What are the signs and symptoms of endocarditis resulting from a tooth infection?

Signs and Symptoms of Endocarditis from Tooth Infection

Endocarditis resulting from a tooth infection typically presents with fever, often accompanied by systemic symptoms including fatigue, weakness, arthralgias, myalgias, weight loss, rigors, and diaphoresis, with heart murmurs found in up to 85% of patients. 1

Clinical Presentation

General Symptoms

• Fever (present in up to 90% of cases) 1
• Systemic symptoms:
  • Chills
  • Poor appetite and weight loss
  • Fatigue and weakness
  • Arthralgias and myalgias
  • Rigors
  • Diaphoresis (night sweats) 1

Cardiac Manifestations

• New or changing heart murmurs (found in up to 85% of patients) 1
• Changing cardiac auscultatory findings 1
• Development of congestive heart failure 1
• Cardiac conduction abnormalities 1

Embolic Phenomena

• Present in up to 25% of patients at time of diagnosis 1
• Emboli to the brain, lung, or spleen (occur in 30% of patients) 1
• Symptoms associated with ischemia or hemorrhage due to emboli 1
• Neurological findings from systemic emboli 1

Immunological and Vascular Phenomena

• Petechiae
• Splinter hemorrhages (linear hemorrhages under nails)
• Roth spots (retinal hemorrhages with pale centers)
• Janeway lesions (painless, erythematous macules on palms/soles)
• Osler nodes (painful, tender nodules on finger/toe pads)
• Glomerulonephritis 1

Laboratory Findings

• Elevated inflammatory markers:
  • C-reactive protein (CRP)
  • Erythrocyte sedimentation rate (ESR)
• Leukocytosis
• Anemia
• Microscopic hematuria 1
• Positive blood cultures (cornerstone of diagnosis, positive in 85-90% of cases) 2

Imaging Findings

• Echocardiography is essential for diagnosis:
  • Transthoracic echocardiography (TTE) is recommended as first-line imaging
  • Transesophageal echocardiography (TOE) should be performed if TTE is negative but clinical suspicion remains high 1
  • Evidence of valvulitis, vegetations, valve destruction 1

Presentation Patterns

Subacute Presentation

• Indolent course with prolonged low-grade fever
• Nonspecific somatic complaints
• More common with viridans streptococci (typical oral bacteria) 1

Acute Presentation

• Rapidly changing symptoms
• High, spiking fevers
• Patients appear acutely ill
• More common with Staphylococcus aureus infection 1

Special Considerations

Risk Factors for Endocarditis from Dental Origin

• Pre-existing heart conditions:
  • Prosthetic heart valves (highest risk)
  • Previous history of endocarditis
  • Complex congenital heart disease
  • Cardiac implantable electronic devices 2, 3

Pathogenesis

Endocarditis from dental infection occurs when:

1. Bacteria from dental infection enter bloodstream (bacteremia)
2. These bacteria attach to damaged or abnormal heart valves
3. Vegetations form, composed of platelets, fibrin, microorganisms, and inflammatory cells 2

Diagnostic Approach

The modified Duke criteria are used for diagnosis, which include:

• Major criteria:
  • Positive blood cultures for typical microorganisms
  • Echocardiographic evidence of endocardial involvement
• Minor criteria:
  • Predisposing factors
  • Fever
  • Vascular phenomena
  • Immunological phenomena 2

Prevention

Good oral hygiene and prevention of oral disease are crucial for preventing endocarditis, as daily activities like brushing teeth can cause bacteremia in those with poor oral hygiene 1, 4.

Remember that endocarditis is a serious infection with significant morbidity and mortality, requiring prompt diagnosis and treatment to improve outcomes.