Alternate Names: Subacute endocarditis; Acute endocarditis; Bacterial endocarditis

Causes and Risks:

Infectious endocarditis involves the heart valves. It can be associated with infection of the heart muscle (myocarditis) or lining of the heart (pericarditis). Most people who develop infectious endocarditis have underlying heart disease. Sources of the infection may be transient bacteremia, which is common during dental, upper respiratory, urologic, and lower gastrointestinal diagnostic and surgical procedures. The infection can cause growths on the heart valves, the lining of the heart, or the lining of the blood vessels. These growths may be dislodged and send clots to the brain, lungs, kidneys, or spleen.

Many bacteria can cause endocarditis but a common mouth organism, Streptococcus viridans, is responsible for approximately half of all bacterial endocarditis. Other common organisms include staphylococcus and group D streptococcus. Less common organisms include Pseudomonas, Serratia, Candida, and many others.

Endocarditis may develop symptoms slowly (subacute) or suddenly (acute). Fever is a hallmark of both. In the slower form, fever may be present on a daily basis for months before other symptoms appear. Other symptoms are nonspecific, such as fatigue, malaise (general discomfort), headache, and night sweats. As the illness progresses, small dark lines, called splinter hemorrhages, may appear under the fingernails.

The health care provider may hear changing murmurs and detect an enlarged spleen and mild anemia. Murmurs result from changes in blood flow across valves when clumps of bacteria, fibrin and cellular debris, called vegetations, collect on the heart valves. The mitral valve is the most common valve affected, followed by the aortic valve.

Preexisting conditions that increase the likelihood of developing endocarditis include:

• congenital heart disease: ASD (atrial septal defect), PDA (patent ductus arteriosus), and others.
• prior rheumatic heart disease
• cardiac valve anomalies (such as mitral insufficiency)
• prosthetic heart valves

Since Streptococcus viridans is a common mouth organism and the most common cause of bacterial endocarditis, dental procedures can put children with congenital heart conditions at risk for endocarditis. It is common practice for children with some forms of congenital heart disease to start on antibiotics prior to any dental procedures.

Prevention:

Preventive (prophylactic) antibiotics are often given to people with predisposing congenital or valvular abnormalities before dental procedures or surgeries involving the respiratory, urinary, or intestinal tract. Continued medical follow-up is advised for people with a previous history of infective endocarditis.

Symptoms:

• fatigue
• weakness
• fever
• chills
• night sweats, may be severe
• weight loss
• muscle aches and pains
• heart murmur
• shortness of breath with activity
• swelling of feet, legs, abdomen
• blood in the urine
• sweating, excessive
• skin spots, red - on the palms and soles, called Janeway lesions
• paleness
• nail abnormalities (splinter hemorrhages under the nails)
• joint pain
• abnormal urine color
• red, painful intradermal nodes in the pads of the fingers and toes called Osler’s nodes

Signs and Tests:

A history of congenital heart disease raises the index of suspicion. Physical examination may show an enlarged spleen (splenomegaly). The examiner may detect a new heart murmur, or a change in a previous heart murmur. Examination of the nails may show splinter hemorrhages. Eye examination may show retinal hemorrhages with a central area of clearing, called Roth’s spots.

Tests:

• Repeated blood culture and sensitivity (#1 test for detection)
• ESR
• CBC may show low grade, microcytic (small red blood cells) anemia
• echocardiogram
• transesophageal echocardiogram
• chest X-ray
• CT scan of the chest
• ASO

Treatment:

Hospitalization is required initially to administer intravenous antibiotics. Long-term high-dose antibiotic therapy is required to eradicate the bacteria from the heart chambers and vegetations on the valves. Therapy up to 6 weeks is not uncommon. The chosen antibiotic must be specific for the organism causing the condition. This is determined by the blood culture and the sensitivities tests.

If heart failure develops as a result of damaged heart valves, surgery to replace the affected heart valve may be indicated.

Prognosis: Early treatment of bacterial endocarditis generally results in a good outcome. Valvular damage may be present if diagnosis and treatment are delayed.

Complications:

• congestive heart failure if treatment is delayed
• blood clots or emboli that travel to brain, kidneys, lungs, or abdomen causing severe damage to these organs
• arrhythmias (rapid or irregular heartbeat), such as atrial fibrillation
• glomerulonephritis
• severe valve damage
• stroke
• brain abscess
• neurologic changes
• jaundice

Call your health care provider if you note the following symptoms during or after treatment:

• weight loss without change in diet
• blood in urine
• chest pain
• weakness
• numbness or weakness of muscles
• fever