History
Patients with acute bacterial endocarditis (ABE) present with an acute, toxic, febrile illness and symptoms that have lasted less than 2 weeks. (Between 85% and 99% of patients are febrile.) Often, the heart is structurally normal before ABE onset.
Features in the patient’s history can include fatigue, chills, sweats, anorexia, malaise, cough, headache, myalgia and/or arthralgia, and confusion.
A history of intravenous (IV) drug use may be elicited, as in the patient in the image below.
Patients with congenital heart disease and fever require special consideration.
A young adult with a history of intravenous drug use diagnosed with right-sided staphylococcal endocarditis and multiple embolic pyogenic abscesses on chest radiograph. Patients with subacute bacterial endocarditis (SBE) present with a more nonspecific, flulike illness and symptoms that may have lasted more than 2 weeks. Subacute bacterial endocarditis is more common in patients with an underlying congenital heart defect.
Physical Examination
Physical findings are nonspecific and vary. Factors such as the duration of illness, microbiologic etiology, and patient's age may vary.
As previously mentioned, fever is present in 85-99% of patients with endocarditis. The fever is usually low grade, with a temperature rarely exceeding 39°C that is remittent and is typically not associated with rigors.
A new or changing heart murmur is noted in many patients. These murmurs may be difficult to identify in patients with subacute endocarditis or in infants and young children who may already have a clinically significant murmur secondary to congenital heart disease.
Peripheral signs may be observed, although extracardiac manifestations of endocarditis are less common overall in children than in adults. Petechiae are the most common of these signs (20-40%). They are found on the palpebral conjunctiva, the buccal or palatal mucosa, and the extremities. However, petechiae are not specific for endocarditis.
Splenomegaly is a common finding on abdominal examinations.
Splinter and subungual hemorrhages are dark red, linear streaks in the nail beds of the fingers and toes. Osler nodes are small, tender, subcutaneous nodules that develop in the pulp of the digits.
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Gerber MA, Baltimore RS, Eaton CB, Gewitz M, Rowley AH, Shulman ST, et al. Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. Circulation. Mar 24 2009;119(11):1541-51. [Medline].
Thornhill MH, Dayer MJ, Forde JM, et al. Impact of the NICE guideline recommending cessation of antibiotic prophylaxis for prevention of infective endocarditis: before and after study. BMJ. May 3 2011;342:d2392. [Medline]. [Full Text].
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