View source for Endocarditis

{{Short description|Inflammation of the heart's inner layer (endocardium)}}
{{Infobox medical condition (new)
| name            = Endocarditis
| image           = Blood_culture_negative_endocarditis.jpg
| caption         = ''Bartonella henselae'' bacilli in cardiac valve of a patient with blood culture-negative endocarditis. The bacilli appear as black granulations.
| field           = [[Cardiology]], [[Infectious disease (medical specialty)|infectious disease]]
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'''Endocarditis''' is an [[inflammation]] of the inner layer of the [[heart]], the [[endocardium]]. It usually involves the [[heart valve]]s. Other structures that may be involved include the [[interventricular septum]], the [[chordae tendineae]], the mural endocardium, or the surfaces of intracardiac devices. Endocarditis is characterized by lesions, known as ''[[Vegetation (pathology)|vegetations]]'', which are masses of [[platelet]]s, [[fibrin]], [[microcolony|microcolonies]] of microorganisms, and scant inflammatory cells.<ref name=Harrison>{{cite book | vauthors= Kasper DL, Braunwald E, Fauci AS, Hauser S, Longo DL, Jameson JL | author3-link= Anthony Fauci | title = Harrison's Principles of Internal Medicine | publisher = [[McGraw-Hill]] |date=May 2005 | pages = [https://archive.org/details/harrisonsprincip00kasp/page/n759 731]–740  | isbn = 978-0-07-139140-5 | oclc = 54501403| title-link= Harrison's Principles of Internal Medicine }}</ref> In the [[subacute]] form of infective endocarditis, a vegetation may also include a center of [[granuloma|granulomatous tissue]], which may [[Fibrosis|fibrose]] or calcify.<ref name=Robbins>{{cite book |vauthors=Mitchell RS, Kumar V, Robbins SL, Abbas AK, Fausto N |title=Robbins Basic Pathology |publisher=Saunders/Elsevier |edition= 8th |year=2007 |pages=406–408 |isbn=978-1-4160-2973-1}}</ref>

There are several ways to classify endocarditis. The simplest classification is based on cause: either ''infective'' or ''non-infective'', depending on whether a [[microorganism]] is the source of the inflammation or not. Regardless, the diagnosis of endocarditis is based on clinical features, investigations such as an [[echocardiogram]], and [[blood culture]]s demonstrating the presence of endocarditis-causing microorganisms.

Signs and symptoms include fever, chills, sweating, malaise, weakness, anorexia, weight loss, [[splenomegaly]], flu-like feeling, cardiac murmur, heart failure, [[petechia]] (red spots on the skin), [[Osler's node]]s (subcutaneous nodules found on hands and feet), [[Janeway lesion]]s (nodular lesions on palms and soles), and [[Roth's spot]]s (retinal hemorrhages).

==Infective endocarditis==
{{main|Infective endocarditis}}
<!-- Definition and symptoms -->
Infective endocarditis is an [[infection]] of the [[endocardium|inner surface of the heart]], usually the [[heart valve|valves]].<ref name=Mer2017/> Symptoms may include [[fever]], [[petechia|small areas of bleeding into the skin]], [[heart murmur]], feeling tired, and [[anemia|low red blood cells]].<ref name=Mer2017>{{cite web|title=Infective Endocarditis - Cardiovascular Disorders|url=http://www.merckmanuals.com/en-ca/professional/cardiovascular-disorders/endocarditis/infective-endocarditis|website=Merck Manuals Professional Edition|access-date=11 December 2017|language=en-CA|date=September 2017}}</ref> Complications may include [[valvular insufficiency]], [[heart failure]], [[stroke]], and [[kidney failure]].<ref name=Nj2017>{{cite journal|last1=Njuguna|first1=B|last2=Gardner|first2=A|last3=Karwa|first3=R|last4=Delahaye|first4=F|title=Infective Endocarditis in Low- and Middle-Income Countries.|journal=Cardiology Clinics|date=February 2017|volume=35|issue=1|pages=153–163|doi=10.1016/j.ccl.2016.08.011|pmid=27886786|hdl=1805/14046|hdl-access=free}}</ref><ref name=Mer2017/>

<!-- Cause and diagnosis -->
The cause is typically a [[bacterial infection]] and less commonly a [[fungal infection]].<ref name=Mer2017/> Risk factors include [[valvular heart disease]] including [[rheumatic disease]], [[congenital heart disease]], [[artificial valves]], [[hemodialysis]], [[intravenous drug use]], and [[electronic pacemaker]]s.<ref name=Amb2017/> The bacteria most commonly involved are [[streptococci]] or [[staphylococci]].<ref name=Mer2017/>

