History
Acute disease has become the predominant type of valvular infection because of the rise in intravascular devices such as prosthetic valves and pacemakers. The opioid crisis and the increase of hepatitis C virus infection among injection drug users accounts in large part for this shift, especially among the younger patients. The social isolation brought about by COVID-19 appears to be accelerating this process. [15, 50]
Its clinical history is highly variable, especially among cases with subacute IE. The symptoms often are vague and constitutional in nature. They may focus on primary cardiac effects or secondary embolic phenomena. Fever and chills are the most common symptoms. Anorexia, weight loss, malaise, headache, myalgias, night sweats, shortness of breath, cough, and joint pains are commonly observed. [27] Signs and symptoms of congestive heart failure may be due to valvular insufficiency. Focal neurologic complaints of embolic stroke(20% of cases ) or the back pain associated with vertebral osteomyelitis may be present.
Dyspnea, cough, and chest pain are common complaints of intravenous drug users due to the predominance of tricuspid valve endocarditis in this group and secondary embolic showering of the pulmonary vasculature.
A key concern is the distinction between subacute and acute IE. [51, 52, 53, 54] The diagnosis of subacute IE is suggested by a history of an indolent process characterized by fever, fatigue, anorexia, back pain, and weight loss. Less common developments include cerebrovascular accident or congestive heart failure.
Question the patient about invasive procedures and recreational drug use that may be causing the bacteremia. Most subacute disease caused by S viridans infection is related to dental disease, with most cases not caused by dental procedures but by transient bacteremias secondary to gingivitis. In 85% of patients, symptoms of endocarditis appear within 2 weeks of dental or other procedures.
The interval between the onset of disease and diagnosis averages approximately 6 weeks. The fact that less than 50% of patients have previously-diagnosed underlying valvular disease significantly limits the effectiveness of antibiotic prophylaxis.
Acute IE is a much more aggressive disease. The patient notices the rapid onset of high-grade fevers and chills and a rapid onset of congestive heart failure. Again, a history of antecedent procedures or illicit drug use must be investigated.
The distinction between these 2 polar types of IE has become less clear. Intermittent use of antibiotics aimed at treating misdiagnosed endocarditis can suppress bacterial growth within the valvular thrombus, giving rise to the state of muted IE. This often is the case of HCIE, also referred to as healthcare-associated IE [HCIE]), which commonly manifests with elements of a sepsis syndrome (ie, hypotension, metabolic acidosis, fever, leukocytosis, and multiple organ failure).
The source of the bacteremia may be an infection in another organ (eg, pneumonia, pyelonephritis) or in a central venous catheter. These patients most often are in the intensive care unit. Approximately 45% of cases of HCIE occur in patients with prosthetic valves. Muted IE caused by S aureus infection may resemble IE that results from S viridans infection.
Subacute native valve endocarditis
The symptoms of early subacute native valve endocarditis (NVE) usually are subtle and nonspecific. They include low-grade fever (absent in 3-15% of patients), anorexia, weight loss, influenzalike syndromes, polymyalgia-like syndromes, pleuritic pain, syndromes resembling rheumatic fever (eg, fever, dulled sensorium as in typhoid, headaches), and abdominal symptoms (eg, right upper quadrant pain, vomiting, postprandial distress, appendicitis-like symptoms).
When appropriate therapy is delayed for weeks or months, additional clinical features, embolic or immunologic in origin, develop.
Signs and symptoms secondary to emboli include acute meningitis with sterile spinal fluid, hemiplegia in the distribution of the middle cerebral artery, regional infarcts that cause painless hematuria, infarction of the kidney or spleen, unilateral blindness caused by occlusion of a retinal artery, and myocardial infarction arising from embolization of a coronary artery.
The emboli of right-sided IE commonly produce pulmonary infarcts. The rate of embolization is related to the organism, the size of the vegetation and its rate of growth or resolution, and its location.
The vegetations of S aureus, Haemophilus influenzae, H parainfluenzae, and the fungi are much more likely to embolize than those of S viridans. Those larger than 10 mm in diameter and mobile or prolapsing have a high rate of embolization. A vegetation that grows during therapy is associated with a significant increase in the risk for embolization but with the persistence of bacteremia.
Clinically separating the importance of the absolute size and the rate of change in the size of the vegetation from the causative organism is difficult. The vegetations of the mitral valve are much more likely to embolize than those in any other location. The risk for embolization markedly decreases after 1 week of appropriate antibiotic therapy.
The deposition of circulating immune complexes in the kidney may produce interstitial nephritis or proliferative glomerulonephritis, with renal failure progressing to the point of uremia at the time of the patient’s presentation. Similarly, various musculoskeletal symptoms (44% of patients) arise from immunologically mediated synovitis.
