eMedicine Specialties > Infectious Diseases > Cardiovascular and Intravascular Infections

Infective Endocarditis: Differential Diagnoses & Workup

Author: John L Brusch, MD, FACP, Assistant Professor of Medicine, Harvard Medical School; Consulting Staff, Department of Medicine and Infectious Disease Service, Cambridge Health Alliance
Contributor Information and Disclosures

Updated: Aug 23, 2009

Differential Diagnoses

Antiphospholipid Syndrome
Reactive Arthritis
Atrial Myxoma
Systemic Lupus Erythematosus
Cardiac Neoplasms, Primary
Lyme Disease
Polymyalgia Rheumatica

Other Problems to Be Considered

Thrombotic nonbacterial endocarditis
Vasculitis
Temporal arteritis
Marantic endocarditis

Workup

Laboratory Studies

  • The criterion standard test for diagnosing infective endocarditis (IE) is the documentation of a continuous bacteremia (>30 min in duration) based on blood culture results.
    • Exceptions are observed in patients with prosthetic valve endocarditis (PVE) and right-sided IE. Approximately 5-10% of patients with IE have false-negative blood culture results. Prior use of antibiotics is the most common cause of false-negative blood culture results (see Organism clinical features). Other causes include fastidious organisms and inadequate blood volume; a blood-to-broth ratio of 1:10 is needed. Currently, with modern automated blood culture systems, fastidious organisms such as nutritionally variant streptococci and members of the HACEK group rarely cause culture-negative IE.
    • As many as 50% of positive blood culture results have been estimated to be falsely positive. This rate has probably decreased, but false-positive blood culture results remain a major diagnostic challenge. One such result can lead to 4 days of unnecessary patient hospitalization. The significance of positive blood culture results correlates with (1) the type of organism, (2) the clinical setting (CoNS are significant in patients with prosthetic valves but not in those with native valves.), (3) multiple blood cultures positive for the same organism, (4) shorter incubation time for recovery, and (5) the degree of severity of clinical illness.
    • Never draw only one set of blood cultures; one is worse than none. For diagnosing subacute IE, draw 3-5 sets of blood cultures over 24 hours. This helps detect 92-98% of cases in patients who have not recently received antibiotics. In the case of acute IE, 3 sets may be drawn over 30 minutes (with separate venipunctures) to help document a continuous bacteremia.
    • Using various types of blood culture bottles (with resins added to interfere with antibiotic action) probably has little advantage. Some of these may interfere with bacterial growth.
    • When blood culture results fail to show an infectious agent after blood is drawn 48 hours after antibiotic therapy has been stopped, the second set of blood for cultures must be drawn approximately 7 days later. If these later culture results remain negative, the diagnosis of IE must be reconsidered. In general, blood for culture should not be drawn through intravenous lines unless this is part of an approach for diagnosing line infection.
  • The diagnosis of catheter infection may be made in 1 of 2 ways, as follows:
    • Culturing the device via the roll-plate semiquantitative method is the most common approach but requires a catheter removal. In the case of long-term catheters, blood may be drawn simultaneously through the line and the peripheral vein. If it is impossible to draw blood from a peripheral vein in the presence of a multilumen catheter, one sample may be obtained through each of 2 catheter lumens. In a catheter infection, the colony count of the sample obtained from the suspected port is 3-fold greater than that drawn from a peripheral vein or from another port of the catheter. Retrieval of organisms from blood drawn from a catheter hub at least two hours earlier before their growth is detected in the blood obtained from peripheral vein meets the differential time to positivity criteria of a catheter infection.
    • A sterile culture of the insertion site has a highly negative predictive value for line infection.
  • Patients with culture-negative IE occasionally present with signs and symptoms highly suggestive of IE, but the blood cultures remain negative.
    • Valvular vegetations may be detected during cardiac ultrasonographic examinations, but the blood culture results are persistently negative. In this situation, 3 separate blood cultures spaced over a 24-hour period are usually sufficient to detect microorganisms in the blood. Additional blood cultures are not usually helpful.
    • The most common cause of culture-negative IE is prior antimicrobial therapy that can suppress bacterial growth within the vegetation but is insufficient to eliminate the valvular infection.
    • Many pathogens once considered to be fastidious are no longer classified as such (see above). Bartonella, Legionella, and C burnetii remain significant causes of culture-negative IE. These require special culture media or a prolonged incubation period for retrieval. C burnetii IE is usually diagnosed with serological testing. Buffered charcoal and yeast agar are required for the isolation of Legionella. Brucella species require up to 6 weeks.
  • Serologic tests are often the most practical means for diagnosing valvular infection with fastidious organisms (eg, C burnetii and Chlamydia, Brucella, and Legionella species).
  • Most types of fungal IE have a low rate of positive blood culture results. At best, only 50% of Candida species are associated with positive blood culture results. Histoplasma and Aspergillus are almost never retrieved from the bloodstream. Fungal endocarditis must always be considered in the clinical setting of culture-negative IE that fails to respond to appropriate antibiotic therapy.
  • Establishing the diagnosis of pacemaker IE is difficult because of its subtle presentation, especially late-onset disease. The addition of pocket infection and the presence of pulmonary emboli to the Duke criteria have increased the rate of diagnosis from 16% to 87.5% of cases. Importantly, fever and/or a positive blood culture result without evidence of a primary source in patients with a pacemaker or implantable cardioverter-defibrillator represents device-associated IE until proven otherwise.33,34,35,36,37,38,39

