Endocarditis
Classification & external resources

Bartonella henselae bacilli in cardiac valve of a patient with blood culture-negative endocarditis. The bacilli appear as black granulations.
ICD-10	I33.
ICD-9	421
DiseasesDB	4224
MedlinePlus	001098
eMedicine	emerg/164  med/671 ped/2511
MeSH	D004696

Endocarditis is an inflammation of the inner layer of the heart, the endocardium. The most common structures involved are the heart valves. Image File history File links Source: Photo: Warthin Starry, from Traditional and Molecular Techniques for the Study of Emerging Bacterial Diseases: One Laboratory’s Perspective, Emerging Infectious Diseases Journal, Vol. ... The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or disease. ... The International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) is a coding of diseases and signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or diseases, as classified by the World Health Organization (WHO). ... // I00-I99 - Diseases of the circulatory system (I00-I02) Acute rheumatic fever (I00) Rheumatic fever without mention of heart involvement (I01) Rheumatic fever with heart involvement (I02) Rheumatic chorea (I05-I09) Chronic rheumatic heart diseases (I05) Rheumatic mitral valve diseases (I050) Mitral stenosis (I051) Rheumatic mitral insufficiency (I06) Rheumatic aortic... The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or disease. ... The following is a list of codes for International Statistical Classification of Diseases and Related Health Problems. ... The Disease Bold textDatabase is a free website that provides information about the relationships between medical conditions, symptoms, and medications. ... MedlinePlus (medlineplus. ... eMedicine is an online clinical medical knowledge base that was founded in 1996. ... Medical Subject Headings (MeSH) is a huge controlled vocabulary (or metadata system) for the purpose of indexing journal articles and books in the life sciences. ... An abscess on the skin, showing the redness and swelling characteristic of inflammation. ... The heart and lungs, from an older edition of Grays Anatomy. ... In the heart, the endocardium is the innermost layer of tissue that lines the chambers of the heart. ... Grays Fig. ...

Endocarditis can be classified by etiology as either infective or non-infective, depending on whether a microorganism is the source of the problem. A cluster of Escherichia coli bacteria magnified 10,000 times. ...

Infective endocarditis

As the valves of the heart do not actually receive any blood supply of their own, defense mechanisms (such as white blood cells) cannot enter. So if an organism (such as bacteria) establishes a hold on the valves, the body cannot get rid of them. Human blood smear: a - erythrocytes; b - neutrophil; c - eosinophil; d - lymphocyte. ... White Blood Cells redirects here. ... Phyla/Divisions Actinobacteria Aquificae Bacteroidetes/Chlorobi Chlamydiae/Verrucomicrobia Chloroflexi Chrysiogenetes Cyanobacteria Deferribacteres Deinococcus-Thermus Dictyoglomi Fibrobacteres/Acidobacteria Firmicutes Fusobacteria Gemmatimonadetes Nitrospirae Omnibacteria Planctomycetes Proteobacteria Spirochaetes Thermodesulfobacteria Thermomicrobia Thermotogae Bacteria (singular, bacterium) are a major group of living organisms. ...

Normally, blood flows smoothly through these valves. If they have been damaged (for instance in rheumatic fever) bacteria can have a chance to take hold. Rheumatic fever is an inflammatory disease which may develop after a Group A streptococcal infection (such as strep throat or scarlet fever) and can involve the heart, joints, skin, and brain. ...

Classification

Traditionally, infective endocarditis has been clinically divided into acute and subacute (because the patients tend to live longer in subacute as opposed to acute) endocarditis. This classifies both the rate of progression and severity of disease. Thus subacute bacterial endocarditis (SBE) is often due to streptococci of low virulence and mild to moderate illness which progresses slowly over weeks and months, while acute bacterial endocarditis (ABE) is a fulminant illness over days to weeks, and is more likely due to Staphylococcus aureus which has much greater virulence, or disease-producing capacity. Species S. pneumoniae S. pyogenes S. viridans Streptococcus is a genus of spherical, Gram-positive bacteria of the phylum Firmicutes. ... Binomial name Rosenbach 1884 Staphylococcus aureus , literally Golden Cluster Seed and also known as golden staph, is the most common cause of staph infections. ...

