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Libman-Sacks Endocarditis Clinical Presentation

  • Author: Xiushui (Mike) Ren, MD; Chief Editor: Richard A Lange, MD, MBA  more...
 
Updated: Dec 23, 2014
 

History

Persons with Libman-Sacks endocarditis are usually asymptomatic. Patients who do become symptomatic, however, can display the following:

  • Cardiac failure - May develop secondary to valvular dysfunction (most commonly mitral regurgitation), leading to dyspnea, orthopnea, paroxysmal nocturnal dyspnea, peripheral edema, and lethargy
  • Cerebrovascular embolism - Can lead to symptoms of cerebral ischemia, including focal weakness and/or numbness, visual loss, dysphasia, dysarthria, dysphagia, and memory loss
  • Systemic thromboembolism - A rare manifestation that can result in a wide spectrum of symptoms, including pain, coldness and numbness of the peripheries, or acute abdominal syndromes with pain and vomiting
  • Secondary infective endocarditis - May manifest as fever, weight loss, night sweats, lethargy, and chest pain; these symptoms can be difficult to distinguish from underlying systemic lupus erythematosus disease activity

In addition, symptoms of systemic lupus erythematosus may be noted, including a history of rash, arthritis (joint pain and swelling), and sweating.

Antiphospholipid syndrome

Features of antiphospholipid syndrome may be noted in the history, including recurrent miscarriage, arterial thromboses, venous thromboses, and/or thrombocytopenia.

Patients may report pain, focal neurologic symptoms (eg, focal weakness and/or numbness, visual loss, dysphasia, dysarthria, dysphagia, memory loss), numbness and discoloration of the extremities, and ischemic chest pain with arterial thromboses.

Venous thromboembolism may result in peripheral swelling, pleuritic chest pain, dyspnea, and hemoptysis. Neurologic symptoms due to cerebral ischemia can also occur in the event of a paradoxical embolus.

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Physical Examination

Physical examination findings can be normal. In symptomatic cases, however, the following cardiac murmurs may be heard:

  • Ejection systolic murmur (crescendo decrescendo) - This is most commonly the result of a hyperdynamic state caused by associated conditions and can indicate aortic valve thickening with or without stenosis
  • Holosystolic murmur of mitral regurgitation or tricuspid regurgitation
  • Early diastolic murmur of aortic regurgitation - With or without an Austin-Flint murmur
  • Middiastolic, rumbling murmur of mitral stenosis

Other valvular dysfunction (eg, pulmonary stenosis or regurgitation, tricuspid stenosis) may occur, but only rarely is this due to Libman-Sacks endocarditis.

The following signs of ventricular enlargement and cardiac failure may be noted in Libman-Sacks endocarditis:

  • Tachypnea and cyanosis
  • Pulse - Plateau pulse, low-volume pulse, pulsus alternans
  • Jugular venous distention
  • Displaced apex beat
  • Third and/or fourth heart sounds
  • Pulmonary rales
  • Congestive hepatomegaly
  • Sacral and peripheral edema

A focal neurologic deficit secondary to embolic phenomena or thrombosis with or without the antiphospholipid syndrome may be noted.

Signs due to underlying systemic lupus erythematosus may be present, including rash and joint swelling.

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Contributor Information and Disclosures
Author

Xiushui (Mike) Ren, MD Cardiologist, The Permanente Medical Group; Associate Director of Research, Cardiovascular Diseases Fellowship, California Pacific Medical Center

Xiushui (Mike) Ren, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American Society of Echocardiography

Disclosure: Nothing to disclose.

Coauthor(s)

Elizabeth W Ryan, MBBS Visiting Medical Officer, Department of Medicine, Division of Cardiology, Barwon Health, Australia

Elizabeth W Ryan, MBBS is a member of the following medical societies: Cardiac Society of Australia and New Zealand, Royal Australasian College of Physicians

Disclosure: Nothing to disclose.

Elyse Foster, MD Director of Non-Invasive Cardiology, Department of Medicine, Division of Cardiology, Professor of Medicine, University of California, San Francisco, School of Medicine

Elyse Foster, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Heart Association, American Society of Echocardiography

Disclosure: Received grant/research funds from Abbott Vascular Structural Heart for research.

Chief Editor

Richard A Lange, MD, MBA President, Texas Tech University Health Sciences Center, Dean, Paul L Foster School of Medicine

Richard A Lange, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American Heart Association, Association of Subspecialty Professors

Disclosure: Nothing to disclose.

Acknowledgements

Craig T Basson, MD, PhD Gladys and Roland Harriman Professor of Medicine, Director of the Center for Molecular Cardiology, Director of Cardiovascular Research, Division of Cardiology, Department of Medicine, Weill Cornell Medical College; Attending Physician, New York Presbyterian Hospital

Craig T Basson, MD, PhD is a member of the following medical societies: American College of Cardiology and American Heart Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References
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  3. Moyssakis I, Tektonidou MG, Vasilliou VA, Samarkos M, Votteas V, Moutsopoulos HM. Libman-Sacks endocarditis in systemic lupus erythematosus: prevalence, associations, and evolution. Am J Med. July 2007. 120:636-42. [Medline]. [Full Text].

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  9. Dandekar UP, Watkin R, Chandra N, Santo KC, Bhudia S, Pitt M, et al. Aortic valve replacement for Libman-Sacks endocarditis. Ann Thorac Surg. 2009 Aug. 88(2):669-71. [Medline].

  10. Bouma W, Klinkenberg TJ, van der Horst IC, Wijdh-den Hamer IJ, Erasmus ME, Bijl M, et al. Mitral valve surgery for mitral regurgitation caused by Libman-Sacks endocarditis: a report of four cases and a systematic review of the literature. J Cardiothorac Surg. 2010 Mar 23. 5(1):13. [Medline]. [Full Text].

 
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Transesophageal image of a mitral valve with masses characteristic of Libman-Sacks endocarditis.
 
 
 
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