Imaging Studies

  • Although blood cultures remain key in making the diagnosis of IE, the need for indirect diagnostic techniques that are both specific and sensitive is increasing. This is because the nature of valvular infections has changed over the years. The numbers of fastidious organisms have increased, and the rate of the classic peripheral stigmata of IE is much lower. Patients who are elderly, chronically ill, or immunosuppressed are often afebrile and unable to mount a significant fever or exhibit the classic stigmata of valvular infection.
  • Echocardiography has become the indirect diagnostic method of choice, especially in patients who present with a clinical picture of IE but who have nondiagnostic blood culture results. Echocardiography is useful for predicting the potential complications of IE, especially those that are embolic in nature (see Complications). The diagnosis of IE can never be excluded based on negative echocardiogram findings, either transthoracic or transesophageal.
    • Transthoracic echocardiography (TTE) can detect vegetations in approximately 60% of patients with native valve endocarditis (NVE) but in only 20% of patients with PVE.
    • Transesophageal echocardiography (TEE) was developed to overcome the problems in visualizing prosthetic valve thrombi and right-sided events. TEE eliminates the need for the operator to find a clear field for the beam. The use of higher-frequency waveforms is permitted because of the decreased distance between the heart and the probe. The sensitivity of TEE in detecting the vegetations of NVE is 90-100%. In patients with PVE, the sensitivity of TEE under optimal circumstances is greater than 90%. TEE is far more sensitive than TTE for detecting myocardial abscesses (95% vs 28%).
    • TEE successfully visualizes vegetations of the leads or of the tricuspid valve in more than 90% of cases of pacemaker IE, compared with less than the 50% achieved by TTE.
    • Neither TEE nor TTE should be used for screening purposes (ie, patients with fever of unknown origin or those with positive blood culture results and no other signs or symptoms of IE) because nearly 60% of vegetations revealed are sterile. Approximately 15% of positive study results are false-positive results because the images are, in reality, not those of vegetations but of thickened valves, nodules, or valvular calcifications.
    • Echocardiographic predictors of systemic embolization in patients with IE are (1) large valvular vegetations (>10 mm in diameter), (2) multiple vegetations, (3) mobile but pedunculated vegetations, (4) noncalcified vegetations, (5) vegetations that are increasing in size, and (6) prolapsing vegetations.
    • In summary, the indications for performing echocardiography with Doppler in patients with IE are (1) to provide a baseline in proven or highly suggestive cases of IE and (2) to provide a means of documenting complications during therapy.
      • In most cases, TTE is sufficient.
      • TEE is indicated (1) when mechanical prosthetic valves are present, (2) to detect right-sided lesions, and (3) to visualize myocardial abscesses. Because of the endoscopic portion of the test, TEE carries the risk factor of inducing bacteremias.
      • Approximately 15% of cases of IE do not demonstrate any detectable vegetations at the time of the echocardiographic study.
  • Two-dimensional cardiac ultrasound Doppler testing has been a significant advance for diagnosing and evaluating IE. It provides information about the presence and size of vegetations, which helps in diagnosis and, to some extent, in predicting embolization.
    • The Doppler method can detect distorted blood flow and certain types of cardiac pathology not otherwise visualized by standard echocardiography.
    • It is good for visualizing jet lesions and differentiating cusp perforation from valvular insufficiency.
    • The combination of TEE and color Doppler is excellent for detecting intracardiac fistulas.
    • The resolution of either TEE or TTE in real life is approximately 2 mm.
    • Conditions that are positively related to the detection of valvular thrombi are (1) the location, ie, right-sided structures are poorly visualized, especially by TTE; (2) disease lasting longer than 2 weeks; (3) abscesses of the valves or myocardium; and (4) aneurysms of the sinus of Valsalva.
  • Various radionuclide scans using, for example, gallium Ga 67–tagged white cells and indium In 111–tagged white cells, have proven to be of little use in diagnosing IE. Radionuclide scans of the spleen are useful to help rule out a splenic abscess, which is a cause of bacteremia that is refractory to antibiotic therapy.
  • A CT scan of the head should be obtained in patients who exhibit CNS symptoms or findings consistent with a mass effect (eg, macroabscess of the brain).40,41,42

