Endocarditis

Tags: endocarditis, endocardium, heart valves, bacterial endocarditis, infective endocarditis,

Endocarditis is an infection of the endocardium, which is the inner lining of the heart chambers and heart valves. Other structures that may be involved include the interventricular septum, the chordae tendineae, the mural endocardium, or the surfaces of intracardiac devices.

• Subdivisions of Endocarditis, Infective
  • Endocarditis, Bacterial Acute -- may affect normal heart valves
  • Endocarditis, Bacterial Subacute -- affects heart valves which have been previously damaged by disease
  • Endocarditis, Prosthetic Valvular (PVA) -- develops in patients who have previously had artificial (prosthetic) valve replacement or tissue valve replacement.
• This inner lining also covers the heart valves, and it is these valves which are primarily affected by infective endocarditis. If the infection remains untreated, multiplying bacteria may eventually destroy the valves and result in heart failure.
• Bacteria may also form small clots (emboli) which move through the blood and block small arteries. These clots may lodge in various parts of the body including the brain and cause serious damage.

Endocarditis generally occurs when bacteria, fungi or other germs from another part of the body, such as the mouth, spread through the bloodstream and attach to damaged areas in the heart.

If it's not treated quickly, endocarditis can damage or destroy the heart valves and can lead to life-threatening complications. Treatments for endocarditis include antibiotics and, in certain cases, surgery.

Since there are many ways to develop endocarditis, the doctor might not be able to pinpoint the exact cause. However, people at greatest risk of endocarditis usually have damaged heart valves, artificial heart valves or other heart defects.

Symptoms

Endocarditis may develop slowly or suddenly, depending on what germs are causing the infection and whether you have any underlying heart problems. Endocarditis signs and symptoms can vary from person to person.

Common signs and symptoms can include:

• Flu-like symptoms, such as fever and chills
• A new or changed heart murmur, which is the heart sounds made by blood rushing through your heart
• Fatigue
• Aching joints and muscles
• Night sweats
• Shortness of breath
• Chest pain when you breathe
• Swelling in your feet, legs or abdomen

More uncommon symptoms:

• Unexplained weight loss
• Blood in your urine, which you might be able to see or that your doctor might see when he or she views your urine under a microscope
• Tenderness in your spleen, which is an infection-fighting abdominal organ just below your rib cage on the left side of your body
• Janeway lesions, which are red spots on the soles of your feet or the palms of your hands
• Osler's nodes, which are red, tender spots under the skin of your fingers or toes
• Petechiae (puh-TEE-key-e), which are tiny purple or red spots on the skin, whites of your eyes, or inside your mouth
• With prolonged infection, clubbing of the fingers may also occur.
• Pale, oval spots on the retina of the eye (Roth’s spots) which may hemorrhage.

In addition to the general symptoms of infective endocarditis, specific symptoms may occur more frequently in different types of the disorder.

• Acute bacterial endocarditis
  • may develop valve abscesses and experience rapid destruction of the heart valves.
  • Painless, reddish-blue skin patches (Janeway lesions) may appear on the palms of the hands and the soles of the feet.
  • The course of acute bacterial endocarditis is very rapid.
• Subacute bacterial endocarditis
  • Progresses more slowly than acute bacterial endocarditis.
  • Along with the general symptoms of infective endocarditis, there may be coughing or pain in the chest, abdomen, fingers and toes.
  • A sensation of pricking, tingling or creeping of the skin (paresthesia) may be present.
  • May experience changes in a preexisting heart murmur or develop a new murmur.
  • May also be a rapid heartbeat (tachycardia).
• Prosthetic valvular endocarditis
  • may develop abscesses on or near the valves.
  • Bacteria may also grow in the heart and obstruct the flow of blood through it.
  • Abscesses may form in the middle muscular layer of the heart (myocardium), or the surgical wound may separate leading to instability of the artificial valve.
  • In addition to the general symptoms of infective endocarditis, there may be a heart murmur from blood flowing backward through a defective valve (regurgitative murmur) or a murmur suggestive of blood outflow obstruction (systolic murmur).

Clots (emboli) resulting from the infective endocarditis may produce serious damage, with symptoms depending upon the location of the clot. In 10% to 30% of individuals with infective endocarditis, clots lodge in the brain and may cause weakness on one side of the body, loss of vision or stroke. Clots may also cause abdominal pain, flank pain, or arterial insufficiency in an extremity. Damage from clots may be temporary or permanent.

