Infective endocarditis: the features of its clinical course and the prognosis

The paper covers an investigation of 150 patients with infective endocarditis (IE), including 100 patients (aged 18 to 30 years old) with intravenous drug abuse as the main risk factor. This subgroup is characterized by an acute clinical course of IE, with tricuspid valve disorder in most cases and septic pulmonary embolism relapse in 72% of cases. Heart failure, multiple cardiac valvular disorder and focal lung destruction were found to be the main factors of unfavorable outcome. A relation between the size of vegetation on the heart valves and the mortality rate was established. At the same time, secondary immunodeficiency due to HIV-infection had no significant effect on the mortality rate in the group of drug addicts. More frequent cases of heart failure with systemic circulation embolism lead to higher hospital mortality in the group of patients with a subacute clinical course of IE. In elderly patients other concomitant pathology resulted in late IE detection and a high mortality rate.     

Infective endocarditis in the Western Cape Province of South Africa: a three-year prospective study

BACKGROUND: The last 50 years have seen major changes in the epidemiology of infective endocarditis (IE). AIM: To evaluate local patient characteristics, risk factors, clinical sequelae, microbiology, morbidity and mortality in patients with definite IE. DESIGN: Prospective observational study. METHODS: Over a three-year period, patients referred with probable IE were prospectively enrolled. All received a standardized diagnostic evaluation. Epidemiological data were documented; underlying risk factors for IE were sought. Initial evaluation and follow-up (to 6 months) included the documentation of vascular or immunological phenomena, morbidity and mortality. RESULTS: Of 92 patients referred with probable IE, 47 had definite IE. These patients had a mean age of 37.7 years with a male predominance (1.6:1). Rheumatic heart disease was present in 36 (76.6%). Eight had prosthetic valves. Three had congenital heart disease, mitral valve prolapse or multiple central intravascular catheters, respectively. All denied the use of intravenous recreational drugs and only one tested seropositive for HIV. Renal involvement (59.6%) and clubbing (29.8%) were commonly observed. The 6-month mortality rate was 35.6%, while 44.7% needed valvular replacement. An aetiological diagnosis was made in 21, with viridans streptococci the most common isolate. DISCUSSION: Infective endocarditis in the Western Cape of South Africa is a disease of younger adults, with a male predominance. Rheumatic heart disease is the major predisposing factor. Degenerative heart disease and intravenous drug abuse are not important risk factors. Our data do not support the notion that HIV infection is an independent risk factor for IE. Local mortality rates are much higher than recent international figures, as is the proportion of 'culture-negative' IE.     

Pregnancy and Postpartum Infective Endocarditis: A Systematic Review

The objective of this review was to describe the clinical characteristics, risk factors, and outcomes of infective endocarditis (IE) in pregnancy and the postpartum period. We conducted a systematic review of Ovid MEDLINE, Ovid Embase, Web of Science, and Scopus from January 1, 1988, through October 31, 2012. Included studies reported on women who met the modified Duke criteria for the diagnosis of IE and were pregnant or postpartum. We included 72 studies that described 90 cases of peripartum IE, mostly affecting native valves (92%). Risk factors associated with IE included intravenous drug use (14%), congenital heart disease (12%), and rheumatic heart disease (12%). The most common pathogens were streptococcal (43%) and staphylococcal (26%) species. Septic pulmonary, central, and other systemic emboli were common complications. Of the 51 pregnancies, there were 41 (80%) deliveries with survival to discharge, 7 (14%) fetal deaths, 1 (2%) medical termination of pregnancy, and 2 (4%) with unknown status. Maternal mortality was 11%. Infective endocarditis is a rare, life-threatening infection in pregnancy. Risk factors are changing with a marked decrease in rheumatic heart disease and an increase in intravenous drug use. The cases reported in the literature were commonly due to streptococcal organisms, involved the right-sided valves, and were associated with intravenous drug use.     

Multisystem organ failure secondary to Haemophilus parainfluenzae infective endocarditis on an ICD lead: A case report

Infection of implanted cardiac devices (ICD) is an unusual but life threatening event, rarely caused by Haemophilus parainfluenzae. While clinical presentation varies widely, infective endocarditis (IE) involving an ICD lead requires aggressive resuscitation and a multidisciplinary approach. We present a case of a 33-year-old intravenous drug user who presented in multisystem organ failure secondary to infective endocarditis on an ICD lead. This patient had a complicated hospital course requiring removal of her ICD, highlighting the dramatic presentation of this clinical state.     

