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ENDOCARDITIS The Etiology and the Laboratory Studies Reşat Özaras, MD, Professor, Infectious Diseases Dept. Definition • Endocarditis: it is an inflammation of the inner layer of the heart, the endocardium. Clinical Features • Whom to consider IE – Injection drug users – Prostethic heart valve – Prior IE – Bacteremia – Hemodialysis – HIV infection Clinical Features • Wide spectrum of signs&symptoms – Fatigue – Anorexia – Weight loss – Prolonged fever – Dizziness – Dyspnea – ….. PE • Murmur • Splenomegaly • Findings of complications (emboli etc..) IE: Clinical Classification • Acute IE Main etiology: S. aureus Mortality (untreated) : < 2 months, 100% • Subacute—chronic IE Main etiology: Viridans streptococci Mortality (untreated) : < 1 year, 100% Classification According to the Valve • Native Valve Endocarditis • Prosthetic Valve Endocarditis • Clinical criteria Using specific definitions : – 2 major criteria OR – 1 major and 3 minor criteria OR – 5 minor criteria • Possible IE • 1 major criterion and 1 minor criterion OR 3 minor criteria Major Diagnostic Criteria • Positive blood culture for typical infective endocarditis • Echocardiography findings – with oscillating intracardiac mass – abscess Search Google for echo videos! • http://www.echojournal.org/video/379/Aorti c-valve-vegetation-1-of-2 Minor Diagnostic Criteria • Predisposing heart condition or intravenous drug use • Temp > 38.0° C • Vascular phenomena: arterial emboli, pulmonary infarcts, mycotic aneurysms, intracranial bleed, conjunctival hemorrhages, Janeway lesions • Immunologic phenomena: glomerulonephritis, Osler nodes, Roth spots, rheumatoid factor • Microbiological evidence: positive blood culture but does not meet a major criterion • Echocardiographic findings: consistent with endocarditis but do not meet a major criterion • Clinical criteria Using specific definitions : – 2 major criteria OR – 1 major and 3 minor criteria OR – 5 minor criteria • Possible IE • 1 major criterion and 1 minor criterion OR 3 minor criteria IE: Etiology NV 1-Streptococci: ~%50 2-S. aureus: 3-Enterococci: 4-Coagulase-neg Staph: ~%5 5-Gram-Neg Bacilli: 6-Fungus (Candida): 7-Diphteroids: 8-Polymicrobial: 9-Culture-neg./HACEK: PV ~40% ~70% Our cases with IE 1-Viridans streptococci (8) (40%) 2-S. aureus (MSSA) (4) (20%) 3-Enterococci (2) (10%) 4-MSSE (1) (5%) 5-Anaerobs (1) 6-S. typhi (1) 7-Brucella (1) 8-Culture-negative (2) IE: Streptococci • Viridans streptococci (-hemolytic) (the most frequent ones) 1-S. sanguis 2-S. mutans 3-S. mitis • S. bovis (non-hemolytic) Staphylococci • S. aureus • S. epidermidis Diagnostics Clinical Samples • Blood • Serum (for serology) • Embolus, abscess, or removed infected valve (for microbiological and histolgical studies) IE: S. aureus • Fever+S.aureus: consider IE (echo.) • Fever+S.aureus in injection drug user: consider right side (tricuspid) IE (echo.) Culture-negative IE • Failure to yield any m.o. with automated blood culture systems within 7 days • ~5% • Use of antibiotics • Coxiella burnetii and Bartonella IE: Serology 1-Brucella 2-Coxiella burnetii 3-Bartonella Treatment • Antibiotics • Surgery may be needed IE: Mortality is ~30 Major systemic emboli Heart Failure Septic shock Complications • • • • • • • Cardiac Septic Embolic Neurologic Musculoskeletal Renal Associated with medical treatment Complications • Embolic (eg, cerebral infarct) • Local spread of infection (eg, heart valve destruction) • Metastatic infection (eg, vertebral osteomyelitis) • Immune-mediated damage (eg, glomerulonephritis