infective endocarditis n.
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Infective Endocarditis . Is due to microbial infection of a heart valve, the lining of cardiac chamber or blood vessel, or a congenital anomaly (septal defect). The causative agent is usually abacterium, but may be any organisms. . Pathophysiology .

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Is due to microbial infection of a heart valve, the lining of cardiac chamber or blood vessel, or a congenital anomaly (septal defect).
  • The causative agent is usually abacterium, but may be any organisms.
pathophysiology
Pathophysiology
  • Typically occurs at site of pre-existing endocardial damage.
  • But virulence organism like staph.aureus can affect normal valve.
  • Tricusped valve endocarditis in i.v. drug abuser.
  • Defect associated with high jet like PDA and VSD > liable while defect with low jet less likely as in ASD.
  • Vegetation (organism,fibrin & platelete).
  • Extracardiac manifestations such as vasculitis & skin lesion are due to emboli or immune complex deposition.Mycotic aneurysm may develop in arteries at sites of emboli .
microbiology
Microbiology
  • *Streptococci ;
  • Viridans gr. 30-40 %.
  • Entrococci 10-15 %.
  • Other streptococci 20-25 %.
  • *Staph. :
  • Staph.aureus 9-27 %
  • Coagulase –negative 1-3 %
  • *Gram –ve, Haemophilus & Anaeroes 3-8 %.
  • *Rickettsiae & fungi < 2 %.
clinical features
Clinical features
  • Could be divided in to Acute and subacute with overlap between them .
  • The clinical pattern influenced by the type of organism, the site of infection and prior antibiotic therapy .
  • Sub acuteBacterial Endocarditis : persistent fever, un usual tiredness, night sweating or weight loss ,or new signs of valve dysfunction or heart failure.Less often embolic phenomenon.
  • Osler nodes a painfull tender nodes at finger tips probably due to vasculitis (rare).
  • Digital clubbing is a late sign .
  • The spleen frequently palpable .In Qoxiella infection the spleen and liver may be considerably enlarged..Microscopichaematuria is common.
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Acute endocarditis : sever febrile illness, with prominent and changing murmur and petichiae . Embolic phenomenon is common , and cardiac and renal failure may develop rapidly. Abscesses may be detected on echocardiography.clinical features of chronic endocarditis usually abscent.
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Post operative endocarditis : any un explained fever in a patient who has had heart valve surgery should be investigated for possible endocarditis.

The infection usually affect valve ring & may resemble sub acute or acute endocarditis, depending on virulence of the organism. Morbidity and mortality is high and redo surgery usually required.

investigations
Investigations:
  • Blood culture :3 samples for culture should be obtained on aseptic technique on different sites, aerobic and anaerobic culture are required .
  • Echocardiography :Is the key tool for detecting vegetations and following its progress, as small as 3-5 mm can be detected on TTE and as smaller as 1-1.5 mm on TEE. the later specially important in identifying abscess formation and endocarditis of the prosthetic valve.
  • Elevation of ESR and a normochromic ,normocytic anaemia ,with leuckocytosis are common.
  • Measurement of CRP(C-reactive Protein ) is more reliable for monitoring the treatment than ESR.
  • Proteinurea & microscpichaematuria may occur and usually is the only positive finding.
  • ECG is important t for monitoring the development of conduction defect and aortic root abscess by showing P-R prolongation.
  • Chest X-ray show evidence of cardiac failure and cardiomegaly.
management
Management
  • Mortality rate is about 20 % and may be higher in special cases (prosthetic valve endocarditis and resistant microorganism).
  • A 2 week treatment regimen may be sufficient for fully sensitive strains of Streptococcal viridans and Strep.bovis.
  • For empirical treatment of bacterial endocarditis ,Penicillin plus gentamicin is the treatment of choice for most of the cases.
  • However when staphylococcal infection is suspected vancomycin plus gentamicine is recommended.
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Cardiac surgery (debridement of infected material & valve replacement) is advisable for the following conditions ;
  • 1-Heart failure due to valve damage.
  • 2-failure of antibiotic therapy.
  • 3-Large vegetation on left sided valve.
  • 4-Abscess formation.
  • 5-prosthetic valve endocarditis.
  • 6-Fungal endocarditis.