Other Tests

  • Electrocardiography may help detect the 10% of patients who develop a conduction delay during IE by documenting an increased P-R interval.
  • Rheumatoid factor (ie, "poor man's" circulating immune complex) becomes positive in 50% of patients with subacute disease. It becomes negative after successful treatment.
  • Durack and colleagues developed diagnostic criteria that combine the clinical, microbiological, pathological, and echocardiographic characteristics of a specific case.43
    • Major blood culture criteria
      • Two blood cultures positive for organisms typically found in patients with IE (ie, S viridans, Streptococcus bovis, a HACEK group organism, community-acquired S aureus, or enterococci in the absence of a primary focus)
      • Blood cultures persistently positive for one of the above organisms from cultures drawn more than 12 hours apart
      • Three or more separate blood cultures drawn at least 1 hour apart
    • Major echocardiographic criteria
      • Echocardiogram positive for IE, documented by an oscillating intracardiac mass on a valve or on supporting structures, in the path of regurgitant jets, or on implanted material in the absence of an alternative anatomical explanation
      • Myocardial abscess
      • Development of partial dehiscence of a prosthetic valve
      • New-onset valvular regurgitation
    • Minor criteria
      • Predisposing heart condition or intravenous drug use
      • Fever of 38°C (100.4°F) or higher
      • Vascular phenomenon, including major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhage, or Janeway lesions
      • Immunological phenomenon such as glomerulonephritis, Osler nodes, Roth spots, and rheumatoid factor
      • Positive blood culture results not meeting major criteria or serologic evidence of active infection with an organism consistent with IE (eg, Brucella, C burnetii [ie, Q fever], Legionella)
      • Echocardiogram results consistent with IE but not meeting major echocardiographic criteria
    • Definitive pathological diagnosis is established by demonstrating microorganisms, by culture or histology, in vegetations removed by surgery, embolectomy, or drainage of an intracardiac abscess. Alternatively, a definitive clinical diagnosis is made based on the presence of 2 major criteria, 1 major criterion and 3 minor criteria, or by 5 minor criteria.
    • A diagnosis of possible IE is made when findings consistent with IE fall short of the criteria for definite IE but do not meet the criteria for rejection.
    • Rejection criteria for the diagnosis of IE are as follows:
      • The presence of a firm alternative diagnosis of the manifestations of endocarditis
      • Resolution of manifestations of endocarditis after 4 or fewer days of antimicrobial therapy
      • No pathologic evidence of IE at surgery or autopsy after 4 or fewer days of antimicrobial therapy
    • These criteria may, at times, overdiagnose IE and may not be as applicable in patients with subacute disease.
  • A major clinical challenge is that at least 25% of S aureus BSIs represent IE or metastatic infections. The question is whether a continuous bacteremia in the presence of an intravascular line is representative of IE.
    • Blood cultures should only be drawn through intravascular lines for the purpose of diagnosing catheter-related BSIs and have limited value for answering this clinical challenge.
    • Because of the ability of S aureus to produce an endotheliosis, the presence of a continuous bacteremia does not necessarily imply an infected valvular vegetation.
    • An important clue to continuous bacteremia/IE is the presence of S aureus bacteruria associated with hematuria. Hematuria in the setting of IE is due to embolic renal infarction or immunologically mediated glomerulonephritis. Echocardiography has developed into a useful tool for meeting this clinical challenge.
    • Twenty-five percent of patients with staphylococcal bacteremia and 23% of those with catheters as the primary focus have evidence of IE based on TEE findings, in the absence of clinical and TTE findings.43