Osler nodes and Roth spots arise from immune-mediated vasculitis. Patients may experience palpitations, ie, the symptoms of an immune-mediated myocarditis.
The origin of lumbosacral back pain in patients with subacute IE (15%) is unclear but probably results from the deposition of immune complexes in the disk space; however, antibiotic therapy rapidly abolishes these symptoms. In 50% of patients with cerebral emboli, this event is the first manifestation of IE and is associated with a mortality rate that is 2 to 4 times higher. Stroke in younger individuals should always raise the possibility of underlying IE.
Bacteria-free infective endocarditis
Rarely observed today, the bacteria-free state of IE is one in which patients have multiple negative blood culture results in the presence of severe congestive heart failure, renal failure, multiple sterile emboli, massive splenomegaly, severe anemia, brown facial pigmentation, bilateral thigh pain, and massive leg edema. These patients usually are afebrile. This process appears to indicate prolonged and unchecked stimulation of the immune system.
Acute infective endocarditis
The clinical symptoms of acute IE result from either embolic or intracardiac suppurative complications. The onset of illness is abrupt, with rapidly progressive destruction of the infected valve. The valvular leaflets are quickly destroyed by bacteria that multiply rapidly within the ever-growing friable vegetations. Complications develop within a week. These include the dyspnea and fatigue of severe congestive heart failure and a wide spectrum of neuropsychiatric complications resulting from CNS involvement.
Acute bacterial endocarditis caused by Staphylococcus aureus with perforation of the aortic valve and aortic valve vegetations. Courtesy of Janet Jones, MD, Laboratory Service, Wichita Veterans Affairs Medical Center.
Acute bacterial endocarditis caused by Staphylococcus aureus with aortic valve ring abscess extending into myocardium. Courtesy of Janet Jones, MD, Laboratory Service, Wichita Veterans Affairs Medical Center.
Opioid Use Disorder Infective Endocarditis (OUDIE)
Patients with right-sided intravenous drug abuse (IVDA) IE (53% of cases) frequently present with pleuropulmonary (pneumonia and/or empyema) manifestations. Symptoms from metastatic infection develop early in a disease course caused by S aureus. Right-sided disease is associated with a low rate of congestive heart failure and valvular perforation. [54]
Infection with P aeruginosa has a high rate of neurologic involvement, with 2 distinctive features: (1) mycotic aneurysms with a higher-than-average rate of rupture and (2) panophthalmitis (10% of patients). The course of infection with P aeruginosa is much slower than that of S aureus.
The course of left-sided IVDA IE is similar to that of non-IVDA disease.
Approximately 5-8% of febrile individuals who abuse IV drugs have underlying IE. Many users of illicit drugs may lose their fever within a few hours of hospitalization. This phenomenon, termed cotton wool fever, is probably caused by the presence of adulterants contained within the injected drugs.
Prosthetic valve endocarditis
Clinical features of PVE closely resemble those of NVE. Early PVE is defined as infection occurring within 60 days of valve implantation; late PVE occurs after this period. For valvular infection with CoNS, this division should be extended to 12 months.
Congestive heart failure occurs earlier and is more severe in persons with PVE. The patient may present with symptoms of myocarditis or pericarditis, and the rate of embolic stroke is high in the first 3 days of PVE.
Pacemaker infective endocarditis
The clinical presentation in a person with a pacemaker infection and pacemaker IE depends on several factors, including the site of infection (eg, generator pocket vs intravascular leads or epicardial leads), the type of organism, and the origin of the infection (eg, pocket erosion, localized infection of the generator pocket, bacteremia from a remote site). The risk of developing IE is directly associated with the complexity of the permanent pacemaker. The risk associated with internal cardiac defibrillators was almost twice that of single-chamber pacemakers. Mortality also was greater in the former group.
Half of cases of right-sided IE associated with a cardiac device are a result of CoNS. [55]
Early infections, within a few months of implantation, manifest as acute or subacute infections of the pulse-generator pocket. Bacteremia may be present even in the absence of clinical signs and symptoms. Fever is the most common finding and may be the only finding in approximately 33% of patients.
Late infections of the pocket may be due to erosion of the overlying skin without systemic involvement. Such erosions always indicate infection of the underlying device.
The most significant late infections involve the transvenous or epicardial leads. With epicardial infection, signs and symptoms of pericarditis or mediastinitis may be present along with bacteremia. Infection of the transvenous electrode produces signs and symptoms of right-sided endocarditis. Those that occur early after implantation (33% of cases) show prominent systemic signs of infection, often with obvious localization to the pacemaker pocket.
