This document discusses infective endocarditis, including its definition, classification, common sites of involvement, risk factors, general lesions, mortality rates, and Osler's nodes and Janeway lesions as associated findings on physical examination. Key points covered include that infective endocarditis is an infection of the endocardial surface, most commonly involving the heart valves. It can be classified as acute or subacute/chronic based on temporal factors and severity. Overall mortality is around 40% usually due to heart failure from valve dysfunction. Having a prosthetic valve or previous endocarditis are major risk factors.

1. D R I H A B S U L I M A N
3 / 1 0 / 2 0 1 9
Endocarditis Presentation to
Internal Medicine

2.  https://www.aae.org/uploadedfiles/clinical_resourc
es/guidelines_and_position_statements/aae_antibi
otic-prophylaxis-2017update.pdf

3. Q1
 Which of the following is accurate about the etiology of
infective endocarditis?
 The most common underlying cause of native valve
endocarditis (NVE) is congenital heart disease
 Early prosthetic valve endocarditis (PVE) and late PVE
both have the same bacteriology and prognosis, with a
subacute presentation similar to that of NVE
 Overall, Staphylococcus aureus is the most common
cause of infective endocarditis, and more than one half of
cases are not associated with underlying valvular disease
 Pseudomonas aeruginosa is the most common etiologic
organism in patients with intravenous drug abuse
(IVDA) infective endocarditis

4. A1
 Overall, Staphylococcus aureus is the most common
cause of infective endocarditis, and more than one
half of cases are not associated with underlying
valvular disease

5. Explanation
 Overall, S aureus infection is the most common cause of
infective endocarditis, including PVE, acute infective
endocarditis, and IVDA infective endocarditis.
Approximately 35%-60.5% of staphylococcal bacteremias
are complicated by infective endocarditis. More than one
half of all cases are not associated with underlying
valvular disease.
 The mortality rate of S aureus infective endocarditis is
40%-50%. S aureus infection is the second most
common cause of nosocomial bloodstream infections,
second only to coagulase-negative staphylococci
infection.

6. Q2
 Which of the following is accurate about the presentation
of infective endocarditis?
 Dyspnea, cough, and chest pain are the most common
symptoms across all types of infective endocarditis
 Cerebrovascular accidents and congestive heart failure
are common developments associated with subacute
endocarditis
 Most cases of subacute infective endocarditis are caused
by dental procedures, with symptoms appearing within
3-4 days of such procedures in 85% of patients
 Nosocomial infective endocarditis often manifests with
elements of sepsis and mostly occurs in patients with
prosthetic valves

7. A2
 Nosocomial infective endocarditis often manifests with elements of sepsis and mostly occurs in patients with
prosthetic valves
 Nosocomial infective endocarditis commonly manifests with elements of a sepsis syndrome (ie, hypotension,
metabolic acidosis fever, leukocytosis, and multiple organ failure). The source of bacteremia may develop from
an infection in another organ (eg, pneumonia, pyelonephritis) or from a central venous catheter. Most often,
these patients are in the intensive care unit. The aging of the population is associated with an increased
incidence of staphylococcal healthcare-associated endocarditis, in addition to an increased mortality rate
associated with the disease. Approximately 45% of cases of nosocomial/healthcare-associated infective
endocarditis occur in patients with prosthetic valves.
 Fever and chills are the most common symptoms; anorexia, weight loss, malaise, headache, myalgias, night
sweats, shortness of breath, cough, or joint pains are common symptoms as well. Dyspnea, cough, and chest
pain are common symptoms in intravenous drug users with infective endocarditis. This is probably related to
the predominance of tricuspid valve endocarditis in this group and secondary embolic showering of the
pulmonary vasculature.
 A key concern is the distinction between subacute and acute infective endocarditis. The diagnosis of subacute
infective endocarditis is suggested by a history of an indolent process characterized by fever, fatigue, anorexia,
back pain, and weight loss. Less common developments include a cerebrovascular accident or congestive heart
failure.
 The patient should be questioned about invasive procedures and recreational drug use that may be causing the
bacteremia. Most subacute disease caused by Streptococcus viridans infection is related to dental disease.
Most cases are caused not by dental procedures, but by transient bacteremias secondary to gingivitis. In 85%
of patients, symptoms of endocarditis appear within 2 weeks of dental or other procedures.

