Endocarditis natural history, complications and prognosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Complications of endocarditis can occur as a result of the locally destructive effects of the infection. These complications include perforation of valve leaflets causing congestive heart failure, abscesses, disruption of the heart's conduction system, and embolization to the brain (causing a stroke), to the coronary artery (causing a heart attack), to the lung (causing pulmonary embolism), to the spleen (causing a splenic infarct) and to the kidney (causing a renal infarct).

Monitoring for Complications of Infectious Endocarditis

Among those patients at high risk, careful monitoring should be undertaken to detect the early development of complications such as:

1. Valvular dysfunction, usually insufficiency of the mitral or aortic valves;
2. Myocardial or septal abscesses
3. Congestive heart failure
4. Metastatic infection
5. Embolic phenomenon

A complete list of complications of infective endocarditis include the following:

Cardiac

1. Murmur
2. A new aortic diastolic murmur suggests dilatation of the aortic annulus or eversion, rupture, or fenestration of an aortic leaflet
3. The sudden onset of a loud mitral pansystolic murmur suggests rupture of chorda tendineae or fenestration of a mitral valve leaflet
4. Congestive heart failure
5. Cardiac rhythm disturbances including AV block
6. Occasionally, pericarditis

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This is an electrocardiogram from a man in his 80's. The patient has severe lung disease, has mitral regurgitation secondary to bacterial endocarditis , and is taking digoxin, Lasix and potassium.

The electrocardiogram shows sinus rhythm and a QRS with a left axis deviation, a QRS duration of 118 milliseconds and a tall are wave in the first precordial lead V1 with an R wave height of approximately 21 mm. The prolonged QRS duration and the S waves that are seen as lead one and lead the six suggest a right on the Branch block and the a left axis deviation suggests a left anterior hemi-block . Finally the tall R wave in V1 lead suggests right to ventricular hypertrophic

Cutaneous

1. Petechiae of the conjunctiva, oropharynx, skin, and legs
2. Linear subungual splinter haemorrhages of the lower or middle nail bed
3. Osler’s nodes
4. Janeway lesions

Musculoskeletal

1. Myalgias
2. Arthralgias
3. Arthritis
4. Low back pain
5. Rheumatoid factor is elevated in up to 50% of patients with endocarditis for > 6 wk
6. Clubbing of fingers is present in < 15% of patients

Ocular

1. Petechial hemorrhages
2. Flame-shaped hemorrhages
3. Roth's spots,
4. Cotton-wool exudates in the retina

Embolic

1. Significant arterial emboli occur in 30%–50% of patients, causing the following:

   Stroke

   Monocular blindness

   Acute abdominal pain, ileus, and melena

   Pain and gangrene in the extremities

2. CNS emboli are common
3. Coronary emboli, often asymptomatic, can cause myocardial infarction
4. Pulmonary emboli common in right-sided endocarditis, causing pulmonary infarcts or focal pneumonitis

Splenic

1. Splenomegaly is observed in 15%–30% of patients
2. Splenic infarcts occur in up to 40% of patients
3. Splenic abscesses occur in ~ 5% of patients

Renal

1. Microscopic hematuria occurs in ~ 50% of patients
2. Embolic renal infarction
3. Diffuse membranoproliferative glomerulonephritis

Mycotic aneurysms

Occur in any artery in 2%–8% of patients, causing the following:

1. Pain or headache
2. Pulsatile mass
3. Fever
4. Sudden expanding hematoma
5. Signs of major blood loss

Neurologic

1. Neurologic complications occur in 25%–40% of cases
2. Strokes caused by cerebral embolisms in ~ 15% of cases, causing the following:

   Altered level of consciousness

   Seizures

   Fluctuating focal neurologic signs

3. Cerebral aneurysms occur in 1%–5% of cases, causing the following:

   Headache

   Focal signs

   Acute intracerebral or subarachnoid hemorrhage caused by rupture

   Mild meningeal irritation resulting from slow leakage

4. Brain abscesses may occur in acute endocarditis caused by Staphylococcus aureus
5. Seizures