Late infections have much more subtle manifestations. They may occur up to several years after implantation or reimplantation.
Fever is almost universal in persons with pacemaker IE. Signs of right-sided endocarditis (ie, pneumonia, septic emboli) are observed in up to 50% of patients.
Healthcare infective endocarditis (HCIE)
Healthcare infective endocarditis commonly presents with elements of sepsis (ie, hypotension, metabolic acidosis, fever, leukocytosis, and multiple organ failure). The source of bacteremia may develop from an infection in another organ (eg, pneumonia, pyelonephritis) or from a central venous catheter. These patients most often are in the intensive care unit.
The aging of the population is associated with an increased incidence of staphylococcal healthcare-associated endocarditis, in addition to an increased mortality rate linked to the disease. [43]
Approximately 45% of cases of HCIE occur in patients with prosthetic valves.
Infective endocarditis associated with dialysis catheters has a fairly high rate of MRSA involvement. Eighty percent of cases involve the mitral valve. [47]
Physical Examination
General findings
Fever, possibly low-grade and intermittent, is present in 90% of patients.
The American Heart Association (AHA; endorsed by the Infectious Diseases Society of America [IDSA]) guideline on cardiovascular implantable electronic device (CIED) infections and their management recommends that patients with CIED who develop unexplained fever or BSI should seek evaluation for CIED infection by cardiologists or infectious disease specialists. [55]
Heart murmurs are present in 85% of patients. Change in the characteristics of a previously noted murmur occurs in 10% of these patients and increases the likelihood of secondary congestive heart failure.
One or more classic signs of IE are found in as many as 50% of patients. They include the following:
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Petechiae - Common but nonspecific finding
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Subungual (splinter) hemorrhages - Dark red linear lesions in the nailbeds
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Osler nodes - Tender subcutaneous nodules usually found on the distal pads of the digits
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Janeway lesions - Nontender maculae on the palms and soles
-
Roth spots - Retinal hemorrhages with small, clear centers; rare and observed in only 5% of patients.
A middle-aged man with a history of intravenous drug use who presented with severe myalgias and a petechial rash. He was diagnosed with right-sided staphylococcal endocarditis.
Signs of neurologic disease occur in as many as 40% of patients. Embolic stroke with focal neurologic deficits is the most common etiology. Other etiologies include intracerebral hemorrhage and multiple microabscesses. [1]
Signs of systemic septic emboli result from left heart disease and are more commonly associated with mitral valve vegetations. Multiple embolic pulmonary infections or infarctions are due to right heart disease.
Signs of congestive heart failure, such as distended neck veins, frequently are due to acute left-sided valvular insufficiency.
Splenomegaly may be present.
Other signs include the following:
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Stiff neck
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Delirium
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Paralysis, hemiparesis, aphasia
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Conjunctival hemorrhage
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Pallor
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Gallops
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Rales
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Cardiac arrhythmia
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Pericardial rub
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Pleural friction rub
Subacute infective endocarditis
Approximately 3-5% of patients with subacute IE (primarily elderly and chronically ill individuals) have normal or subnormal temperatures. Most patients have detectable heart murmurs. The presence of a murmur is so common (99% of cases) that its absence should cause clinicians to reconsider the diagnosis of IE. The major exception is right-sided IE, in which only one third of patients have a detectable murmur. [20, 21, 22, 51]
As many of these murmurs are hemodynamically insignificant and have been present for years, their role in the patient’s illness may be underestimated. In SBE, only 15 % of preexisting murmurs are documented to change.
The peripheral lesions of subacute IE are observed in only approximately 20% of patients, compared with 85% in the preantibiotic era. The most common of these is petechiae. They may occur on the palpebral conjunctivae, the dorsa of the hands and feet, the anterior chest and abdominal walls, the oral mucosa, and the soft palate.
Subungual hemorrhages (ie, splinter hemorrhages) are linear and red. They usually are caused by workplace trauma to the hands and feet rather than by valvular infection. Hemorrhages that do not extend for the entire length of the nail more likely are the result of infection rather than trauma.
Osler nodes are smallish tender nodules that range from red to purple and are located primarily in the pulp spaces of the terminal phalanges of the fingers and toes, soles of the feet, and the thenar and hypothenar eminences of the hands. Their appearance often is preceded by neuropathic pain. They last from hours to several days and remain tender for a maximum of 2 days. The underlying mechanism is probably the circulating immunocomplexes of subacute IE. They have been described in various noninfectious vasculitides.
Clubbing of fingers and toes almost universally was found, but it now is observed in less than 10% of patients. It primarily occurs in those patients who have an extended course of untreated IE.
