Snapshot A 43-year-old man with a history of IV drug abuse reports fever, chills, cough, and pleuritic chest pain for several days. He has an episode of hemoptysis in the ER. Physical exam reveals a temp of 39 degrees Celsius, scattered rales, and a II/VI systolic murmor at the lower left sternal border that increases with inspiration. A lesion is found on the palm of his hand. Introduction Inflammation of the heart valve, usually secondary to infection Usually left-sided unless patient has a history of IV drug use in which case it is usually right-sided involving tricuspid valve Acute endocarditis caused by Streptococcus pneumoniae Streptococcus pyogenes Neisseria gonorrhoeae Staphylococcus aureus (especially in IV drug users) Subacute bacterial endocarditis has slower onset of symptoms with less severe symptoms caused by Enterococcus: the source is typically from a cystoscopy in the setting of a UTI S. viridans: the source is typically an upper respiratory infection Staphylococcus epidermidis: the source is typically the skin Murantic endocarditis occurs due to metastatic cancer seeding to the valves commonly associated with cerebral infarcts due to malignant emboli very poor prognosis Libman-Sacks endocarditis caused by systemic lupus erythematous (SLE) usually asymptomatic but murmur can be heard Risk factors include history of RHD valvular heart disease IV drug use immunosuppression prosthetic heart valve Common cause of "fever of unknown origin (FUO)" Intravascular infection that can spread to other organs must watch for signs of neurologic, joint, and lung manifestations Presentation Symptoms patients present with range of symptoms that may include high fever that can last for weeks cough SOB systemic symptoms (weakness, fever, malaise) Physical exam heart auscultation usually reveals a murmur often mid-systolic of tricuspid regurgitation over LLSB Osler's nodules small, red-purple, tender nodules on fingers and toes immune-mediated small-vessel vasculities in response to long-standing micro-abscesses Janeway lesions non-tender, dark macules on palms and soles result from septic micro-embolisms Roth spots retinal hemorrhages subungal petechiae (splinter hemorrhages) Evaluation Diagnosis based on Duke Criteria (1994, revised 2000) major criteria include positive blood cultures evidence of endocardial involvement minor criteria include: predisposing heart condition or history of IV drug use fever vascular phenomena, including major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway lesions immunologic phenomena, including glomerulonephritis, Osler’s nodes, Roth’s spots, and rheumatoid factor blood cultures not meeting major criteria echocardiographic findings not included in major findings Blood cultures positive blood cultures drawn at least 12 hours apart or multiple positive cultures (at least 3 of 4) with the first and last drawn at least 1 hour apart Echocardiography look for vegetations negative echo does not rule out endocarditits CXR may reveal septic emboli in right-sided endocarditits Differential Osteomyellits, abscess, pneumonia, rheumatic fever, prostatitis in males, STDs in females, other causes of FUO Treatment Empiric prolonged antibiotic therapy treat fo 4-6 weeks recent evidence shows 2 weeks OK for certain organisms tailor for organism based on cultures Surgical valve replacement indicated in cases with worsening valve function abscess formation conduction disturbance (arrhythmia) Prognosis, Prevention, and Complications Prognosis is good May prevent secondary infection with prophylactic antibiotics (amoxicillin or erythromycin) before dental work Complications occur secondary to embolic phenomena as described