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A Case of Infective Endocarditis
1. A case of infective
endocarditis
By Dr P. Arul
M4, Prof P. Vijayaraghavan’s unit
2. 46 year old male presented with c/o
◦ Fever 3 weeks duration
◦ Slurring of speech 1 day
◦ Weakness of left upper and lower limbs 1
day
History of present illness:
◦ Fever
3 weeks duration
Intermittent
High grade
Not associated with chills, rigors.
3. ◦ Patient suddenly developed an episode of
sudden loss of consciousness which
lasted for 2 minutes and recovered
spontaneously, following which he noticed
difficulty in standing and walking due to
weakness of his left lower limb. His family
members also noticed that his speech
was slurred.
◦ No h/o seizure
◦ No h/o bladder, bowel disturbance
◦ No h/o regurgitation of feeds
4. ◦ No h/o burning micturition, increased
frequency.
◦ No h/o abdominal pain, vomiting,
diarrhea.
◦ No h/o cough with expectoration,
breathlessness
◦ No h/o skin ulcers, rash, jaundice
5. Past history:
◦ Was diagnosed to have cardiac valvular
lesion (?RHD) 1 yr back and on drugs
since then.
◦ Not a known diabetic, hypertensive,
epileptic, COPD, PT, IHD.
◦ No previous similar episodes.
Personal history:
◦ Not a smoker, drinks alcohol occasionally
6. Family history:
◦ No family h/o cardiac ailment
Treatment history:
◦ Patient consulted a private practitioner 1
yr back for reduced exercise tolerance
and was evaluated for cardiac causes.
Echo picked up mitral regurgitation and
patient was put on penicillin prophylaxis
along with T. lasix.
7. General Examination
Conscious
Oriented
Afebrile
No cyanosis
No clubbing
No pallor
Not icteric
No pedal edema
No petichiae
No Splinter
hemorrhages
No Oslers node
No Janway lesion
Retinal
hemorrhage+
-Roth’s spot
8. CVS:
◦ S1, S2 heard,
◦ A pan systolic murmur with a musical
quality heard in the mitral area,
◦ P2 loud.
RS:
◦ Normal vesicular breath sounds heard
P/A
◦ Soft, no organomegaly
9. CNS
◦ HMF
Conscious
Orientation
Time +
Place +
Dysarthria with Anomic Aphasia(difficulty in
naming persons and objects)
Memory intact
10. ◦ Cranial nerves
I-VI – normal
VII – UMN type facial palsy on left side
VIII-XII – normal
◦ Motor system
Grade 4/5 power in both left lower and upper
limb
Deep tendon reflex brisk in the left side
Tone – mild increase in the left side
Babinski positive on the left side
11. ◦ Sensory system:
Normal
◦ Cerebellar functions:
Normal
◦ Spine and cranium:
Normal
◦ No meningeal signs
Imp:- RHD – mitral regurgitation/
infective endocarditis/ embolic CVA –
left hemiparesis
16. Cardiologist opinion:
◦ Continue antibiotics repeat echo weekly
for assessing reduction in size of
vegetations.
17. Follow up
Repeat blood culture (3rd week)
◦ No growth
ECHO
◦ Mitral regurgitation (moderate)
◦ Rupture of chordae tendinae
18. Discussion
Infective endocarditis is microbial infection of
cardiac valves.
The features of infective endocarditis have
changed dramatically during the past three
decades.
Patients with classic manifestations such as
fever, splenomegaly, changing murmurs,
signs of peripheral embolization and multiple
positive blood cultures have become
distinctly unusual.
Originally endocarditis was classified as
acute or sub-acute depending on the duration
of the disease.
19. Patients dying within 8 weeks were said
to have acute form while those surviving
more than 8 weeks were said to have
sub-acute form.
Patients with endocarditis due to
staphylococcus aureus, Neisseria
meningitidis, Hemphilus influenzae or
Streptococcus pyogenes were
considered to have the acute form.
Streptococcus viridans or
staphylococcus epidermidis were
associated with the sub acute form.
20. Incidence
0.16 to 5.4 per 1000 hospital
admissions.
Mean age is between 55 and 57
years.
Uncommon in the first decade.
When it occurs in infants it is of the
acute variety involving normal cardiac
valves.
Men predominate with a ratio of 2:1 to
as high as 9:1 in older age group.
21. Predisposing conditions
72% of patients have a preexisting
structural cardiac abnormality.