The arthritis associated with subacute IE is asymmetrical and is limited to 1 to 3 joints. Clinically, it resembles the joint changes found in patients with rheumatoid arthritis, Reiter syndrome, or Lyme disease. The fluid is usually sterile.
Splenomegaly is more commonly observed in patients with long-standing subacute disease and may persist long after successful therapy.
Roth spots are retinal hemorrhages with pale centers. The Litten sign represents cotton-wool exudates.
Acute infective endocarditis
In approximately one third of patients with acute IE, murmurs are absent. The most common type is an aortic regurgitation murmur. Because of the suddenness of onset, the left ventricle does not have a chance to dilate. In this situation, the classic finding of increased pulse pressure in significant valvular insufficiency is absent.
Fever is always present, and it usually is high.
Janeway lesions are irregular erythematosus and painless macules (1-4 mm in diameter). They most often are located on the thenar and hypothenar eminences of the hands and feet. Janeway lesions usually represent an infectious vasculitis of acute IE resulting from S aureus infection.
Acute septic monoarticular arthritis in patients with acute IE most often is caused by S aureus infection.
Purulent meningitis may be observed in patients with acute IE, compared with the aseptic type observed in patients with subacute disease. Other neurologic findings are similar to those observed in patients with subacute disease. [52, 53, 54, 56, 57, 58, 59, 60, 61]
Complications
The following are potential complications of IE [51, 52, 53, 54, 56, 57, 58, 59, 60, 61, 62] :
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Myocardial infarction, pericarditis, cardiac arrhythmia
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Cardiac valvular insufficiency
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Congestive heart failure
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Sinus of Valsalva aneurysm
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Aortic root or myocardial abscesses
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Arterial emboli, infarcts, mycotic aneurysms
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Arthritis, myositis
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Glomerulonephritis, acute renal failure
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Stroke syndromes
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Mesenteric or splenic abscess or infarct
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Myocarditis or IE related to COVID-19 infection
Congestive heart failure caused by aortic valve insufficiency is the most common intracardiac complication of subacute endocarditis. It develops after months of untreated disease but may occur a full year following microbiological cure.
The complication of arterial embolization is second in frequency to congestive heart failure for both subacute and acute IE. The frequency of this complication has decreased, from 80% in the preantibiotic era to 15-35% today. The emboli usually are sterile because of the minimally invasive nature of the causative organisms (eg, S viridans).
Those most at risk are younger (20-40 years), have mitral or aortic valve (native or prosthetic) involvement, and are infected with certain organisms such as Candida or Aspergillus species, S aureus, Haemophilus parainfluenzae, group B streptococci, and nutritionally variant streptococci.
The prevalence of embolization appears to be the same for both types of disease. The most common areas of deposition include the coronary arteries, kidneys, brain, and spleen. Infarction at the site of embolization is common; abscess formation is not. Cerebral emboli occur in 33% of patients and the middle cerebral artery is involved most often.
Other neurologic embolic damage includes cranial nerve palsies, cerebritis, and mycotic aneurysms caused by weakening of the vessel walls and produced by embolization to the vasa vasorum. Mycotic aneurysms may occur in the abdominal aorta and the splenic, coronary, and pulmonary arteries.
In acute IE, the frequency of aneurysms and other suppurative intracardiac complications is high. In addition to valvular insufficiency, other intracardiac complications of acute IE include (1) aortocardiac and other fistulas, (2) aneurysms of the sinus of Valsalva, (3) intraventricular abscesses, (4) ring abscesses, (5) myocardial abscesses, (6) mycotic aneurysms, (7) septic coronary arterial emboli, and (8) pericarditis.
In patients with acute disease, especially disease caused by S aureus infection, emboli almost inevitably lead to abscesses in the areas where they are deposited. Multiple abscesses can occur in almost every organ, including the kidneys, heart, and brain. Mycotic aneurysms may occur in almost any artery. Paradoxically, they are less common in patients with acute IE.
It appears that older patients have higher rates of myocardial infarction and death but lower rates of neurological complications.
The role of the gut and oral microbiomes and probiotics on the pathogenesis and symptomatology of IE
The metabolic products of the gut and the oral microbiomes(fecal and mouth flora) may have significant positive and/or negative effects on the host. Much more is known about that of the gut. Initially, it was felt that the organisms of the gut microbiome were restricted to the surface biofilm of the intestinal tract. In some patients, they may invade the deeper tissue of the intestinal tract, where they may replicate. This process may be quite sloppy. Such can result in significant resistance to the available antibiotics and antifungals.
