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Endocarditis infective, infectious endocarditis
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- Endocarditis refers to an infection
of the inner lining of the heart (endocardium) that also
covers the heart valves. The infection can also extend to the
lining covering the heart (pericarditis) or the heart muscle
(myocarditis). The valves affected may be healthy, previously
damaged, or artificial (prosthetic). The cause is often a
bacterium, but may also be caused by other agents such as
fungi, viruses, and other microorganisms.
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- The bacteria that are normally found in the mouth (alpha
hemolytic streptococci such as Streptococcus viridans), the
upper respiratory tract (e.g. sinuses, nasal passages,
throat and upper airways), intestine, skin, or the urinary
tract can sometimes enter the blood (bacteremia) during
surgical or dental procedures, travel to the endocardium,
grow and multiply on the valves (vegetations) and damage the
valve, specially if the valve (and endocardium) is already
diseased (as in Rheumatic Fever) or abnormal (as in
congenital heart defects present at birth). Pieces of the
bacterial vegetation can break off (called emboli) and
travel to other organs) such as the brain, and cause severe
damage.
- Bacteria from dental abscesses and other infections
already present, such as Pneumonia, Urinary Tract Infections, Cellulitis, can also serve as sources for
bacteremia and eventual endocarditis.
- Acute form -- often caused by very aggressive bacteria
that can damage and infect the healthy heart valve (e.g.,
Staphylococcus aureus and group B streptococcus)
- Subacute -- refers to infection of a valve that is
already diseased or damaged (Streptococcus viridians)
- Prosthetic valve endocarditis refers to infection of an
artificial valve
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- Fatigue
- Headache
- Fever
- Night sweats and chills
- Weight loss
- Joint pain
- Back pain
- Chest pain
- Cough
- Shortness of breath
- Swelling of feet and legs
- Blood in the Urine
- Nail changes -- splinter hemorrhages are small lines (bleeding that occurs after embolization of vegetations) under nail beds
- Tiny red skin spots known as Janeway's spots
- Confusion
- Paralysis
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- Clinical exam and past medical /surgical history is very helpful.
- On exam the doctor:
- Will look at the skin, the nails, for hemorrhages.
- He may notice painful nodules at the tips of toes or fingers known as Osler nodes.
- Using an ophthalmoscope, if he looks inside the eyes he will see Roth spots (areas of hemorrhage).
- Listening to the heart one may hear a murmur, which is the flow of blood across a valve which may be damaged and narrow.
- The abdomen when palpated may show an enlarged spleen.
- Blood cultures to identify the bacteria -- results may take a few days
- Blood test may show a high white count (leukocytosis) and anemia, elevated ESR, low levels of complement activity in the blood (C3, C4, CH50), a positive Rheumatoid factor, and ASO antibodies (detect group A streptococcal infections).
- Urine analysis may show presence of red blood cells (hematuria).
- Transesophageal echocardiography uses Ultrasound waves to demonstrate the vegetation growths on the valve and any subsequent heart damage.
- CAT scan may be done to see if there is abscess formation in any other organs.
- Cardiac catheterization may be done to assess degree of heart and valvular damage.
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- Previous bacterial endocarditis
- Congenital heart disease -- Ventricular Septal Defect, Atrial Septal Defect, Patent Ductus Arteriosus -- are abnormalities that one is born with.
- Damaged or scarred valves as seen in someone with history of Rheumatic Fever
- Valve abnormalities such as mitral valve prolapse with a murmur
- Hypertrophic cardiomyopathy.
- Dental procedures -- teeth cleaning and other dental procedures
- Procedures such as upper endoscopy, Bronchoscopy, Cystoscopy
- Surgeries -- tonsillectomy, adenectomy, prostate surgery, gallbladder surgery, abscess drainage. Vaginal hysterectomy and any procedure done in the presence of an infection.
- Prosthetic valve
- Intravenous drug abuse -- has been associated with increased risk of endocarditis of the tricuspid valve most commonly by Staphylococcus aureus
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- Often patients are sick and must be hospitalized.
- If very sick they are often monitored in the ICU (intensive care unit).
- Antibiotics are started intravenously (often for up to 4 weeks or longer)
- Oxygen is given
- If Heart Failure has developed, medications are given to stabilize it.
- In the case of kidney failure, hemodialysis may be needed to do the job of the kidneys until they recover.
- Surgery may be done if there is severe valve damage (ruptured valve), damaged aortic root, or myocardial abscess.
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- Patients with risk factors for endocarditis must discuss with their physicians any dental or surgical procedures that they are planning, since it is recommended that they should receive prophylactic antibiotics prior to any such procedures, life long.
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