph.– If not treated, usually If not treated, usually

fatal within 6 weeksfatal within 6 weeks

SubacuteSubacute– Often affects damaged Often affects damaged

heart valvesheart valves– Indolent natureIndolent nature– If not treated, usually If not treated, usually

fatal by one yearfatal by one year

PathophysiologyPathophysiology

1.1. Turbulent blood flow Turbulent blood flow disrupts the disrupts the endocardium making it “sticky”endocardium making it “sticky”

2.2. Bacteremia Bacteremia delivers the organisms to delivers the organisms to the endocardial surface the endocardial surface

3.3. AdherenceAdherence of the organisms to the of the organisms to the endocardial surfaceendocardial surface

4.4. Eventual invasionEventual invasion of the valvular of the valvular leafletsleaflets

EpidemiologyEpidemiology

Incidence difficult to ascertain and varies Incidence difficult to ascertain and varies according to locationaccording to location

Much more common in males than in Much more common in males than in femalesfemales

May occur in persons of any age and May occur in persons of any age and increasingly common in elderlyincreasingly common in elderly

Mortality ranges from 20-30%Mortality ranges from 20-30%

Risk FactorsRisk Factors

Intravenous drug abuseIntravenous drug abuse

Artificial heart valves and pacemakers Artificial heart valves and pacemakers

Acquired heart defectsAcquired heart defects– Calcific aortic stenosisCalcific aortic stenosis– Mitral valve prolapse with regurgitationMitral valve prolapse with regurgitation

Congenital heart defectsCongenital heart defects

Intravascular cathetersIntravascular catheters

Infecting OrganismsInfecting Organisms

Common bacteriaCommon bacteria– S. aureusS. aureus– Streptococci Streptococci – EnterococciEnterococci

Not so common bacteriaNot so common bacteria– FungiFungi– PseudomonasPseudomonas– HACEKHACEK

SymptomsSymptoms

AcuteAcute– High grade fever and High grade fever and

chillschills– SOBSOB– Arthralgias/ myalgiasArthralgias/ myalgias– Abdominal painAbdominal pain– Pleuritic chest painPleuritic chest pain– Back painBack pain

SubacuteSubacute– Low grade feverLow grade fever– AnorexiaAnorexia– Weight lossWeight loss– FatigueFatigue– Arthralgias/ myalgiasArthralgias/ myalgias– Abdominal painAbdominal pain– N/VN/V

The onset of symptoms is usually ~2 weeks or less from the initiating bacteremia

SignsSignsFever Fever

Heart murmurHeart murmur

Nonspecific signs – petechiae, subungal or Nonspecific signs – petechiae, subungal or “splinter” hemorrhages, clubbing, “splinter” hemorrhages, clubbing, splenomegaly, neurologic changessplenomegaly, neurologic changes

More specific signs - Osler’s Nodes, More specific signs - Osler’s Nodes, Janeway lesions, and Roth SpotsJaneway lesions, and Roth Spots

PetechiaePetechiae

Photo credit, Josh Fierer, M.D. medicine.ucsd.edu/clinicalimg/ Eye-Petechiae.html

Harden Library for the Health Scienceswww.lib.uiowa.edu/ hardin/md/cdc/3184.html

1. Nonspecific2. Often located on extremities

or mucous membranes

dermatology.about.com/.../ blpetechiaephoto.htm

Splinter HemorrhagesSplinter Hemorrhages

1. Nonspecific2. Nonblanching3. Linear reddish-brown lesions found under the nail bed4. Usually do NOT extend the entire length of the nail

Osler’s NodesOsler’s Nodes

1. More specific2. Painful and erythematous nodules3. Located on pulp of fingers and toes4. More common in subacute IE

American College of Rheumatologywebrheum.bham.ac.uk/.../ default/pages/3b5.htm www.meddean.luc.edu/.../

Hand10/Hand10dx.html

Janeway LesionsJaneway Lesions

1. More specific2. Erythematous, blanching macules 3. Nonpainful4. Located on palms and soles

TheThe EssentialEssential Blood TestBlood Test

Blood CulturesBlood Cultures– Minimum of three blood culturesMinimum of three blood cultures11

– Three separate venipuncture sitesThree separate venipuncture sites– Obtain 10-20mL in adults and 0.5-5mL in childrenObtain 10-20mL in adults and 0.5-5mL in children22

