Thanks to Janhavi for presenting the case of a middle-aged man with no significant PMH presenting with acute onset of malaise, myalgias, and a “stubbed toe,” septic with petechiae on palms and soles, found to have mitral valve endocarditis.

Clinical Pearls:

• Endocarditis is more common in men (2:1)
• ~50% of cases of endocarditis occur in people with no known underlying valve disease
• 80% of cases are caused by staph and strep species
• TEE is the gold standard for diagnosis and recommended when clinical suspicion for endocarditis is high.  TTE is more helpful to rule out disease when clinical suspicion is low.
• Indications for early surgery based on this NEJM article include:
  • Heart failure
  • Uncontrolled infection
  • Prevention of embolic events

Duke’s criteria:

Major criteria:

• Blood culture positive:
  • Typical organism in two separate blood cultures
  • Persistently positive blood cultures
  • Single positive culture for Coxiella
• E/o endocardial involvement
  • Echo positive for vegetation
  • New valve regurgitation

Minor criteria:

• Predisposition to IE (i.e. IVDU, prosthetic valve, congenital cyanotic heart disease)
• Fever >38
• Vascular phenomena ⇒ arterial emboli, pulmonary infarcts, mycotic aneurysms, intracranial hemorrhage, conjunctival hemorrhage, Janeway lesions
• Immunologic phenomena ⇒ GN, Osler’s nodes, Roth’s spots, RF
• Microbiologic evidence: positive blood culture not meeting major criteria

Probability of endocarditis:

Definite IE:

• 2 major, 1 major + 3 minor, 5 minor

Possible IE:

• 1 major + 1 minor, or 3 minor

Rejected IE:

• Firmly established alternative diagnosis
• Resolution of symptoms < 4 days with antibiotics
• Does not meet definite/possible criteria

Indications for surgery:

• Valve dysfunction causing heart failure
• Perivalvular extension with development of abscess, fistula, and/or heart block
• Fungi or other highly resistant organisms that are difficult to treat with abx alone
• Persistent bacteremia despite maximal treatment
• Recurrent embolization with persistent vegetations
• Large vegetations (>1 cm) with severe valvular regurg
• S aureus prosthetic valve endocarditis

Indications for early surgery:

• Heart failure
• Uncontrolled infection
• Prevention of embolic events

Complications:

• Most common cause of death: heart failure
• Heart block
• Emboli
  • More likely with s. aureus or S. bovis, veg > 1 cm, or increased veg mobility on echo
  • Antiplatelet therapy initiation is not recommended because of increased risk of hemorrhagic conversion of septic emboli

Want more?

• Check out this blog post and this great review article in the NEJM.