INFECTIVE ENDOCARDITIS Jayasree.B Second year MBBS(4th sem) Pondicherry Institute of Medical Sciences

Definition of Infective Endocarditis: Microbial infection of heart valves or mural endocardium, Leading to formation of vegetations composed of thrombotic debris and organisms, associated with destruction of underlying cardiac tissues.

Vegetation: Platlet + Fibrin = Damaged vascular endothelium When organisms adheres and grows on it then it becomes infective vegetation.

Types of vegetations RHD IE NBTE LSE Small,Firm, Friable Large, bluky, irregular Small friable Medium sized flat verrucous Along the lines of closure Valve cusps and mural endocardium Both surface of valves involved

RHD Infective Endocarditis Non bacterial thrombotic endocarditis Libman sac endocarditis

Classification Main a)Native valve IE b)Prosthetic valve IE Additionally: a)IV Drug abuse IE b)Nosocomial IE

Native Valve IE Acute IE Subacute IE Site Normal valves Damaged valves Duration Days to weeks (aggressive) Weeks to months (indolent) Organisms Staph. aureus Group B streptococci Streptococcus viridans Enterococci Coagulase –ve Staph. Lesions Invasive and suppurative Less severe Clinical features Fever, Chills, Weakness Splenomegaly, Clubbing, Petechiae

Prosthetic valve IE 10%-30% in developed countries Early: Late: <60 days of surgery Complications of surgery CoNS Late: >60 days Later infection Streptococci

Causative Organisms On native and previously damaged valve. Because in Prosthetic heart valves Streptococcus viridans Staphylococcus epidermidis

Culture negative endocarditis On previously normal heart valve: HACEK group: Haemophilus Actinobacillus Cardiobacterium Eikenella Kingella 10% No microorganism in blood culture: Anibiotic treatment before blood culture Embedded inside large vegetations Staphylococcus aureus Culture negative endocarditis

Predisposing factors Conditions that lead to transient bacterimea IV drug abusers Conditions that lead to transient bacterimea Underlying heart disease: RHD , Mitral valve prolapse Conditions impairing host defence. Periodontal infections Genito urinary tract infections

Pathophysiology Routes Entry of bacteria into blood stream BACTERAEMIA On normal heart valve: Staphylococcus aureus Entry of bacteria into blood stream BACTERAEMIA On previously damaged native heart valve: Streptococcus viridans Prosthetic heart valve: Staphylococcus epidermidis Reach heart internal surface Implants on heart valve or mural endocardium

Grows and proliferates in large numbers inside Mature vegetation occurs Fibrin + Platelets + Microorganisms + inflammatory cells

Breaks and forms EMBOLUS which is infective Spreads and causes: Stroke Cerebral hemorrhage Aneurysms

Lack of blood Supply to the heart valve Why the vegetations are only confined to valves?????? Lack of blood Supply to the heart valve

Clinical Manifestations Fever If spreads: SEPSIS! INFECTION Chills Leukocytosis

Infective vegetation breaks off Left sided heart: Brain, Kidney, Spleen Right sided heart: Lung PE Infective vegetation breaks off EMBOLUS When reaches Peripheral vessels: Oslers node Splinter hemorrhage Janeway lesions Roth spots

Valvular abnormalities Decreased cardiac output Murmurs Valvular abnormalities Dysarrethmias

Splinter Hemorrhage Tiny bleeding points in the nail bed and hyponchium of the nail unit Due to peripheral vascular embolus on the nail bed small amount of bleeding occurs at the grooves of nail bed Bleeding is trapped by the overlying nail plate Due to its linear construction the blood assumes a straight line appearance

Painful More specific Painful and erythematous nodules Located on the pulp of finger and toes

Janeway lesions NOT Painful Hemorrhagic macular or nodular lesions on the palm or soles Not painful Microabscess caused by the septic embolus that deposit bacteria.

Roth spots A red spot (caused by hemorrhage) With a pale white center(fibrin platelet plug) Seen also in leukemia diabetes HIV

Clubbing Clubbing refers to swelling in the tip of the digit that results in loss of the normal angle seen between the nail and the nail bed The fingertips appear broader and rounder .

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