Combination of Libman-Sacks endocarditis with infectious endocarditis

Out of 242 patients treated for systemic lupus erythematosus (SLE) in Novosibirsk for 15 years, valvular lesions and endocarditis were diagnosed in 41(16.9%) patients. Combination of Libman-Sax endocarditis (LSE) with infectious endocarditis (IE) was observed in three patients (two women, one man, age 18-40 year). SLE ran a subacute course in one woman, an acute one--in the other. LSE emerged early in SLE in two patients. All the patients had polyorganic lupus pathology, lupus nephritis with nephrotic syndrome (morphological class IV). Two patients had mitral valve disease, one patient--mitral-aortic disease. The rise of secondary IE was seen after massive immunosuppressive therapy. The diagnosis of secondary IE was made after SLE duration for 10-36 months. At IE diagnosis, all the patients had high titers of blood antiphospholipid antibodies. IE was of staphylococcal origin in two patients and candidosis-induced in one patient. In SLE with IE there was thromboembolic syndrome. LSE and IE have related aspects which should be regarded in clinical practice: possible "IE mask" in LSE, risk of secondary IE in about 10% of LSE patients, prophylactic measures necessary to prevent IE in hemodynamically prominent forms of LSE.     

A rare case of infected splenic hematoma

Splenic hematoma is a relatively benign condition in consideration that a majority are spontaneously absorbed. Rarely, they can become infected, a condition that is difficult to diagnose and is associated with significant morbidity and mortality if left untreated. We present a patient with a known history of intravenous drug abuse and recent abdominal trauma who was found to have infective endocarditis and subsequently an infected splenic hematoma. The related literature is also discussed.     

Survival of patients with infectious endocarditis in various treatment methods

The aim of the study was to compare survival of patients with infectious endocarditis (IE) by abuse of intravenous narcotic substances in conservative and combined treatment in acute IE phase. A total of 195 IE patients were examined. 121 of them was treated conservatively, 74 patients received a combined treatment including surgical one. A long-term prognosis was studied by the Kaplan-Meier method. Among drug addicts with IE, the number of survivors in the observation period in early operation in the active IE phase was significantly higher than in the conservative therapy. Long-term survival of drug addicts with IE in combined treatment was also higher: 1-2- and 3-year survival was 85.8, 76.3 and 61.0% against 64.8, 49.0 and 34.2% in conservative treatment, respectively. In non-addicts the differences were weaker: long-term survival in combined treatment was higher than in conservative one only in 5-year survival (74.1 and 41.6%, respectively).     

Infectious endocarditis in intravenous drug abusers

Clinical course of infectious endocarditis (IE) was analysed for 43 intravenous drug abusers. 42 of them had primary IE, one patient--secondary. Acute course and high activity of the disease were registered in 86% of the patients. IE was provoked by Staphylococcus aureus (50%), Staphylococcus epidermidis 920%), Staphylococcus haemolyticus (11%), E. coli (8%), Pseudomonas aeruginosa (2%), Candida albicans (2%), mixed microflora (7%). Vegetations were detected on the tricuspid, mitral and aortic valves (52, 23 and 19%, respectively), on more than one valve (6%). Pneumonia, pleuricy, hydrothorax, enlargement of the liver, spleen, nephritis and anemia were found in 76, 44, 9, 100, 75, 70 and 88% of the patients, respectively. Cardiac failure aggravated the disease in half of the patients, lethality was 18%. Thus, IE in intravenous drug abusers is characterized by a primary form, acute active course, prevalent damage to the tricuspid valve, polyorganic involvement, high lethality. IE cure in such patients is feasible only in adequate antibacterial therapy, timely surgical correction and giving up drug abuse.     

Appropriate use of echocardiography in managing Staphylococcus aureus bacteremia

Staphylococcus aureus bacteremia (SAB) is increasing, both in the community and in healthcare settings. Accurate and timely diagnosis of underlying infective endocarditis (IE) is critical for optimal management of SAB cases as it has significant management and prognostic implications. Reported prevalence of IE in patients with SAB varies depending on the study population, and ranges from 10 to 30%. As clinical presentation of IE can be nonspecific, echocardiography is usually recommended in SAB cases to 'rule out' IE. Due to its poor sensitivity (<50%), especially for diagnosing prosthetic valve IE, transthoracic echocardiography is considered inadequate in this setting and clinicians have to rely on transesophageal echocardiography (TEE) to confirm or exclude endocarditis in SAB cases. Although some experts recommend TEE in all patients presenting with SAB, it is believed that the use of TEE could be guided by individual patient risk factors, mode of acquisition of SAB and clinical presentation. In this article, published data regarding the use of TEE in the SAB population are reviewed and a simplified algorithm to guide use of TEE in SAB cases is proposed.     

Infectious endocarditis: An update for emergency clinicians

Introduction

Infectious endocarditis (IE) is a potentially deadly disease without therapy and can cause a wide number of findings and symptoms, often resembling a flu-like illness, which makes diagnosis difficult.