Isolated valvular aortic stenosis was the
congenital defect most often associated
with IE followed by VSD, TOF, idiopathic
subaortic stenosis and ASD
(uncommon).
In patients with valvular lesion mitral
valve is involved most often followed by
aortic valve, tricuspid valve involvement
is uncommon (1%).
Cardiac prosthetic valves and parentral
narcotic drug constitutes a major risk for
IE.
24. Pathogenesis
Source of infection
◦ The bacteremia or fungemia that initiates the
infection is transient and arises form the
oropharynx, genitourinary or gastrointestinal
mucosa
◦ Bacteremia following dental procedures
occurs in 60% patients, 85% following
suction abortion, 30% following tonsillectomy
, 16% following nasotracheal intubation, 15%
following bronchoscopy and10% after UGI
scopy.
◦ Staphylococcus aureus endocarditis are
more likely to have a demonstrable source of
infection.
25. Invasive predisposing factors to bacterial endocarditis
Dental procedures
Oral and upper respiratory tract surgery
Certain gastrointestinal procedures
Genitourinary surgery
Cardiac surgery
Certain trauma
Alimentation catheters in the right heart
Intravenous drug use
26. Cardiac pathology
Endocarditis develops following
implantation of a microorganism on a
preexisting sterile thrombotic
vegetation present at a point of
structural endocardial abnormality.
It has been shown experimentally that
bacteria are often deposited in areas
of high blood flow velocity.
Consequently vegetations develop
more frequently in a regurgitant valve.
27. Valve affected Site of vegetation/complication
Mitral valve Along chordae tendinae toward
papillary muscle causing their
rupture
Aortic valve Develop ring abscess
VSD Right ventricular wall, the site of jet
impact
Regurgitant mitral lesion Wall of left atrium in the area
termed MacCallum’s patch
Regurgitant Aortic lesion Chordae tendinae of anterior mitral
leaflet
28. Extracardiac pathology
Systemic embolism is reported to
occur in over 50% cases in autopsy
studies.
Most common sites are kidneys, skin,
spleen, eye and CNS.
There is increasing evidence to show
that embolic phenomena actually
represent “immune complex”
deposition in small systemic arteries.
31. Heart murmurs
◦ Was the sine qua non for the diagnosis
◦ It has been found that 15% don’t have
murmurs at initial diagnosis, however
most develop a murmur during the course
of the disease
◦ Changing murmurs – factors other than
valvular integrity like change in cardiac
output, temperature, hematocrit may play
a role. However new onset regurgitant
murmur in a setting of acute sepsis is
virtually diagnostic.
32. Cutaneous manifestations
◦ Petichiae (20-40%)
◦ Subcunjunctival and subungual splinter
hemorrhages due to lipid microembolism.
◦ Osler nodes
Tender, purplish erythematous papules in pulp of distal
fingers
Due to hypersensitive angitis – cultures are negative
◦ Janeway lesions
Erythematous, non-tender nodules on palms or soles.
◦ Clubbing found only in 10-20%.
Ocular manifestations
◦ Roth spot- flame shaped hemorrhage
occasionally takes the form of cotton wool spot.
34. Diagnosis – duke’s criteria
Major Criteria
1. Positive blood culture
Typical microorganism for infective endocarditis from two
separate blood cultures or
Persistently positive blood culture, defined as recovery of
a microorganism consistent with infective endocarditis
from blood cultures drawn >12 h apart or
Single positive blood culture for Coxiella burnetii or
phase I IgG antibody titer of >1:800
2. Evidence of endocardial involvement
◦ Positive echocardiogram
Oscillating intracardiac mass on valve, or
Abscess, or
New partial dehiscence of prosthetic valve, or
◦ New valvular regurgitation
35. Minor Criteria
1. Predisposition:
◦ Predisposing heart condition or
◦ Injection drug use
2. Fever ≥38.0°C (≥100.4°F)
3. Vascular phenomena:
◦ Major arterial emboli, septic pulmonary infarcts, mycotic
aneurysm, intracranial hemorrhage, conjunctival hemorrhages,
Janeway lesions
4. Immunologic phenomena:
◦ Glomerulonephritis, Osler’s nodes, Roth’s spots, Rheumatoid
factor
5. Microbiologic evidence:
◦ Positive blood culture but not meeting major criterion as noted
previously or
◦ Serologic evidence of active infection with organism consistent
with infective endocarditis
Documentation of two major criteria, of one
major and three minor criteria, or of five minor
criteria allows a clinical diagnosis of definite
endocarditis