The diagnosis of infective endocarditis relies on the [[Duke criteria]], which were originally described in 1994 and modified in 2000. Clinical features and microbiological examinations are the first steps to diagnose an infective endocarditis. The imaging is also crucial. Echocardiography is the cornerstone of imaging modality in the diagnosis of infective endocarditis. Alternative imaging modalities as computer tomography, magnetic resonance imaging, and positron emission tomography/computer tomography (PET/CT) with [[Fluorodeoxyglucose (18F)|2-[18F]fluorodeoxyglucose (FDG)]] are playing an increasing role in the diagnosis and management of infective endocarditis.<ref>{{Cite journal |last1=Hubers |first1=Scott A. |last2=DeSimone |first2=Daniel C. |last3=Gersh |first3=Bernard J. |last4=Anavekar |first4=Nandan S. |date=May 2020 |title=Infective Endocarditis: A Contemporary Review |journal=Mayo Clinic Proceedings |language=en |volume=95 |issue=5 |pages=982–997 |doi=10.1016/j.mayocp.2019.12.008|pmid=32299668 |s2cid=215803991 |doi-access=free }}</ref>

<!-- Prevention and treatment -->
The usefulness of [[antibiotics]] following [[dental procedure]]s has changed over time.<ref>{{cite journal|last1=Cahill|first1=TJ|last2=Harrison|first2=JL|last3=Jewell|first3=P|last4=Onakpoya|first4=I|last5=Chambers|first5=JB|last6=Dayer|first6=M|last7=Lockhart|first7=P|last8=Roberts|first8=N|last9=Shanson|first9=D|last10=Thornhill|first10=M|last11=Heneghan|first11=CJ|last12=Prendergast|first12=BD|title=Antibiotic prophylaxis for infective endocarditis: a systematic review and meta-analysis.|journal=Heart|date=June 2017|volume=103|issue=12|pages=937–944|doi=10.1136/heartjnl-2015-309102|pmid=28213367|s2cid=25918810|url=http://eprints.whiterose.ac.uk/112532/7/Cahill_et_al_13_12_16.pdf}}</ref> Prevention is recommended in patients at high risk.<ref name=Mer2017/> Treatment is generally with [[intravenous antibiotics]].<ref name=Mer2017/> The choice of antibiotics is based on the blood cultures.<ref name=Mer2017/> Occasionally [[heart surgery]] is required.<ref name=Mer2017/><ref>{{cite journal |last1=Delgado |first1=V |last2=Ajmone Marsan |first2=N |last3=de Waha |first3=S |last4=Bonaros |first4=N |last5=Brida |first5=M |last6=Burri |first6=H |last7=Caselli |first7=S |last8=Doenst |first8=T |last9=Ederhy |first9=S |last10=Erba |first10=PA |last11=Foldager |first11=D |last12=Fosbøl |first12=EL |last13=Kovac |first13=J |last14=Mestres |first14=CA |last15=Miller |first15=OI |last16=Miro |first16=JM |last17=Pazdernik |first17=M |last18=Pizzi |first18=MN |last19=Quintana |first19=E |last20=Rasmussen |first20=TB |last21=Ristić |first21=AD |last22=Rodés-Cabau |first22=J |last23=Sionis |first23=A |last24=Zühlke |first24=LJ |last25=Borger |first25=MA |title=2023 ESC Guidelines for the management of endocarditis. |journal=European Heart Journal |date=14 October 2023 |volume=44 |issue=39 |pages=3948–4042 |doi=10.1093/eurheartj/ehad193 |pmid=37622656|doi-access=free |hdl=10281/436142 |hdl-access=free }}</ref> Populations at high risk of infective endocarditis include patients with previous infective endocarditis, patients with surgical or transcatheter prosthetic valves or post-cardiac valve repair, and patients with untreated CHD and surgically corrected congenital heart disease.<ref>{{cite journal |last1=Delgado |first1=V |last2=Ajmone Marsan |first2=N |last3=de Waha |first3=S |last4=Bonaros |first4=N |last5=Brida |first5=M |last6=Burri |first6=H |last7=Caselli |first7=S |last8=Doenst |first8=T |last9=Ederhy |first9=S |last10=Erba |first10=PA |last11=Foldager |first11=D |last12=Fosbøl |first12=EL |last13=Kovac |first13=J |last14=Mestres |first14=CA |last15=Miller |first15=OI |last16=Miro |first16=JM |last17=Pazdernik |first17=M |last18=Pizzi |first18=MN |last19=Quintana |first19=E |last20=Rasmussen |first20=TB |last21=Ristić |first21=AD |last22=Rodés-Cabau |first22=J |last23=Sionis |first23=A |last24=Zühlke |first24=LJ |last25=Borger |first25=MA |title=2023 ESC Guidelines for the management of endocarditis. |journal=European Heart Journal |date=14 October 2023 |volume=44 |issue=39 |pages=3948–4042 |doi=10.1093/eurheartj/ehad193 |pmid=37622656|doi-access=free |hdl=10281/436142 |hdl-access=free }}</ref><ref>{{cite journal |last1=Verzelloni Sef |first1=A |last2=Jaggar |first2=SI |last3=Trkulja |first3=V |last4=Alonso-Gonzalez |first4=R |last5=Sef |first5=D |last6=Turina |first6=MI |title=Factors associated with long-term outcomes in adult congenital heart disease patients with infective endocarditis: a 16-year tertiary single-centre experience. |journal=European Journal of Cardio-Thoracic Surgery |date=2 May 2023 |volume=63 |issue=5 |doi=10.1093/ejcts/ezad105 |pmid=36946284}}</ref>