This terminology is now discouraged. The terms short incubation (meaning less than about six weeks), and long incubation (greater than about six weeks) are preferred. ^{[citation needed]}

Infective endocarditis may also be classified as culture-positive or culture-negative. Culture-negative endocarditis is due to micro-organisms that require a longer period of time to be identified in the laboratory. Such organisms are said to be 'fastidious' because they have demanding growth requirements. Some pathogens responsible for culture-negative endocarditis include Aspergillus species, Brucella species, Coxiella burnetii, Chlamydia species, and HACEK bacteria. An Agar Plate -- an example of a bacterial growth medium. ... Species Aspergillus caesiellus Aspergillus candidus Aspergillus carneus Aspergillus clavatus Aspergillus deflectus Aspergillus flavus Aspergillus fumigatus Aspergillus glaucus Aspergillus nidulans Aspergillus niger Aspergillus ochraceus Aspergillus oryzae Aspergillus parasiticus Aspergillus penicilloides Aspergillus restrictus Aspergillus sojae Aspergillus sydowi Aspergillus terreus Aspergillus ustus Aspergillus versicolor Aspergillus is a genus of around 200 filamentous fungi... Species B. abortus B. melitensis Brucella is a genus of Gram-negative bacteria. ... Binomial name (Derrick 1939) Philip 1948 Coxiella burnetii is a species of intracellular, pathogenic bacteria, and is the causative agent of Q fever. ... Chlamydia is a common term for Chlamydiae. ... A HACEK organism is one of a set of slow-growing Gram negative bacteria that form a normal part of the human flora. ...

Finally, the distinction between native-valve endocarditis and prosthetic-valve endocarditis is clinically important.

Patients who inject narcotics intravenously may introduce infection which will travel to the right side of the heart. In other patients without a history of intravenous exposure, endocarditis is more frequently left-sided. The term narcotic, derived from the Greek word for stupor, originally referred to a variety of substances that induced sleep (such state is narcosis). ...

Etiology and pathogenesis

As previously mentioned, altered blood flow around the valves is a risk factor in obtaining endocarditis. The valves may be damaged congenitally, from surgery, by auto-immune mechanisms, or simply as a consequence of old age. The damaged part of a heart valve becomes covered with a blood clot, a condition known as non-bacterial thrombotic endocarditis (NBTE). “Surgeon” redirects here. ... Autoimmune diseases arise from an overactive immune response of the body against substances and tissues normally present in the body. ...

In a healthy individual, a bacteremia (where bacteria get into the blood stream through a minor cut or wound) would normally be cleared quickly with no adverse consequences. If a heart valve is damaged and covered with a piece of a blood clot, the valve provides a place for the bacteria to attach themselves and an infection can be established. Bacteremia (Bacteræmia in British English, also known as blood poisoning or toxemia) is the presence of bacteria in the blood. ...

The bacteremia is often caused by dental procedures, such as a cleaning or extraction of a tooth. It is important that a dentist or a dental hygienist is told of any heart problems before commencing. Antibiotics are administered to patients with certain heart conditions as a precaution. This article is about the dental profession. ... Surgical extraction of an impacted molar. ... A mans visible teeth. ... X-rays can reveal if a person has cavities Dentistry is the practical application of knowledge of dental science (the science of placement, arrangement, function of teeth) to human beings. ... A Dental hygienist attends to a patient A dental hygienist is a licensed dental auxiliary who specializes in preventive dental care, typically but not limited to focusing on techniques in oral hygiene . ... An antibiotic is a drug that kills or slows the growth of bacteria. ...

Another group of causes result from a high number of bacteria getting into the bloodstream. Colorectal cancer, serious urinary tract infections, and IV drug use can all introduce large numbers of bacteria. With a large number of bacteria, even a normal heart valve may be infected. A more virulent organism (such as Staphylococcus aureus, but see below for others) is usually responsible for infecting a normal valve. Colorectal cancer, also called colon cancer or bowel cancer, includes cancerous growths in the colon, rectum and appendix. ... A urinary tract infection (UTI) is a bacterial infection that affects any part of the urinary tract. ... An intravenous drug (IV drug) is a drug administered intravenously, either by an intravenous drip or a syringe. ... Binomial name Rosenbach 1884 Staphylococcus aureus , literally Golden Cluster Seed and also known as golden staph, is the most common cause of staph infections. ...

Intravenous drug users tend to get their right heart valves infected because the veins that are injected enter the right side of the heart. The injured valve is most commonly affected when there is a pre-existing disease. (In rheumatic heart disease this is the aortic and the mitral valves, on the left side of the heart.) In the circulatory system, a vein is a blood vessel that carries blood toward the heart. ...