8. Q3
 Which of the following is accurate about the physical
examination and associated findings in patients with infective
endocarditis?
 Heart murmurs are heard in the majority of patients with
infective endocarditis
 Multiple embolic pulmonary infections or infarctions are due
to left heart disease, whereas signs of systemic septic emboli
are due to right heart disease
 Purulent meningitis is observed in patients with subacute
disease compared with the aseptic type observed in patients
with acute infective endocarditis
 Splenomegaly is observed more commonly in patients with
recent subacute disease compared with long-standing
subacute disease

9. A3
 Heart murmurs are heard in the majority of patients with infective endocarditis.
 Heart murmurs are heard in approximately 85% of patients. A change in the
characteristics of a previously noted murmur occurs in 10% of these patients and
increases the likelihood of secondary congestive heart failure.
 Signs of systemic septic emboli are due to left heart disease and are more commonly
associated with mitral valve vegetations. Multiple embolic pulmonary infections or
infarctions are due to right heart disease.
 Purulent meningitis may be observed in patients with acute infective endocarditis,
compared with the aseptic type observed in patients with subacute disease. Other
neurologic findings are similar to those observed in patients with subacute disease.
 Splenomegaly is observed more commonly in patients with long-standing subacute
disease. It may persist long after successful therapy.

10. Q4
 Which of the following is accurate about the workup of
infective endocarditis?
 The presence of a continuous bacteremia is sufficient to
diagnose an infected valvular vegetation
 The criterion standard test for diagnosing infective
endocarditis is documentation of continuous bacteremia
(> 30 minutes) on the basis of blood culture results
 Leukocytosis is commonly observed in subacute
endocarditis, with anemia common in acute endocarditis
 A diagnosis of infective endocarditis can be excluded on
the basis of negative echocardiography findings, either
from transesophageal echocardiography or transthoracic
echocardiography

11. A4
 The criterion standard test for diagnosing infective endocarditis is
documentation of continuous bacteremia (>30 minutes) on the basis of
blood culture results. Although blood cultures remain key in making the
diagnosis of infective endocarditis, the need for indirect diagnostic
techniques that are both specific and sensitive is increasing. This is because
the nature of valvular infections has changed over the years. The number of
fastidious organisms has increased, and the rate of the classic peripheral
stigmata of infective endocarditis is much lower. Patients who are elderly,
chronically ill, or immunosuppressed are often afebrile and do not mount a
significant fever or exhibit the classic stigmata of valvular infection.
 Because S aureus can produce endotheliosis, the presence of a continuous
bacteremia does not necessarily imply an infected valvular vegetation.
 Anemia is common in subacute endocarditis. Leukocytosis is observed in
acute endocarditis. Erythrocyte sedimentation rate, although not specific, is
elevated in more than 90% of cases. Decreased C3, C4, and CH50 are
evident in subacute endocarditis.

12. Q5
 Which of the following is accurate about the treatment of
infective endocarditis?
 Patients with subacute infective endocarditis must be
treated with antibiotics before culture and sensitivity
results, owing to the increased risk for complication over
time
 Patients with PVE should receive monotherapy with
rifampin as the first-line treatment
 Congestive heart failure in a patient with NVE is the
primary indication for surgery
 Continuously infused vancomycin is the best therapy for
aminoglycoside-resistant enterococci

13. A5
 Approximately 15%-25% of patients with infective endocarditis
eventually require surgery. Indications for surgical intervention in
patients with NVE are as follows:
 Congestive heart failure that is refractory to standard medical
therapy
 Fungal infective endocarditis (except that caused by Histoplasma
capsulatum)
 Persistent sepsis after 72 hours of appropriate antibiotic treatment
 Recurrent septic emboli, especially after 2 weeks of antibiotic
treatment
 Rupture of an aneurysm of the sinus of Valsalva
 Conduction disturbances caused by a septal abscess
 Kissing infection of the anterior mitral leaflet in patients with
infective endocarditis of the aortic valve
•Conduction disturbances caused by a septal abscess
•Kissing infection of the anterior mitral leaflet in patients with infective endocarditis of the aortic valve

18. Endocarditis: Definition
 Infective Endocarditis: a microbial
infection of the endocardial surface of the
heart
 Common site: heart valve, but may occur at
septal defect, on chordae tendinae or in the
mural endocardium
 Classification:
 acute or subacute-chronic on temporal basis,
severity of presentation and progression
 By organism
 Native valve or prosthetic valve

22. Oslers’ nodes
Tender, s/c
nodules
Janeway lesions
Nontender
erythematous,
haemorrhagic,
or pustular
lesions often
on palms or
soles.

