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Pediatric Bacterial Endocarditis Clinical Presentation

  • Author: Michael H Gewitz, MD; Chief Editor: P Syamasundar Rao, MD  more...
 
Updated: Mar 31, 2016
 

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 it was in the patient whose chest x-ray is below.

A young adult with a history of intravenous drug u 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 congenital heart disease and fever require special consideration.

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. Clinical findings are related to four underlying phenomena, namely, bacteremia (or fungemia), valvulitis, immunologic responses, and/or emboli.

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Physical Examination

Physical findings are nonspecific and vary. Factors such as the duration of illness, microbiologic etiology, and patient's age may vary. Thus, the frequency with which different signs and symptoms are manifested is variable. One study that analyzed 76 consecutive cases revealed the following prevalences: fever,  99%; petechiae, 21%; changing murmur, 21%; hepatosplenomegaly, 14%; congestive heart failure, 9%; splenomegaly, 7%; splinter hemorrhages, 5%; retinal hemorrhages (Roth spots), 5%; Osler nodes, 4%; and arthritis, 3%.[7]

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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Contributor Information and Disclosures
Author

Michael H Gewitz, MD Physician-in-Chief, Chief, Section of Pediatric Cardiology, Maria Fareri Children’s Hospital at Westchester Medical Center; Professor and Vice Chairman, Department of Pediatrics, New York Medical College

Michael H Gewitz, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Association for Physician Leadership, American Heart Association, American Pediatric Society, American Society of Echocardiography, New York Academy of Medicine, New York Academy of Sciences, Royal Society of Medicine, Society of Pediatric Echocardiography

Disclosure: Nothing to disclose.

Coauthor(s)

Brian Keith Eble, MD Associate Professor of Pediatrics, Section of Cardiology, University of Arkansas for Medical Sciences, Arkansas Children's Hospital

Brian Keith Eble, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, Arkansas Medical Society, Society for Cardiovascular Angiography and Interventions

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Julian M Stewart, MD, PhD Associate Chairman of Pediatrics, Director, Center for Hypotension, Westchester Medical Center; Professor of Pediatrics and Physiology, New York Medical College

Julian M Stewart, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Autonomic Society, American Physiological Society

Disclosure: Received grant/research funds from Lundbeck Pharmaceuticals for none.

Chief Editor

P Syamasundar Rao, MD Professor of Pediatrics and Medicine, Division of Cardiology, Emeritus Chief of Pediatric Cardiology, University of Texas Medical School at Houston and Children's Memorial Hermann Hospital

P Syamasundar Rao, MD is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, American College of Cardiology, American Heart Association, Society for Cardiovascular Angiography and Interventions, Society for Pediatric Research

Disclosure: Nothing to disclose.

Additional Contributors

Jeffrey Allen Towbin, MD, MSc FAAP, FACC, FAHA, Professor, Departments of Pediatrics (Cardiology), Cardiovascular Sciences, and Molecular and Human Genetics, Baylor College of Medicine; Chief of Pediatric Cardiology, Foundation Chair in Pediatric Cardiac Research, Texas Children's Hospital

Jeffrey Allen Towbin, MD, MSc is a member of the following medical societies: American Academy of Pediatrics, American Association for the Advancement of Science, American College of Cardiology, American College of Sports Medicine, American Heart Association, American Medical Association, American Society of Human Genetics, New York Academy of Sciences, Society for Pediatric Research, Texas Medical Association, Texas Pediatric Society, Cardiac Electrophysiology Society

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Gerardo Reyes, MD, and Dwight Bailey, MD, to the development and writing of the source article.

References
  1. Baddour LM, Wilson WR, Bayer AS, Fowler VG Jr, Bolger AF, Levison ME, et al. Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America. Circulation. 2005 Jun 14. 111(23):e394-434. [Medline].

  2. Pasquali SK, He X, Mohamad Z, McCrindle BW, Newburger JW, Li JS, et al. Trends in endocarditis hospitalizations at US children's hospitals: impact of the 2007 American Heart Association Antibiotic Prophylaxis Guidelines. Am Heart J. 2012 May. 163(5):894-9. [Medline]. [Full Text].

  3. Johnson JA, Boyce TG, Cetta F, Steckelberg JM, Johnson JN. Infective endocarditis in the pediatric patient: a 60-year single-institution review. Mayo Clin Proc. 2012 Jul. 87(7):629-35. [Medline]. [Full Text].

  4. Ware AL, Tani LY, Weng HY, Wilkes J, Menon SC. Resource utilization and outcomes of infective endocarditis in children. J Pediatr. 2014 Oct. 165 (4):807-12.e1. [Medline].

  5. Russell HM, Johnson SL, Wurlitzer KC, Backer CL. Outcomes of surgical therapy for infective endocarditis in a pediatric population: a 21-year review. Ann Thorac Surg. 2013 Jul. 96(1):171-4: discussion 174-5. [Medline].

  6. Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2007 Oct 9. 116(15):1736-54. [Medline].

  7. Martin JM, Neches WH, Wald ER. Infective endocarditis: 35 years of experience at a children's hospital. Clin Infect Dis. 1997 Apr. 24 (4):669-75. [Medline].

  8. Li JS, Sexton DJ, Mick N, Nettles R, Fowler VG Jr, Ryan T, et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis. 2000 Apr. 30(4):633-8. [Medline].

  9. Habib G. Management of infective endocarditis. Heart. 2006 Jan. 92(1):124-30. [Medline]. [Full Text].

  10. 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. 2009 Mar 24. 119(11):1541-51. [Medline].

  11. Baltimore RS, Gewitz M, Baddour LM, et al, for the American Heart Association Rheumatic Fever, Endocarditis, et al. infective endocarditis in childhood: 2015 update: a scientific statement from the American Heart Association. Circulation. 2015 Oct 13. 132 (15):1487-515. [Medline].

  12. Nichols KR, Israel EN, Thomas CA, Knoderer CA. Optimizing guideline-recommended antibiotic doses for pediatric infective endocarditis. Ann Pharmacother. 2016 Feb 25. [Medline].

  13. Patel J, Kupferman F, Rapaport S, Kern JH. Preprocedure prophylaxis against endocarditis among United States pediatric cardiologists. Pediatr Cardiol. 2014 Oct. 35 (7):1220-4. [Medline].

  14. 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. 2011 May 3. 342:d2392. [Medline]. [Full Text].

 
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A young adult with a history of intravenous drug use diagnosed with right-sided staphylococcal endocarditis and multiple embolic pyogenic abscesses on chest radiograph.
Long axis echocardiographic view demonstrating a vegetation (Veg) on the aortic (Ao) valve. LA, left atrium; LV, left ventricle.
 
 
 
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