Clinical and pathological features

• Fever, i.e. fever of unknown origin (often spiking caused by septic emboli)
• Continuous presence of micro-organisms in the bloodstream determined by serial collection of blood cultures
• Vegetations on valves on echocardiography, which sometimes can cause a new or changing heart murmur, particularly murmurs suggestive of valvular regurgitation
• Vascular phenomena: Septic emboli (causing thromboembolic problems such as stroke in the parietal lobe of the brain or gangrene of fingers), Janeway lesions (painless hemorrhagic cutaneous lesions on the palms and soles), intracranial hemorrhage, conjunctival hemorrhage, splinter haemorrhages
• Immunologic phenomena: Glomerulonephritis, Osler's nodes (painful subcutaneous lesions in the distal fingers), Roth's spots on the retina, positive serum rheumatoid factor

An analogue medical thermometer showing the temperature of 38. ... An echocardiogram. ... Murmurs are abnormal heart sounds that are produced as a result of turbulent blood flow which is sufficient to produce audible noise. ... For other uses, see Stroke (disambiguation). ... The parietal lobe is a lobe in the brain. ... The human brain In animals, the brain (enkephalos) (Greek for in the skull), is the control center of the central nervous system, responsible for behavior. ... Gangrene is the necrosis and subsequent decay of body tissues caused by infection or thrombosis. ... Janeway lesions are non-tender, small erythematous or haemorrhagic macules or nodules in the palms or soles, which are pathognomonic of infective endocarditis. ... Glomerulonephritis, also known as glomerular nephritis and abbreviated GN, is a primary or secondary immune-mediated renal disease characterized by inflammation of the glomeruli, or small blood vessels in the kidneys. ... Oslers nodes are red, raised lesions in the finger pads, indicative of the heart disease, subacute bacterial endocarditis. ... A lesion is a non-specific term referring to abnormal tissue in the body. ... Roths spots are retinal hemorrhages with white or pale centers composed of coagulated fibrin. ... Human eye cross-sectional view. ... Rheumatoid factor (RF) is a blood test performed in patients with suspected rheumatoid arthritis (RA). ...

Diagnosis

In general, a patient should fulfill the Duke Criteria^[1] in order to establish the diagnosis of endocarditis.

As the Duke Criteria relies heavily on the results of echocardiography, research has addressed when to order an echocardiogram by using signs and symptoms to predict occult endocarditis among patients with intravenous drug abuse^[2][3][4] and among non drug-abusing patients ^[5][6]. Unfortunately, this research is over 20 years old and it is possible that changes in the epidemiology of endocarditis and bacteria such as staphylococcus make the following estimates incorrectly low. An echocardiogram. ... The echocardiogram is an ultrasound of the heart. ... Species S. aureus S. caprae S. epidermidis S. haemolyticus S. hominis S. lugdunensis S. pettenkoferi S. saprophyticus S. warneri S. xylosus Staphylococcus (in Greek staphyle means bunch of grapes and coccos means granule) is a genus of Gram-positive bacteria. ...

Among patients who do not use illicit drugs and have a fever in the emergency room, there is a less than 5% chance of occult endocarditis. Mellors ^[6] in 1987 found no cases of endocarditis nor of staphylococcal bacteremia among 135 febrile patients in the emergency room. The upper confidence interval for 0% of 135 is 5%, so for statistical reasons alone, there is up to a 5% chance of endocarditis among these patients. In contrast, Leibovici ^[5] found that among 113 non-selected adults admitted to the hospital because of fever there were two cases (1.8% with 95%CI: 0% to 7%) of endocarditis. Species S. aureus S. caprae S. epidermidis S. haemolyticus S. hominis S. lugdunensis S. saprophyticus S. warneri S. xylosus Staphylococcus (in Greek staphyle means bunch of grapes and coccos means granule) is a genus of gram-positive bacteria. ...

Among patients who do use illicit drugs and have a fever in the emergency room, there is about a 10% to 15% prevalence of endocarditis. This estimate is not substantially changed by whether the doctor believes the patient has a trivial explanation for their fever^[4]. Weisse^[2] found that 13% of 121 patients had endocarditis. Marantz ^[4] also found a prevalence of endocarditis of 13% among such patients in the emergency room with fever. Samet ^[3] found a 6% incidence among 283 such patients, but after excluding patients with initially apparent major illness to explain the fever (including 11 cases of manifest endocarditis), there was a 7% prevalence of endocarditis.

Among patients with staphylococcal bacteremia (SAB), one study found a 29% prevalence of endocarditis in community-acquired SAB versus 5% in nosocomial SAB^[7]. However, only 2% of strains were resistant to methicillin and so these numbers may be low in areas of higher resistance.