23. General Lesions
 Enlarged Spleen
 Arthritis
 Clubbing Of Fingers
 Cardiac Failure
 Conduction Abnormalities
 Stroke
 Psychiatric Disease
 Renal Failure

24. Mortality
Overall Rate About 40%
Death Usually Due To Heart
Failure Resulting From Valve
Dysfunction
Highest Death Rate Is In Early
Prosthetic Valve Endocarditis

25. Risk Factors
 Presence of a prosthetic valve (highest risk)
 Previous endocarditis (highest risk)
 Complex cyanotic congenital heart disease (e.g., single-
ventricle states)
 Surgically constructed systemic pulmonary shunts or conduits
 Acquired valvular dysfunction (e.g., rheumatic heart disease)
 Hypertrophic cardiomyopathy
 Mitral valve prolapse with regurgitation
 IVDA

26. Q1

27. A1
 C- VALVULAR Aortic Regurgitaion

28. Q2

29. A2
 B- Amyloidosis

30. Q3

31. A3
 B- Suppurative Pericarditis

32. Q4

33. A4
 D- Large ASD

34. Q5

35.  B- The presence of prosthetic valve

36. Q6

37. A6
 D-Candida

38. Q7

39. A7
 A-Viridans Streptococci

40. Q8

41. A8
 C-STAPH EPEDERMIDIS

42. Q9

43. A9
 D)Enterococcus fecalis.

44. Q10

45. A10
 C)Decreased erythrocyte sedimentation rate

46. Q11

47. A11
 B)positive blood cultures and echocardiographic
changes.

48. Q12

49. A12
 B)subacute, left-sided IE.

50. Q13

51. A13
 B)Clinical cure can only occur if synergistic
aminoglycosides are used in combination with a β-
lactam agent.

52. Q14

53. A14
B) Penicillin G 12-18 million units
every 24 hours for 4 weeks

54. Q15

55. A15
 B)yes, clindamycin 600 mg orally 1 hour before the
procedure.

56. Q16
 Which of these wouldn't be an appropriate
investigation of IE?
 A Blood Culture
 B Blood Tests
 C Cardiac Angiogram
 D ECG
 E Echocardiogram

57. A16
 C Cardiac Angiogram
 A blood culture is important to find the causative
organism. An ECG can be useful, as sometimes there
is a lengthened PR Interval with IE. An
echocardiogram can show the vegetations on the
valves. Blood tests will show a raised ESR/CRP with
infection, and there may also be an anaemia.

58. Q17
 Which of these isn't a common cause of infective
endocarditis?
 A Haemophilus parainfluenzae
 B Staphylococcus Aureus
 C Staphylococcus pidermidis
 D Streprococcus Viridans

59. A17
 A Haemophilus parainfluenzae
 Staphylococcus Aureus is a very common cause of
infective endocarditis (IE), as is streptococcus
viridans. Haemophilus parainfluenzae is one of the
HACEK organisms, a group of gram-negative
bacteria that can cause IE but are rarer. HACEK -
Haemophilus, Aggregatibacter, Cardiobacterium,
Eikenella, Kingella.

60. Q18
 Which of these is NOT a risk factor for IE?
 A IV Drug Use
 B Mitral Valve Disease
 C None - they are all risk factors
 D Prosthetic Valves

61. A18
 C None - they are all risk factors
 All of these options result in damage to valves, and
therefore increase the risk of IE. Although, 50% of IE
occurs on normal valves. Endocarditis normally
follows an acute course, but on abnormal valves it
tends to run a subacute course.

62. Q19
 Which of these is not a sign of infective endocarditis?
 A Aortic Regurgitation
 B Butterfly Rash
 C Fever
 D Janeway Lesions
 E Splinter Haemorrhages

63. A19
 B Butterfly Rash
 The signs of IE can be grouped into 4 main strands:
1. Septic Signs. This includes fever, rigors, night
sweats, malaise, weight loss, anaemia, splenomegaly
and clubbing 2. Cardiac lesions. The vegetations on
the valves may cause regurgitation or obstruction. 3.
Immune complex deposition: splinter haemorrhages,
Osler’s nodes (painful pulp infarcts in fingers or
toes). 4. Embolic phenomena: Janeway lesions
(painless palmar macules), which, together with
Osler’s nodes, are pathognomonic of IE.

64. Q20
 A 30 year old IV drug user presents with shortness of
breath, night sweats and a fever. On examination, you
find that he has splinter haemorrhages. Which of these
investigations is needed LEAST to confirm infective
endocarditis?
 A A single positive blood culture
 B An echocardiogram showing vegetations
 C An echocardiogram showing vegetations and two
positive blood cultures
 D ECG showing a long PR Interva

65.  B An echocardiogram showing vegetations
 The Duke criteria can be used to diagnose infective
endocarditis. The criteria consist of major and minor criteria,
and to diagnose IE, you need 2 major criteria, 1 major and 3
minor criteria or all 5 minor criteria. Major criteria: - Typical
organism in 2 separate cultures or persistently positive blood
cultures - Positive echocardiogram Minor Criteria: -
Predisposition (cardiac lesion; IV drug abuse) - Fever (>38) -
Vascular/immunological signs - Positive blood culture that
doesn't meet major criteria - Positive echocardiogram that
does not meet major criteria This patient has 3 minor criteria.
Therefore, they only need 1 major for a diagnosis - an
echocardiogram showing vegetations. They don't need both.