The pathogens of the microbiomes may also trigger widespread sterile inflammation that can persist after the valvular infection is eradicated. The patient may have pain along with elevation in various inflammatory markers. Microthrombi and aneurysms often are present, but clinically are usually "silent". The key in recognizing this phase is that the patient will state that the pain and other symptoms differ significantly from his or her valvular infection. The issue of anticoagulation in this situation must be decided on a case-by-case basis.
This 2-stage "attack " has been best worked out for S gordonii, a member of the S viridans group that migrated to the United States from Norway since the turn of 21st century. In reviewing several valvular infections, with this sterile inflammatory response much time was spent obtaining follow-up imaging studies prompted by over reading of these marginal findings. [53, 54, 61]
To improve the functioning of the microbiome, probiotics and prebiotics are added to many of the commercial foods that we ingest. Probiotics are living organisms that hopefully will improve the quality of the gut flora. Prebiotics are nutritional substances that are meant to nourish the probiotics. There is limited evidence that they are very helpful. [63]
The effects of probiotics on IE are becoming more apparent. Probiotics are substances or foods that contain live organisms. The mechanism of this is not clear, but the use of probiotics is extremely widespread and needs to be re-examined. [64]
There is evidence that altered antibiotics that reside in the deep gut microbiome may also subvert the beneficial effects of the probiotic flora.
The role of the oral microbiome has not been as well established. Procedures that disrupt the oral biofilm (tonsillectomy, gum surgery, dental extractions) are significant events. [61]
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Acute bacterial endocarditis caused by Staphylococcus aureus with perforation of the aortic valve and aortic valve vegetations. Courtesy of Janet Jones, MD, Laboratory Service, Wichita Veterans Affairs Medical Center.
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Acute bacterial endocarditis caused by Staphylococcus aureus with aortic valve ring abscess extending into myocardium. Courtesy of Janet Jones, MD, Laboratory Service, Wichita Veterans Affairs Medical Center.
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A middle-aged man with a history of intravenous drug use who presented with severe myalgias and a petechial rash. He was diagnosed with right-sided staphylococcal endocarditis.
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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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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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Mitral valve: endocarditis with valve destruction and vegetation. Note the posterior leaflet of the mitral valve, with an irregular vegetation on the atrial surface, resulting in valve destruction at the commissure between the anterior leaflet and the posterior leaflet.
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Aortic valve: healed endocarditis. Note the gaping hole with the fibrous rim, and a small strand at the free edge. The hole is at the line of closure. The affected valve is the left cusp. Note the right noncoronary cusp (immediate to the left in this image) demonstrates a small, multichanneled fenestration at the commissure, immediately adjacent to similar fenestrations in the left coronary cusp. These are physiologic lesions occurring with age and are unrelated to endocarditis.
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Aortic valve: bicuspid, with infectious endocarditis. In this excised valve, note the bulky vegetations on the ventricular surfaces, with distortion of the valve surfaces.
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Mitral valve: postrheumatic, with infectious endocarditis. A defect is seen in the scarred valve, with focal surface hemorrhage. The patient also underwent aortic valve replacement, as there was contiguous infection.
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The surface of the valves, in most cases, demonstrates areas of acute neutrophilic inflammation with admixed fibrin and platelets. Degenerated bacterial colonies are seen at the left. Also, areas of microcalcification may mimic bacterial deposits.
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Infectious endocarditis, subacute phase. Hemorrhage and prominent granulation tissue with neovascularity is apparent throughout. This aortic valve showed fibrin exudate on the ventricular surface (below), with more prominent organization and granulation on the aortic surface (above).
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Infectious endocarditis, surface of valve leaflet with fibrin; higher magnification of previous image. A chronic infiltrate is seen, just under the denuded thrombosed surface, with primarily macrophages and focal macrophage giant cells.
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Bioprosthetic valve with endocarditis. Note the large bacterial colony (staphylococci by culture) in the absence of significant inflammation; the xenograft tissue is not viable, and nuclear detail is not apparent.
Tables
Causative Organism(s) |
Clinical Features of IE |
Staphylococcus aureus |
|
Streptococcus viridans |
|
| Streptococcus intermedius group |
|
Abiotrophia |
|
Group D streptococci |
|
Nonenterococcal group D |
|
Group B streptococci |
|
Group A, C, and G streptococci |
|
Coagulase-negative S aureus |
|
Staphylococcus lugdunensis |
|
Pseudomonas aeruginosa |
|
HACEK (ie, Haemophilus aphrophilus, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella kingae) |
|
Fungal |
|
Bartonella |
|
Multiple pathogens (polymicrobial |
|
|
|
|
|