Positive ResultPositive ResultTypical organisms present in at least Typical organisms present in at least 22 separate samples separate samples

– Persistently positive blood culture (atypical organisms)Persistently positive blood culture (atypical organisms)• Two positive blood cultures obtained at least 12 hours apartTwo positive blood cultures obtained at least 12 hours apart• Three or a more positive blood cultures in which the first and last Three or a more positive blood cultures in which the first and last

samples were collected at least one hour apartsamples were collected at least one hour apart

Additional LabsAdditional Labs

CBCCBC

ESR and CRPESR and CRP

Complement levels (C3, C4, CH50)Complement levels (C3, C4, CH50)

RFRF

UrinalysisUrinalysis

Baseline chemistries and coagsBaseline chemistries and coags

ImagingImaging

Chest x-ray Chest x-ray – Look for multiple focal infiltrates and Look for multiple focal infiltrates and

calcification of heart valvescalcification of heart valves

EKGEKG– Rarely diagnosticRarely diagnostic– Look for evidence of ischemia, conduction Look for evidence of ischemia, conduction

delay, and arrhythmiasdelay, and arrhythmias

EchocardiographyEchocardiography

Indications for EchocardiographyIndications for Echocardiography

Transthoracic echocardiography (TTE)Transthoracic echocardiography (TTE)– First line if suspected IEFirst line if suspected IE– Native valvesNative valves

Transesophageal echocardiography (TEE)Transesophageal echocardiography (TEE)– Prosthetic valvesProsthetic valves– Intracardiac complicationsIntracardiac complications– Inadequate TTE Inadequate TTE – Fungal or S. aureus or bacteremiaFungal or S. aureus or bacteremia

Making the DiagnosisMaking the Diagnosis

Pelletier and Petersdorf criteriaPelletier and Petersdorf criteria (1977) (1977)–Classification scheme of definite, probable, and possible IEClassification scheme of definite, probable, and possible IE–Reasonably specific but lacked sensitivityReasonably specific but lacked sensitivity

Von Reyn criteriaVon Reyn criteria (1981) (1981)–Added “rejected” as a categoryAdded “rejected” as a category–Added more clinical criteriaAdded more clinical criteria– Improved specificity and clinical utilityImproved specificity and clinical utility

Duke criteriaDuke criteria (1994) (1994)– Included the role of echocardiography in diagnosisIncluded the role of echocardiography in diagnosis–Added IVDA as a “predisposing heart condition”Added IVDA as a “predisposing heart condition”

Modified Duke CriteriaModified Duke Criteria

Definite IEDefinite IE– Microorganism (via culture or histology) in a valvular vegetation, Microorganism (via culture or histology) in a valvular vegetation,

embolized vegetation, or intracardiac abscessembolized vegetation, or intracardiac abscess– Histologic evidence of vegetation or intracardiac abscessHistologic evidence of vegetation or intracardiac abscess

Possible IEPossible IE– 2 major2 major– 1 major and 3 minor1 major and 3 minor– 5 minor5 minor

Rejected IERejected IE– Resolution of illness with four days or less of antibioticsResolution of illness with four days or less of antibiotics

TreatmentTreatment

Parenteral antibioticsParenteral antibiotics– High serum concentrations to penetrate High serum concentrations to penetrate

vegetationsvegetations– Prolonged treatment to kill dormant bacteria Prolonged treatment to kill dormant bacteria

clustered in vegetationsclustered in vegetations

SurgerySurgery– Intracardiac complicationsIntracardiac complications

Surveillance blood culturesSurveillance blood cultures

ComplicationsComplications

Four etiologiesFour etiologies– EmbolicEmbolic– Local spread of infectionLocal spread of infection– Metastatic spread of infectionMetastatic spread of infection– Formation of immune complexes – Formation of immune complexes –

glomerulonephritis and arthritisglomerulonephritis and arthritis

Embolic ComplicationsEmbolic Complications

Occur in up to 40% of patients with IEOccur in up to 40% of patients with IE

Predictors of embolizationPredictors of embolization– Size of vegetationSize of vegetation– Left-sided vegetationsLeft-sided vegetations– Fungal pathogens, S. aureus, and Strep. BovisFungal pathogens, S. aureus, and Strep. Bovis