Echocardiography
The transthoracic echocardiogram has a sensitivity and specificity of approximately 65% and 95% if the echocardiographer believes there is 'probabable' or 'almost certain' evidence of endocarditis^[8][9].

[Discussion is needed here, including transthoracic versus transesophageal]

Blood Cultures:-

• >3 Blood samples from 3 different venepuncture sites

ECGs (MI)

Chest X-Ray (Pulmonary Embolism at Right sided failure)

Duke's Criteria

Major Criteria

 Positive blood culture for Infective Endocarditis Typical microorganism consistent with IE from 2 separate blood cultures, as noted below: • viridans streptococci, Streptococcus bovis, or HACEK group (what's this?), or • community-acquired Staphylococcus aureus or enterococci, in the absence of a primary focus or Microorganisms consistent with IE from persistently positive blood cultures defined as: • 2 positive cultures of blood samples drawn >12 hours apart, or • all of 3 or a majority of 4 separate cultures of blood (with first and last sample drawn 1 hour apart) Evidence of endocardial involvement Positive echocardiogram for IE defined as : • oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets, or on implanted material in the absence of an alternative anatomic explanation, or • abscess, or • new partial dehiscence of prosthetic valve or New valvular regurgitation (worsening or changing of preexisting murmur not sufficient) 

Minor Criteria

1.Predisposing factor presence 2.Fever >38 degree Celcius 3.Immunological problems like Glomerulonephritis, Osler's Nodes 4.Positive Blood Culture 5.Evidence of embolism 6. Positive Echocardiogram

Micro-organisms responsible

Many types of organism can cause infective endocarditis. These are generally isolated by blood culture, where the patient's blood is removed, and any growth is noted and identified. blood culture Blood culture is microbiological culture of blood. ...

Alpha-haemolytic streptococci, that are present in the mouth will often be the organism isolated if a dental procedure caused the bacteraemia. Streptococcus is a genus of spherical shaped Gram-positive bacteria, belonging to the phylum Firmicutes[1] and the lactic acid bacteria group. ...

If the bacteraemia was introduced through the skin, such as contamination in surgery, during catheterisation, or in an IV drug user, Staphylococcus aureus is common.

A third important cause of endocarditis is Enterococci. These bacteria enter the bloodstream as a consequence of abnormalities in the gastrointestinal or urinary tracts. Enterococci are increasingly recognized as causes of nosocomial or hospital-acquired endocarditis. This contrasts with alpha-haemolytic streptococci and Staphylococcus aureus which are causes of community-acquired endocarditis. Species E. faecalis etc. ... Species E. faecalis etc. ... Binomial name Rosenbach 1884 Staphylococcus aureus , literally Golden Cluster Seed and also known as golden staph, is the most common cause of staph infections. ...

Some organisms, when isolated, give valuable clues to the cause, as they tend to be specific.

• Candida albicans, a yeast, is associated with IV drug users and the immunocompromised.
• Pseudomonas species, which are very resilient organisms that thrive in water, may contaminate street drugs that have been contaminated with drinking water. P. aeruginosa can infect a child through foot punctures, and can cause both endocarditis and septic arthritis.^[10]
• Streptococcus bovis and Clostridium septicum, which are part of the natural flora of the bowel, are associated with colonic malignancies. When they present as the causative agent in endocarditis, it usually call for a concomitant colonoscopy due to worries regarding hematogenous spread of bacteria from the colon due to the neoplasm breaking down the barrier between the gut lumen and the blood vessels which drain the bowel.^[11]
• HACEK organisms are a group of bacteria that live on the dental gums, and can be seen with IV drug abusers who contaminate their needles with saliva. Patients may also have a history of poor dental hygiene, or pre-existing valvular disease.^[12]

