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endocarditis(en?do-kar-di'tis) [? + ? + itis, inflammation]
acute bacterial endocarditisAbbreviation: ABE
atypical verrucous endocarditis
infective endocarditisAbbreviation: IE
Patients with subacute IE may have vague symptoms, including low-grade fevers, loss of appetite, malaise, and muscle aches. Acutely infected patients often present with high fevers, prostration, chills and sweats, stiff joints or back pain, symptoms of heart failure (esp. if the infection has completely disrupted a heart valve or its tethers), heart block (if the infection erodes into the conducting system of the heart), symptoms caused by the spreading of the infection to lungs or meninges (e.g., cough, headache, stiff neck, or confusion), stroke symptoms, symptoms of renal failure, rashes (including petechiae), or other findings. Signs of the illness typically include documented fevers, cardiac murmurs, or (more rarely) nodular eruptions on the hands and feet (Osler's nodes or Janeway lesions). Cottonwool spots may be seen on the retinas of some affected persons. See: illustration
Blood cultures, esp. if persistently positive, form the basis for the diagnosis of endocarditis. Contemporary criteria for diagnosis also include visual confirmation of endocardial infection (vegetations) by echocardiography, the presence of several other suggestive anomalies (e.g., persistent fevers in a patient who is known to inject drugs or a patient with an artificial heart valve), infective emboli in the lungs or other organs; and characteristic skin findings. Occasionally, a patient who dies of a febrile illness may be found to have infective vegetations on the heart valves at autopsy.
Endocarditis is deadly in about 10% to 25% of patients. Death is most likely to occur in patients who suffer strokes resulting from infected fragments embolizing to the brain and in patients who suffer congestive heart failure. Patients with right-sided endocarditis have a better prognosis than patients with other forms of the disease.
Many patients recover after treatment with prolonged courses of parenteral antibiotics. Some (e.g., those with heart failure or severely injured hearts) may not respond without surgery to replace damaged valves or débride abscesses within the myocardium.
During the acute phase of treatment, patients are monitored for signs and symptoms of heart failure (e.g., dyspnea, orthopnea, crackles, dependent edema, changes in the heart murmur, and a postsystolic gallop), cerebral emboli (e.g., paralysis, aphasias, changes in mental status), and embolization to the kidney (e.g., decreased urine output, hematuria); lung involvement (e.g., dyspnea, cough, egophony, hemoptysis, pleuritic pain, or friction rub) or spleen involvement (e.g., left upper quadrant abdominal pain radiating to the left shoulder, abdominal rigidity); and peripheral vascular occlusion (e.g., numbness or tingling, changes in pulses, pallor, and coolness in an extremity). Blood cultures may be taken periodically to monitor the effectiveness of antibiotic therapy. Before the administration of antibiotics, a history of allergies is obtained. Treatment peak and trough drug levels are checked (e.g. when aminoglycoside or vancomycin is given) to maintain therapeutic levels and prevent toxicity. Supportive treatment includes bedrest, sufficient fluid intake to preserve hydration, and aspirin or acetaminophen for fever and aches.
Passive and active limb exercises are used to maintain muscle tone and quiet, diversional activities to prevent excessive physical exertion until a slow, progressive activity program that limits cardiac workload can be established.
The American Heart Association recommends that patients at high risk for endocarditis should receive prophylactic antibiotics prior to many procedures, including dental and periodontal cleanings and extractions, intraligamentary local anesthetic injections, tonsillectomy, adenoidectomy, bronchoscopy with rigid instrument, sclerotherapy for esophageal varices, esophageal stricture dilation, biliary tract procedures, barium enema or colonoscopy, surgery involving the respiratory or intestinal mucosa, prostate surgery, cystoscopy, and urethral dilation.