Procedures

  • Catheterization of the heart is rarely required for the diagnosis of IE or any of its complications. The findings from echocardiography correlate well with the findings from cardiac catheterization.

Histologic Findings

The characteristic findings of IE are intravascular endocardial vegetations that contain microorganisms surrounded by fibrin and platelets (see Pathophysiology).

More on Infective Endocarditis

Overview: Infective Endocarditis
Differential Diagnoses & Workup: Infective Endocarditis
Treatment & Medication: Infective Endocarditis
Follow-up: Infective Endocarditis
Multimedia: Infective Endocarditis
References
Further Reading
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Keywords

infective endocarditis, IE, subacute bacterial endocarditis, acute bacterial endocarditis, fungal endocarditis, nosocomial infective endocarditis, NIE, intravenous drug abuse endocarditis, intravenous drug abuse infective endocarditis, IVDA endocarditis, IVDA IE, prosthetic valve endocarditis, PVE, pacemaker endocarditis, PM infective endocarditis, PM IE, endocardial infection, rheumatic heart disease, RHD, calcific aortic stenosis, congenital heart disease, ventricular septal defect, VSD, tetralogy of Fallot, Fallot tetralogy, mitral valve prolapse, MVP, native valve endocarditis, NVE, HACEK infection, bloodstream infection

Staphylococcus aureus, S aureus, Streptococcus viridans, S viridans, Streptococcus intermedius, S intermedius, Pseudomonas aeruginosa, P aeruginosa, Haemophilus aphrophilus, H aphrophilus, Actinobacillus actinomycetemcomitans, A actinomycetemcomitans, C hominis, Cardiobacterium hominis, Eikenella corrodens, E corrodens, Kingella kingae, K kingae, Candida albicans, C albicans, Candida parapsilosis, C parapsilosis, Candida tropicalis, C tropicalis, Bartonella quintana, B quintana,Coxiella burnetii

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Contributor Information and Disclosures

Author

John L Brusch, MD, FACP, Assistant Professor of Medicine, Harvard Medical School; Consulting Staff, Department of Medicine and Infectious Disease Service, Cambridge Health Alliance
John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Medical Editor

Wesley W Emmons, MD, FACP, Assistant Professor, Department of Medicine, Thomas Jefferson University; Consulting Staff, Infectious Diseases Section, Department of Internal Medicine, Christiana Care, Newark, DE
Wesley W Emmons, MD, FACP is a member of the following medical societies: American College of Physicians, American Medical Association, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, and International AIDS Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Thomas M Kerkering, MD, Chief of Infectious Diseases, Virginia Tech, Carilion School of Medicine, Roanoke, Virginia
Thomas M Kerkering, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Public Health Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Medical Society of Virginia, and Wilderness Medical Society
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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