Infective endocarditis: A case series

Shadiya Sulthana. S

General medicine resident, Kauvery Hospital, Tennur, Trichy

Editor’s Note: This paper is adapted from a presentation made at a clinical meeting.

Background

Infective endocarditis is the inflammation of the endocardium, the inner lining of the heart, as well as the heart valves.

Clinically, infective endocarditis may present with a multitude of signs and symptoms, and clinicians should consider this diagnosis in any patient with risk factors who present with fever or sepsis of unknown origin. A host of intracardiac and extracardiac complications can stem from infective endocarditis. A thorough history and careful physical examination can help guide management limiting morbidity and mortality.

Vegetation – Is a mass of platelets, fibrin, microorganisms, and scant inflammatory cells

Case Series

This paper presents a case series of five such successfully managed patients with infective endocarditis each of who presented with varied manifestations.

Here is the initial assessment of the five patients :

VitalsCase 1
Mr. J
Case 2
Mr. J
Case 3
Mr. A
Case 4
Mrs. S
Case 5
Mr. K
Fever++++-
Anorexia, weight loss, malaise+++-+
Myalgias, arthralgias--+--
Heart murmur+++++
Arterial emboli+--+-
Aneurysm-+--+
Pallor+++++
Clubbing+++-+
Neurologic manifestations+--+-
Peripheral manifestations (Osler’s nodes, subungual hemorrhages, Janeway lesions, Roth’s spots)+----
Anemia, Leukocytosis+++++
Elevated CRP+++++

Case 1

This patient presented with peripheral manifestations (Osler’s nodes, subungual haemorrhages, Janeway lesions, Roth’s spots).

Case 2

This patient presented with the above-mentioned complaints, was advised for CT scan

Impression

CECT: Pseudo aneurysm with partial thrombus – distal common hepatic artery

Case 3

This patient presented with complaints of fever, anorexia, weight loss, and malaise along with an elevated ESR. Absence of neurologic and peripheral manifestation.

Case 4

This patient was confirmed with the above-mentioned initial assessments, especially with neurologic manifestation. so advised for MRI and Doppler Tests.

Impressions

MRI Brain: Acute infarct involving left temporal lobe, posterior parietal and B/L periventricular cortex

Doppler: Subacute thrombosis of right distal brachial artery.

Case 5

This patient presented without fever but with anemia, leukocytosis and elevated ESR. CT – angiogram was advised for  the patient.

 

 

Impression

CT angio: 3.3×3.1×3.6 cm SMA Aneurysm

Blood Culture Drawing

Three, two-bottle blood culture sets containing the appropriate volume of blood (10 mL per bottle) were obtained from different venipuncture sites over 1–2 hr.

Management

VitalsCase 1 - Mr. JCase 2 - Mr. VCase 3 - Mr. ACase 4 - Mrs. SCase 5 - Mr. K
EchoFlail AML – mass attached to aml
Mass attached to pml
Severe MS/ moderate MR
Moderate LV dysfunction (ef – 38%)
MVP- PML, grade 2 MR, normal LV functionBicuspid aortic valve thickened
Vegetations attached to aortic valve
Severe AR
Normal LV function
RHD/ flail aml / moderate MR/ mobile vegetation of size 5*5mm attached to tip of AML/ Mild AR/TR/PAH.Ruptured chordae
Vegetations in mitral valve (1.4×1.1cm)
Severe MR
Normal LV function
Empirical antibiotic therapyCeftriaxone and vancomycinCeftriaxone and vancomycinCeftriaxone and gentamicinCeftriaxone and vancomycinCeftriaxone and vancomycin

Emergencies

Case 1 Mr. J

  • Had developed bradycardia and complete heart block
  • Had to undergo emergency temporary pacemaker implantation
  • Reverted to sinus rhythm and pacemaker removed

 

Case 2 Mr V

  • Had pseudoaneurysm with thrombus from distal common hepatic artery + Splenic infarcts
  • Had to undergo percutaneous glue embolization under fluoroscopy guidance of large common hepatic artery mycotic aneurysm