Appropriate use of echocardiography in managing Staphylococcus aureus bacteremia

Staphylococcus aureus bacteremia (SAB) is increasing, both in the community and in healthcare settings. Accurate and timely diagnosis of underlying infective endocarditis (IE) is critical for optimal management of SAB cases as it has significant management and prognostic implications. Reported prevalence of IE in patients with SAB varies depending on the study population, and ranges from 10 to 30%. As clinical presentation of IE can be nonspecific, echocardiography is usually recommended in SAB cases to ‘rule out’ IE. Due to its poor sensitivity (<50%), especially for diagnosing prosthetic valve IE, transthoracic echocardiography is considered inadequate in this setting and clinicians have to rely on transesophageal echocardiography (TEE) to confirm or exclude endocarditis in SAB cases. Although some experts recommend TEE in all patients presenting with SAB, it is believed that the use of TEE could be guided by individual patient risk factors, mode of acquisition of SAB and clinical presentation. In this article, published data regarding the use of TEE in the SAB population are reviewed and a simplified algorithm to guide use of TEE in SAB cases is proposed.     

Infective endocarditis complicated with cerebral and splenic infarction in a hemodialysis patient

BACKGROUND:

Infective endocarditis (IE) has a high risk of morbidity and mortality. Complications are often due to systemic embolization. We treated a 47-year-old hemodialysis man with infective endocarditis complicated with cerebral and splenic infarction.

METHODS:

The patient was brought to the emergency department because of altered mental status and fecal incontinence. Although he did not meet the Duke Criteria for IE diagnosis, clinical suspicions of IE warranted further diagnostic studies. Magnetic resonance imaging of the brain revealed cerebral infarction with abnormal neurological findings. An abdominal computerized tomography revealed an incidental and unexpected splenic infarction without physical findings. Echocardiography revealed a vegetative growth (−1.2×1 cm) over the mitral posterior leaflet with severe mitral valve regurgitation. Based on these results, the patient was diagnosed with IE complicated with severe cerebral and splenic infarction.

RESULTS:

The patient was treated with intravenous teicoplanin including gentamicin, subcutaneous low molecular weight heparin, and oral acetylsalicylic acid. Mitral valve replacement surgery was performed after the patient improved clinically.

CONCLUSION:

Emergency physicians should be aware of the life-threatening complications of IE, which may be presented subtly or without clinical evidence.KEY WORDS: Infective endocarditis, Cerebral infarction, Splenic infarction     

The course of infectious endocarditis in IV drug abusers and in subjects predisposed to heart diseases

40 patients with infective endocarditis (IE) abusing intravenous drugs (heroin, opium surrogates) and 9 IE patients predisposed to heart diseases were examined by Duke diagnostic criteria. IE in drug abusers is characterized by acute course of the disease with affection of the intact valves of the right heart (97.5%) and septicemia provoked by high-virulent microflora (Staph. aureus in 65%). Drug abusers showed the following principal clinical syndromes of IE: thromboembolic (65%); septic with formation of acute DIC syndrome (75%), development of pyodestructive foci in the organs and polyorganic insufficiency (23.3%); acute circulatory insufficiency (37.5%); secondary nephropathy (100%). In IE abusers with predisposition to heart diseases IE ran subacutely in the presence of bacteriemia caused by low-virulent microflora (Strept. viridans in 11%) or in the absence of microbial growth in blood seeding (78%). High IE lethality in drug abusers (40%) is explained both by severe complications and concomitant diseases (viral hepatitis B and C, HIV infection, etc.).     

Pleural effusions in right-sided endocarditis: characteristics and pathophysiology.

The incidence, characteristics, and pathogenesis of pleural effusions in patients with right-sided endocarditis (RSE) are poorly defined. We have recently observed four patients with a history of intravenous drug abuse and bacteremia due to Staphylococcus aureus who had pleural effusions during an episode of RSE. We report the pleural fluid characteristics of five effusions in these four patients and attempt to define the pathogenesis of each. We found that (1) an exudative, sterile, serosanguineous, or bloody effusion is common in RSE, (2) empyema occurred in only one patient, and (3) transudative effusions due to CHF were not observed. Possible mechanisms of pleural fluid formation in RSE include parapneumonic effusion, septic pulmonary emboli with or without infarction, and empyema. Congestive heart failure does not appear to be a common cause of pleural effusion in pure right-sided endocarditis.     

Multivalvular vegetations in a patient with enterococcal endocarditis diagnosed by echocardiography.

A patient with enterococcal endocarditis of 11 months' duration is presented, and the role of surgery and echocardiography is reviewed. Echocardiography revealed vegetations of the aortic and mitral valves. After appropriate antibiotic therapy the patient had successful aortic and mitral valve replacement with porcine heterografts. Enterococcal endocarditis is increasing in frequency and is likely to infect young women of childbearing age, elderly men who have had genitourinary tract manipulation, and abusers of intravenous drugs. Aortic and mitral valves are most frequently affected, cardiac failure is common, and often no evidence of underlying heart disease can be found. The use of echocardiography in this patient provided accurate diagnosis of valvular vegetations and assessment of the hemodynamic severity of the lesion, thus preventing the need for cardiac catheterization and its potential risk of septic embolization.     