When to see a doctor

If you develop signs or symptoms of endocarditis, and if they don't go away, see your doctor as soon as possible — especially if you have risk factors for this serious infection, such as a heart defect or a previous case of endocarditis.

Risk factors


If your heart is healthy, you could be less likely to develop endocarditis, although it is still possible. The germs that cause infection tend to stick to and multiply on damaged or surgically implanted heart valves, or on endocardium that has a rough surface.

People at highest risk of endocarditis are those who have:

• Artificial heart valves:. Germs are more likely to attach to an artificial (prosthetic) heart valve than to a normal heart valve.
• Congenital heart defects: If you were born with certain types of heart defects, such as an irregular heart or abnormal heart valves, your heart may be more susceptible to infection.
• A history of endocarditis. Endocarditis can damage heart tissue and valves, increasing the risk of a future heart infection.
• Damaged heart valves: Certain medical conditions, such as rheumatic fever or infection, can damage or scar one or more of your heart valves. This can make them more prone to endocarditis.
• A history of intravenous (IV) illegal drug use: People who use illegal drugs by injecting them are at a greater risk of endocarditis. The needles used to inject drugs can be contaminated with the bacteria that can cause endocarditis.
• Over 50% of infective endocarditis cases are associated with heart damage resulting from rheumatic fever.

Complications

In endocarditis, clumps of bacteria and cell fragments form in the heart at the site of the infection. These clumps, called vegetations, can break loose and travel to the brain, lungs, abdominal organs, kidneys or limbs. As a result, endocarditis can cause several major complications, including:

• Heart problems, such as heart murmur, heart valve damage, abnormal heartbeat and heart failure
  • Heart murmurs are present in over 85% of individuals
• Stroke
• Seizure
• Loss of the ability to move part of all of your body (paralysis)
• Pockets of collected pus (abscesses) that develop in the heart, brain, lungs and other organs
• Pulmonary embolism — an infected vegetation that travels to the lungs and blocks a lung artery
• Kidney damage
• Enlarged spleen -- 60% have enlarged spleens

Statistics

• Approximately twice as common in men as women
• The average age of onset is 50 years since antibiotics became available
• Most frequently affects individuals with heart valve damage due to rheumatic fever or birth defects of the heart (congenital heart defects) affecting heart chambers or valves.
• Common among those with artificial heart valves or changes of the valves due to aging.
• In individuals who have undergone surgical heart valve replacement, the risk of such infection appears to be highest within the first year after the procedure. Although the risk subsequently declines, it remains slightly higher than normal

Prognosis

• With prompt diagnosis and proper medical treatment, over 90% of patients with bacterial endocarditis recover.
• Those whose endocarditis affects the right side of the heart usually have a better outlook than those with left-side involvement.
• In cases in which endocarditis is caused by fungi, the prognosis is usually worse than for bacterial endocarditis.
• Untreated endocarditis is always fatal, but with early treatment, involving an aggressive use of antibiotics, most patients survive.
  • However, it can still be fatal in older people, patients with an underlying condition, and those whose infection involves a resistant type of bacteria.
• The National Heart, Lung and Blood Institute (NHLBI) encourage those who are at risk of endocarditis to have regular dental checkups and to brush and floss their teeth regularly. Since 2007, the American Heart Association (AHA) has recommended that those with a high risk of endocarditis should receive antibiotics before undergoing dental procedures.

Supporting Organizations:

• American Heart Association
• Centers for Disease Control and Prevention
• Genetic and Rare Diseases (GARD) Information Center
• NIH/National Heart, Lung and Blood Institute

Resources & Additional Reading

• Mayo Clinic - Endocarditis
• MedlinePlus - Endocarditis
• WebMD - What is Endocarditis?
• NORD (Rare Disease Database) - Endocarditis, Infective
• Cedars-Sinai -- Bacterial Endocarditis
• American Heart Association - Heart Valves and Infective Endocarditis
• Harvard Heath Publishing, Harvard Medical School - Endocarditis. Published: February 2019
• Medical News Today - Endocarditis: What you need to know. By: Christian Nordquist; Reviewed by Alana Biggers, MD, MPH. Last updated 22 Jan 2018
• Wikipedia - Endocarditis

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