Incidence decreases significantly after Incidence decreases significantly after initiation of effective antibioticsinitiation of effective antibiotics

Embolic ComplicationsEmbolic Complications

StrokeStroke

Myocardial InfarctionMyocardial Infarction– Fragments of valvular vegetation or vegetation-Fragments of valvular vegetation or vegetation-

induced stenosis of coronary ostiainduced stenosis of coronary ostia

Ischemic limbsIschemic limbs

Hypoxia from pulmonary emboliHypoxia from pulmonary emboli

Abdominal pain (splenic or renal infarction) Abdominal pain (splenic or renal infarction)

Septic Pulmonary EmboliSeptic Pulmonary Emboli

http://www.emedicine.com/emerg/topic164.htm

Septic Retinal EmbolusSeptic Retinal Embolus

Local Spread of InfectionLocal Spread of Infection

Heart failureHeart failure– Extensive valvular damageExtensive valvular damage

Paravalvular abscessParavalvular abscess (30-40%) (30-40%)– Most common in aortic valve, IVDA, and S. aureusMost common in aortic valve, IVDA, and S. aureus– May extend into adjacent conduction tissue causing May extend into adjacent conduction tissue causing

arrythmiasarrythmias– Higher rates of embolization and mortalityHigher rates of embolization and mortality

PericarditisPericarditis

Fistulous intracardiac connectionsFistulous intracardiac connections

Local Spread of InfectionLocal Spread of Infection

Acute S. aureus IE with perforation of the aortic valve and aortic valve vegetations.

Acute S. aureus IE with mitral valve ring abscess extending into myocardium.

Metastatic Spread of InfectionMetastatic Spread of Infection

Metastatic abscess Metastatic abscess – Kidneys, spleen, brain, soft tissuesKidneys, spleen, brain, soft tissues

Meningitis and/or encephalitisMeningitis and/or encephalitis

Vertebral osteomyelitisVertebral osteomyelitis

Septic arthritisSeptic arthritis

Poor Prognostic FactorsPoor Prognostic Factors

FemaleFemale

S. aureusS. aureus

Vegetation sizeVegetation size

Aortic valve Aortic valve

Prosthetic valveProsthetic valve

Older ageOlder age

Diabetes mellitusDiabetes mellitus

Low serum albumen Low serum albumen

Apache II scoreApache II score

Heart failureHeart failure

Paravalvular abscessParavalvular abscess

Embolic eventsEmbolic events

What do these patients What do these patients have in common?have in common?

Pt. A:Pt. A: 65 y/o female with PMH of 65 y/o female with PMH of esophageal cancer who presents to clinic esophageal cancer who presents to clinic with deyhdration, cough, SOB, and with deyhdration, cough, SOB, and “oozing” near her mediport site.“oozing” near her mediport site.

Pt. B:Pt. B: 30 y/o male IVDA with a several 30 y/o male IVDA with a several weeks of fatigue and low grade fevers.weeks of fatigue and low grade fevers.

Pt. C:Pt. C: 24 y/o female IVDA with severe 24 y/o female IVDA with severe N/V/abd pain and fevers up to 104 for two N/V/abd pain and fevers up to 104 for two weeks. Pt also c/o cough with DOE. weeks. Pt also c/o cough with DOE.

All these patients have All these patients have MRSA endocarditis!MRSA endocarditis!

Patients A, B, and CPatients A, B, and C

Try to classify each patient’s IE.Try to classify each patient’s IE.

Which of these patients likely has acute IE? Which of these patients likely has acute IE? Which has subacute IE? Which has subacute IE?

What was the likely etiology of each What was the likely etiology of each patient’s bacteremia?patient’s bacteremia?

Patient C: Patient C: HistoryHistory

2 wks of high fever, cough, green sputum, and 2 wks of high fever, cough, green sputum, and DOE.DOE.2 wks of N/V (5x/day), diarrhea (20x/day), and 2 wks of N/V (5x/day), diarrhea (20x/day), and diffuse abdominal pain.diffuse abdominal pain.Diagnosed with PNA after a (-) LP and (+) Diagnosed with PNA after a (-) LP and (+) CXR and an outside ER. Given PO abx but CXR and an outside ER. Given PO abx but didn’t fill Rx.didn’t fill Rx.Last IVDA 3 wks ago.Last IVDA 3 wks ago.