Complexity and subtlety of infective endocarditis

Infective endocarditis (IE) is an uncommon clinical entity that, if unrecognized, leads to serious morbidity and mortality. Approximately 15,000 new cases of IE occur in the United States each year. Despite advances in early diagnosis, antimicrobial treatment, and surgical techniques, reported mortality from referral centers has changed little throughout several decades. Early recognition of IE requires understanding of its epidemiology, risk factors, clinical presentations, physical examination signs, microbiological associations, and electrocardiographic and chest radiographic findings. Once IE is suspected, further testing with blood cultures and echocardiography can confirm the diagnosis and lead to early treatment with bactericidal antibiotics and surgery when appropriate, thus reducing the morbidity and mortality of IE. Unrecognized and untreated, IE is invariably fatal. Early recognition of IE and an in-depth understanding of the clinical vagaries of IE are mandatory for all patient care providers.     

Cryptococcal endocarditis of native valves without immunodeficiency or drug abuse: a case report

Cryptococcal endocarditis has rarely been reported. Most patients with this condition are associated with risk factors, such as structural heart disease/valve replacement, immunodeficiency/immunosuppression or drug abuse. We report a case of cryptococcal endocarditis of the native valves without any risk factors. A 50-year-old Chinese man was admitted to hospital with fever for 1 month without any underlying heart disease, immunodeficiency, or drug use. He was diagnosed as having Cryptococcus neoformans infective endocarditis and was discharged after valve replacement surgery and long-term antifungal therapy.     

Infective endocarditis in intravenous drug users: does HIV status alter the presenting temperature and white blood cell count?

The intent of this study was to determine if HIV seropositivity alters the maximum temperature (T(max)) and WBC count of febrile intravenous (i.v.) drug users with infective endocarditis (IE). A review of 497 charts of patients with endocarditis provided 228 eligible patient visits (46%), with 158 cases (69.3%) of IE among 126 patients (74 HIV+ and 52 HIV-). Mean T(max) for all patients with IE was 39.1 degrees C (102.4 degrees F). Mean T(max) was similar between the HIV+ (39.1 degrees C, 102.4 degrees F) and HIV- (39.2 degrees C, 102.5 degrees F) groups. There were no differences in mean T(max) among HIV+ patients with CD4 counts > 200 (39.0 degrees C, 102.3 degrees F), those with CD4 < or =200 (39.2 degrees C, 102.5 degrees F), and the HIV- group (39.2 degrees C, 102.5 degrees F). Nearly 8% of i.v. drug users with confirmed IE presented to the ED with a T(max) below 37.8 degrees C (100.0 degrees F). Mean WBC count was significantly lower in HIV+ (11.1 k/mm(3)) than in HIV- patients (15.4 k/mm(3)) and significantly lower in the group with CD4 < or =200 (8.0 k/mm(3)) than in the HIV- group. In conclusion, HIV infection was not associated with lower T(max), but it was associated with decreased WBC count in the general HIV+ group and in the group with CD4 < or =200.     

Neisseria sicca endocarditis with embolic phenomena.

Two patients with poor oral hygiene developed Neisseria sicca endocarditis, one after probable intravenous drug abuse and Staphylococcus aureus endocarditis and the other after a periodontal surgical procedure. Both experienced significant embolic phenomena and both required 6 or more weeks of intravenous antibiotic therapy. The diagnosis of N. sicca endocarditis must be considered when this organism is isolated from blood cultures in patients with emboli.     

Tricuspid valve endocarditis: Cardiovascular imaging evaluation and management

Right-sided infective endocarditis is an increasingly recognized disease entity, with tricuspid valve being most frequently involved. Risk factors for tricuspid valve endocarditis (TVIE) include intravenous drug use, cardiac implantable electronic devices and indwelling catheters. Staphylococcus aureus is the predominant causative organism in TVIE. The diagnosis of infective endocarditis (IE) is based on clinical manifestations, blood cultures, and the presence of valvular vegetations detected by echocardiography. Complementary imaging is helpful when there is ongoing clinical suspicion for IE following initially negative echocardiography. Multislice computed tomography allows for assessment of extra-cardiac complications in TVIE, including pulmonary septic emboli. 18F-fluorodeoxyglucose positron emission tomography/computed tomography and radiolabelled white blood cell, single-photon emission computed tomography provide important clinical information concerning the presence of IE in right-sided prosthetic valves or cardiac implantable electronic devices. The aim of this review is to provide an update on TVIE, discussing the role of multimodality imaging in TVIE and the management of these patients.