Endocarditis - Overview and Differential Diagnosis Framework Who? Infectious: • Pre-existing valvular disease • Prosthetic valve • Congenital heart disease • IV substance use • IV catheter • Recent dental procedure • Cardiac implantable electronic devices (CIED) Non-Infectious (NTBE): • Malignancy (Marantic, verrucous) - Lung, Pancreas, Gastric & Ovarian CA, involves aortic and mitral regurgitation • Autoimmune (SLE Libman Sacks) • Atrial myxoma • Hypercoagulable (APLAS) Microbiology: Blood cultures are positive in 90% of IE cases Culture Positive: • Acute: S. Aureus, S. Epidermidis, S. Pyogenes, Enterococci • Subacute: S. Viridans (Sanguinis, Mitis, Oralis, Mutans), S. Bovis, S. gallolyticus, HACEK, H. Parainfluenzae, H. Influenza • Prosthetic Valve Endocarditis: s. aureus, Coagulase-negative staphylococci Culture Negative: • Bartonella • Brucella • Coxiella Burnetii • Streptobacillus Moniliformis • Tropheryma Whipplei • Aspergillus • Cryptococcus, Histoplasma What? Generalized: Chills, night sweats, fever, Malaise, fatigue, weight loss, Myalgias Cardiac: • New cardiac murmur • Valvular insufficiency • New-onset heart failure • Dyspnea Vascular: • Systemic emboli: Cerebral > Splenic, Pulmonary • Janeway lesions • Mycotic aneurysm • Splinter hemorrhages • Petechiae Immunologic: • Osler nodes • Roth’s spots • Glomerulonephritis DDX: • Rheumatic valvular disease • Degenerative valvular disease • Vasculitis • Cholesterol emboli syndrome • Fibroelastoma • Lamb’s excrescences • Paradoxical emboli via ASD • Metastatic disease and tumor embolism Septic emboli cause injury by: • Early embolic/ischemic insult due to vascular occlusion that may lead to infarction • Infectious insult that leads to inflammation and possible abscess formation • Other vegetations can also embolize: Marantic (NTBE) Diagnosis: • Blood cultures • 2D Echo TTE ○ TTE nondiagnostic + ↑Suspicion → TEE • Duke Criteria • ↑ ESR, CRP • EKG: Conduction abnormalities (suggests perivalvular abscess) • Leukocytosis, anemia, and hematuria, + RF Treatment • IV antibiotics • Surgery • Marantic: Treat underlying cause + Systemic anticoagulation Pearls? • Left sided > Right sided • IV substance use: R > L Tricuspid • Marantic: Emboli > Regurgitation • Colon CA: S. Bovis, gallolyticus, clostridium septicum • S. Viridans Surgery: • Valvular dysfunction → symptomatic heart failure • Left sided IE: Heart block, annular or aortic abscess, or destructive lesion • Complications: Abscess, destructive penetrating lesions, heart block • Persistent bacteremia/fevers > than 5 to 7 days after onset of appropriate antimicrobial therapy • >10-mm left sided vegetations to prevent emboli • S. aureus prosthetic valve endocarditis #Endocarditis #Differential #Diagnosis #cardiology #infectiousdiseases
