eMedicine Specialties > Emergency Medicine > Infectious Diseases

Endocarditis: Differential Diagnoses & Workup

Author: Keith A Marill, MD, Faculty, Department of Emergency Medicine, Massachusetts General Hospital
Contributor Information and Disclosures

Updated: Nov 23, 2009

Differential Diagnoses

Endocarditis

Other Problems to Be Considered

Connective tissue disease
Fever of unknown origin (FUO)
Intra-abdominal infections
Septic pulmonary infarction
Tricuspid regurgitation

Workup

Laboratory Studies

  • Send baseline studies, such as CBC, electrolytes, creatinine, BUN, glucose, and coagulation panel, to the laboratory for testing.
  • Two sets of blood cultures have greater than 90% sensitivity when bacteremia is present. Three sets of cultures improve sensitivity and may be useful when antibiotics have been administered previously.
  • Anemia of chronic disease is common in subacute endocarditis
  • Erythrocyte sedimentation rate (ESR), while not specific, is elevated in more than 90% of cases.
  • Proteinuria and microscopic hematuria are present in approximately 50% of cases.
  • Leukocytosis is observed in acute endocarditis.
  • Anemia is present in subacute endocarditis.
  • Decreased C3, C4, and CH50 are evident in subacute endocarditis.
  • Rheumatoid factor is noted in subacute endocarditis.
  • Serology for Chlamydia, Q fever (Coxiella), and Bartonella may be useful in culture-negative endocarditis.

Imaging Studies

  • Echocardiography
    • Transesophageal echocardiography has a sensitivity of more than 90% for valvular lesions. Transthoracic echocardiography has generally had a sensitivity of approximately 60% for identification of valvular lesions. However, sensitivity was as high as 82% in a recent series where advanced harmonic imaging and digital processing techniques were used.11 Both techniques are highly specific for valvular vegetations.
    • This test is particularly indicated with culture-negative cases, such as in fungal endocarditis.
    • Visible vegetation suggests a worse prognosis.
    • Echocardiography, as in the image below, is highly useful to assess local complications, such as abscesses. Similar to valvular lesions, the transesophageal technique is generally more sensitive.12

    • This is a magnified portion of a parasternal long...

      This is a magnified portion of a parasternal long axis view from a transthoracic echocardiogram. There is a small curvilinear vegetation on the mitral valve as indicated. The patient presented with a headache and fever, and CT scan of the brain revealed an occipital hemorrhage. The patient had a history of intravenous drug use and multiple blood cultures grew Staphylococcus aureus.

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      This is a magnified portion of a parasternal long...

      This is a magnified portion of a parasternal long axis view from a transthoracic echocardiogram. There is a small curvilinear vegetation on the mitral valve as indicated. The patient presented with a headache and fever, and CT scan of the brain revealed an occipital hemorrhage. The patient had a history of intravenous drug use and multiple blood cultures grew Staphylococcus aureus.

  • Chest radiography: Pulmonary embolic phenomena strongly suggest tricuspid disease, as shown in the image below.

  • A young adult with a history of intravenous drug ...

    A young adult with a history of intravenous drug use, endocarditis involving the tricuspid valve with Staphylococcus aureus, and multiple septic pulmonary emboli. Pulmonary lesions on chest radiograph are most prominent in the right upper lobe with both solid and cavitary appearance.

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    A young adult with a history of intravenous drug ...

    A young adult with a history of intravenous drug use, endocarditis involving the tricuspid valve with Staphylococcus aureus, and multiple septic pulmonary emboli. Pulmonary lesions on chest radiograph are most prominent in the right upper lobe with both solid and cavitary appearance.

  • Ventilation/perfusion (V/Q) scanning: This may be useful in right-sided endocarditis.
  • Computed tomography (CT) scanning: This imaging modality has proven most useful for localizing abscesses. With new advanced multislice techniques, CT can now also be used to identify valvular abnormalities and vegetations.13

Other Tests

  • Electrocardiography
    • Nonspecific changes are common.
    • First-degree AV block and new interventricular conduction delays may signal septal involvement in aortic valve disease; both are poor prognostic signs.

Procedures

  • Cardiac catheterization may be indicated to determine the degree of valvular damage.

More on Endocarditis

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

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Contributor Information and Disclosures

Author

Keith A Marill, MD, Faculty, Department of Emergency Medicine, Massachusetts General Hospital
Keith A Marill, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Medtronic Ownership interest None; Cambridge Heart, Inc. Ownership interest None

Medical Editor

Steven A Conrad, MD, PhD, Chief, Department of Emergency Medicine; Chief, Multidisciplinary Critical Care Service, Professor, Department of Emergency and Internal Medicine, Louisiana State University Health Sciences Center
Steven A Conrad, MD, PhD is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American College of Emergency Physicians, American College of Physicians, International Society for Heart and Lung Transplantation, Louisiana State Medical Society, Shock Society, Society for Academic Emergency Medicine, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

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

Managing Editor

Jon Mark Hirshon, MD, MPH, Associate Professor, Department of Emergency Medicine, University of Maryland School of Medicine
Jon Mark Hirshon, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Public Health Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP, Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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