Case 5 Mr K

  • Had features of impending SMA mycotic aneurysm rupture and suspicion of bowel ischemia
  • Undergone explorative laparotomy with ligation of SMA aneurysm
  • Re exploration after 48 hr showed normal bowel.
VitalsCase 1 Mr. JCase 2 Mr. JCase 3 Mr. ACase 4 Mrs. SCase 5 Mr. K
Blood cultureMRSAVre - enterococcus faecalis - left metacarpal, left cubitalStreptococcus mutantsStreptococcus mutansEnterococcus faecalis
(right and left femoral line and right brachial line)
Antibiotic tailoringTeicoplanin,
Daptomycin + linezolid
Daptomycin and linezolid Vancomycin, teicoplaninCeftriaxone and vancomycinAmpicillin 12g per day (2g 4th hourly) along with ceftriaxone
Modified duke criteria1 major + 3 minor2 major1 major +3 minor1 major + 3 minor2 major

Example,

Definite IE: 2 major (or) 1 major + 3 minor (or) 5 minor

Possible IE: 1 major + 1 minor (or) 3 minor

Discussion

Treatment options

Empirically start on ceftriaxone + vancomycin

Streptococcus
Penicillin-susceptible streptococci:

Ceftriaxone (2 g daily as a single dose for 4 weeks)

Vancomycin (15 mg/kg IV q12h for 4 weeks)

OR

Ceftriaxone for 4 weeks plus Gentamicin for 4 weeks
Penicillin resistant:

Ceftriaxone for 6 weeks + Gentamicin for 6 weeks

Vancomycin for 6 weeks
Enterococcus
Susceptible Enterococci:

Ampicillin (2 g IV q4h) plus ceftriaxone (2 g IV q12h), both for 6 weeks
VRE - Vancomycin Resistant Enterococci:

Daptomycin + Linezolid for 6 weeks
Staphylococcus
MSSA infecting native valves:

Vancomycin (15 mg/kg IV q12h for 6 weeks)
MRSA of native valves:

Vancomycin (15mg/kg IV q8–12h) or daptomycin (8–10 mg/kg daily) for 6 weeks

Failed Medical Therapy

Case 1 Mr J

  • Developed thrombocytopenia again. Linezolid stopped.
  • Fever with large vegetations persisted despite 14 days of Daptomycin. Stopped and Vancomycin started.
  • Because of Failed Medical Therapy shifted to Heart City – for mitral valve replacement
  • MVR done and patient was stable.

Case 2 Mr. A

  • He had a persistent fever so switched to Vancomycin, but developed leucopenia
  • Also developed heart failure
  • Vancomycin stopped, switched to Teicoplanin, and then shifted to Heart City for AVR under high risk.
  • Started responding to teicoplanin, and showed clinical improvement.
  • AVR done, on regular followup – the patient was stable

Surgery Indications

  • Persistent bacteremia without an extracardiac cause despite 7–10 days of optimal antimicrobial therapy
  • Heart failure or shock
  • Paravalvular extension of infection with abscess, fistula, or heart block
  • Fungal or Brucella infection
  • Large (>10-mm) hypermobile vegetation, particularly with prior systemic embolus and significant valve dysfunction
  • Very large (>30-mm) vegetation
  • Right-sided vegetation larger than >20mm.

Measures to Prevent Infective Endocarditis

Which patientsWhich procedures
  • Prosthetic heart valve/surgical or trans catheter

  • Valve clips, annuloplasty

  • Previous relapsed or recurrent IE

  • Repaired congenital defect or residual defect adjacent to the patch

  • RHD – regurgitant lesions and AS, HOCM

  • Invasive dental or oral procedures maximum risk dental extractions

  • OGD, TEE, Colonoscopy or cystoscopy - can be considered on individual basis

    		•

    *Single oral dose 30 – 60 min before the procedure

    Take Home Message

    • Anyone coming with history of fever , with pallor clubbing and heart murmur on examination – suspect infective endocarditis
    • Immediately send blood cultures according to IE protocol
    • Start on Empirical antibiotic therapy (Ceftriaxone and Vancomycin) after cultures are taken.
    • Apply Duke’s Criteria
    • Tailor antibiotics after culture reports

    Dr. Shadia Sultana
    Resident, DNB Internal Medicine

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