Binomial name Candida albicans (C.P. Robin) Berkhout 1923 Synonyms Candida stellatoidea [1] Candida albicans is a diploid asexual fungus (a form of yeast), and a causal agent of opportunistic oral and vaginal infections in humans. ... Typical divisions Ascomycota (sac fungi) Saccharomycotina (true yeasts) Taphrinomycotina Schizosaccharomycetes (fission yeasts) Basidiomycota (club fungi) Urediniomycetes Sporidiales Yeasts are a growth form of eukaryotic microorganisms classified in the kingdom Fungi, with approximately 1,500 species described. ... Immunosuppression is the medical suppression of the immune system. ... Type species Pseudomonas aeruginosa Species group P. aeruginosa P. alcaligenes P. anguilliseptica P. argentinensis P. borbori P. citronellolis P. flavescens P. mendocina P. nitroreducens P. oleovorans P. pseudoalcaligenes P. resinovorans P. straminea group P. aurantiaca P. aureofaciens P. chlororaphis P. fragi P. lundensis P. taetrolens group P. antarctica P. azotoformans... Binomial name Pseudomonas aeruginosa (Schroeter 1872) Migula 1900 Synonyms Bacterium aeruginosum Schroeter 1872 Bacterium aeruginosum Cohn 1872 Micrococcus pyocyaneus Zopf 1884 Bacillus aeruginosus (Schroeter 1872) Trevisan 1885 Bacillus pyocyaneus (Zopf 1884) Flügge 1886 Pseudomonas pyocyanea (Zopf 1884) Migula 1895 Bacterium pyocyaneum (Zopf 1884) Lehmann and Neumann 1896 Pseudomonas polycolor... Septic arthritis is the proliferation of bacteria in joints and resultant inflammation. ... Streptococcus bovis is a rare cause of neonatal septicaemia and meningitis. ... Diagram of the stomach, colon, and rectum Colorectal cancer includes cancerous growths in the colon, rectum and appendix. ... Colonoscopy is the minimally invasive endoscopic examination of the large colon and the distal part of the small bowel with a CCD camera or a fiber optic camera on a flexible tube passed through the anus. ... A HACEK organism is one of a set of slow-growing Gram negative bacteria that form a normal part of the human flora. ...

Treatment

High dose antibiotics are administered by the intravenous route to maximize diffusion of antibiotic molecules into vegetation(s) from the blood filling the chambers of the heart. This is necessary because neither the heart valves nor the vegetations adherent to them are supplied by blood vessels. Antibiotics are continued for a long time, typically two to six weeks. Specific drug regimens differ depending on the classification of the endocarditis as acute or subacute (acute necessitating treating for Staphylococcus aureus with oxacillin or vancomycin in addition to gram-negative coverage). Fungal endocarditis requires specific anti-fungal treatment, such as amphotericin B. Staphylococcus aureus - Antibiotics test plate. ... Binomial name Rosenbach 1884 Staphylococcus aureus , literally Golden Cluster Seed and also known as golden staph, is the most common cause of staph infections. ... Oxacillin sodium (Bactocill®) is an beta-lactam antibiotic in the penicillin class. ... Crystal structure of a short peptide L-Lys-D-Ala-D-Ala (bacterial cell wall precursor, in green) bound to vancomycin (blue) through hydrogen bonds. ... Bacteria that are Gram-negative are not stained dark blue or violet by Gram staining, in contrast to Gram-positive bacteria. ... Divisions Chytridiomycota Zygomycota Ascomycota Basidiomycota The Fungi (singular: fungus) are a large group of organisms ranked as a kingdom within the Domain Eukaryota. ... Amphotericin B (Fungilin®, Fungizone®, Abelcet®, AmBisome®, Fungisome®, Amphocil®, Amphotec®) is a polyene antimycotic drug, used intravenously in systemic fungal infections. ...

Surgical removal of the valve is necessary in patients who fail to clear micro-organisms from their blood in response to antibiotic therapy, or in patients who develop cardiac failure resulting from destruction of a valve by infection. A removed valve is usually replaced with an artificial valve which may either be mechanical (metallic) or obtained from an animal such as a pig; the latter are termed bioprosthetic valves.

Infective endocarditis is associated with a 25% mortality.

Non-infective endocarditis

Non-infective or marantic endocarditis is rare. A form of sterile endocarditis is termed Libman-Sacks endocarditis; this form occurs more often in patients with lupus erythematosus and the antiphospholipid syndrome. Non-infective endocarditis may also occur in patients with cancers, particularly mucinous adenocarcinoma. A rare disease (sometimes known as an orphan disease) has such a low prevalence in a population that a doctor in a busy general practice would not expect to see more than one case a year. ... Libman-Sachs endocarditis is a form of nonbacterial endocarditis that is seen in systemic lupus erythematosus. ... This article, image, template or category should belong in one or more categories. ...

References

A digital object identifier (or DOI) is a standard for persistently identifying a piece of intellectual property on a digital network and associating it with related data, the metadata, in a structured extensible way. ... Year 2001 (MMI) was a common year starting on Monday (link displays the 2001 Gregorian calendar). ... is the 158th day of the year (159th in leap years) in the Gregorian calendar. ... Year 2005 (MMV) was a common year starting on Saturday (link displays full calendar) of the Gregorian calendar. ...

External links

• Endocarditis information from Seattle Children's Hospital Heart Center