<!-- Epidemiology and prognosis -->
The number of people affected is about 5 per 100,000 per year.<ref name=Amb2017/> Rates, however, vary between regions of the world.<ref name=Amb2017/> Males are affected more often than females.<ref name=Mer2017/> The risk of death among those infected is about 25%.<ref name=Amb2017>{{cite journal|last1=Ambrosioni|first1=J|last2=Hernandez-Meneses|first2=M|last3=Téllez|first3=A|last4=Pericàs|first4=J|last5=Falces|first5=C|last6=Tolosana|first6=JM|last7=Vidal|first7=B|last8=Almela|first8=M|last9=Quintana|first9=E|last10=Llopis|first10=J|last11=Moreno|first11=A|last12=Miro|first12=JM|last13=Hospital Clinic Infective Endocarditis|first13=Investigators|title=The Changing Epidemiology of Infective Endocarditis in the Twenty-First Century.|journal=Current Infectious Disease Reports|date=May 2017|volume=19|issue=5|pages=21|doi=10.1007/s11908-017-0574-9|pmid=28401448|s2cid=24935834}}</ref> Without treatment it is almost universally fatal.<ref name=Mer2017/>

==Non-infective endocarditis==
{{main|Noninfective endocarditis}}
[[Nonbacterial thrombotic endocarditis]] (NBTE) is most commonly found on previously undamaged valves.<ref name=Robbins/>  As opposed to infective endocarditis, the vegetations in NBTE are small, sterile, and tend to aggregate along the edges of the valve or the cusps.<ref name=Robbins/>  Also unlike infective endocarditis, NBTE does not cause an inflammation response from the body.<ref name=Robbins/>  NBTE usually occurs during a hypercoagulable state such as system-wide bacterial infection, or pregnancy, though it is also sometimes seen in patients with venous catheters.<ref name=Robbins/>  NBTE may also occur in patients with cancer, particularly mucinous adenocarcinoma<ref name=Robbins/> where [[Trousseau syndrome]] can be encountered. Typically NBTE does not cause many problems on its own, but parts of the vegetations may break off and embolize to the heart or brain, or they may serve as a focus where bacteria can lodge, thus causing infective endocarditis.<ref name=Robbins/>

Another form of sterile endocarditis is termed [[Libman–Sacks endocarditis]]; this form occurs more often in patients with [[lupus erythematosus]] and is thought to be due to the deposition of immune complexes.<ref name=Robbins/>  Like NBTE, Libman-Sacks endocarditis involves small vegetations, while infective endocarditis is composed of large vegetations.<ref name=Robbins/>  These immune complexes precipitate an inflammation reaction, which helps to differentiate it from NBTE.  Also unlike NBTE, Libman-Sacks endocarditis does not seem to have a preferred location of deposition and may form on the undersurfaces of the valves or even on the endocardium.<ref name=Robbins/>

==References==
{{Reflist}}

==Further reading==
* {{Cite journal |vauthors=Meine TJ, Nettles RE, Anderson DJ, Cabell CH, Corey GR, Sexton DJ, Wang A |title=Cardiac conduction abnormalities in endocarditis defined by the Duke criteria |journal=American Heart Journal |volume=142 |issue=2 |pages=280–285 |year=2001 |pmid=11479467 |doi=10.1067/mhj.2001.116964 }}
* {{Cite journal |vauthors=Tissières P, Gervaix A, Beghetti M, Jaeggi ET |title=Value and limitations of the von Reyn, Duke, and modified Duke criteria for the diagnosis of infective endocarditis in children |journal=Pediatrics |volume=112 |issue=6 Pt 1 |pages=e467–e471 |year=2003 |pmid=14654647 |url=http://pediatrics.aappublications.org/cgi/pmidlookup?view=long&pmid=14654647 |doi=10.1542/peds.112.6.e467 |url-access=subscription }}

== External links ==
{{Scholia|topic}}

{{Medical resources
|   DiseasesDB     = 4224
|   ICD11          = {{ICD11|BB40}}
|   ICD10          = {{ICD10|I33}}
|   ICD9           = {{ICD9|421}}
|   ICDO           =
|   OMIM           =
|   MedlinePlus    = 001098
|   eMedicineSubj  = emerg
|   eMedicineTopic = 164
|   eMedicine_mult = {{eMedicine2|med|671}} {{eMedicine2|ped|2511}}
|   MeshID         = D004696
}}
{{Circulatory system pathology}}
{{Authority control}}

[[Category:Inflammations]]
[[Category:Rodent-carried diseases]]
[[Category:Valvular heart disease]]