Patient C:Patient C: HistoryHistory

Which symptoms does Patient C have that Which symptoms does Patient C have that suggest IE?suggest IE?

Does Patient C have any symptoms you Does Patient C have any symptoms you can’t explain?can’t explain?

Patient C:Patient C: ExamExam

Vitals: TVitals: T 104.7, BP 100/50, HR 130, RR 48, 94% on 104.7, BP 100/50, HR 130, RR 48, 94% on 3L FM3L FMPale, distressedPale, distressedPetechia to palate, dry mucus membranesPetechia to palate, dry mucus membranes2/6 SEM at 42/6 SEM at 4thth intercostal space with radiation to intercostal space with radiation to axillaaxillaDiffuse wheezing and cracklesDiffuse wheezing and cracklesDiffuse abdominal pain and right flank pain without Diffuse abdominal pain and right flank pain without rebound or guardingrebound or guardingMultiple track marks, otherwise neg. skin examMultiple track marks, otherwise neg. skin exam

Patient C:Patient C: ExamExam

Which signs does Patient C exhibit that Which signs does Patient C exhibit that suggest IE?suggest IE?

Does Patient C have any signs you can’t Does Patient C have any signs you can’t explain?explain?

Patient C:Patient C: LabsLabs

WBC 20, H/H of 9/27, Platelets 66WBC 20, H/H of 9/27, Platelets 66

pH 7.45, pOpH 7.45, pO22 54, pCO 54, pCO22 27 27Albumen 1.7Albumen 1.7UA: 2+ protein,3+ bloodUA: 2+ protein,3+ bloodEKG: WNL except sinus tachycardiaEKG: WNL except sinus tachycardiaCXR: enlarged right heart, bilateral infiltrates with CXR: enlarged right heart, bilateral infiltrates with nodularitynodularityChest CT: multiple pulmonary abscessesChest CT: multiple pulmonary abscesses

Patient C:Patient C: LabsLabs

Can you explain these results?Can you explain these results?

Are there other lab values you would like to Are there other lab values you would like to know?know?

Patient C: Patient C: DiagnosisDiagnosis

Blood CxBlood Cx: three out of three bottles grew MRSA.: three out of three bottles grew MRSA.

Initial TTEInitial TTE: tricuspid valve not well visualized but : tricuspid valve not well visualized but severe regurg.severe regurg. with PA systolic pressure of with PA systolic pressure of 55 55 mmHg.mmHg.

Repeat TTE (~2 wks after coding!)Repeat TTE (~2 wks after coding!): : oscillating oscillating massmass on at least two leaflets of tricuspid valveon at least two leaflets of tricuspid valve that that prolapse into R atrium during systole as well as prolapse into R atrium during systole as well as thickened pulmonary valvethickened pulmonary valve with possible with possible vegetation.vegetation.

Patient C:Patient C: DiagnosisDiagnosis

What major Duke criteria does Patient C What major Duke criteria does Patient C meet? meet?

What minor Duke criteria does Patient C What minor Duke criteria does Patient C meet?meet?

Patient C:Patient C: TodayToday

s/p chest tube with removals/p chest tube with removal2 separate episodes of respiratory failure with intubation 2 separate episodes of respiratory failure with intubation (now extubated)(now extubated)1 episode of V. fib with cardioversion and a lidocaine gtt. 1 episode of V. fib with cardioversion and a lidocaine gtt. (now weaned off after 1 episode of lidocaine toxicity)(now weaned off after 1 episode of lidocaine toxicity)CT surgery evaluated the pt and felt she wasn’t a surgical CT surgery evaluated the pt and felt she wasn’t a surgical candidate. candidate. She is currently still requiring 3L oxygen and c/o N/V and She is currently still requiring 3L oxygen and c/o N/V and SOB on telemetry.SOB on telemetry.

SummarySummary

IVDA and the elderly are at greatest risk of developing IVDA and the elderly are at greatest risk of developing IE.IE.The signs and symptoms of IE are nonspecific and The signs and symptoms of IE are nonspecific and varied.varied.A thorough but timely evaluation (including serial blood A thorough but timely evaluation (including serial blood cultures, adjunct labs, and an echo) is crucial to cultures, adjunct labs, and an echo) is crucial to accurately diagnose and treat IE.accurately diagnose and treat IE.Beware of life-threatening complications.Beware of life-threatening complications.