What are the signs and symptoms of endocarditis (infection of the inner lining of the heart) that would present to the Emergency Room (ER)?

From the Guidelines

Endocarditis typically presents to the emergency room with a constellation of nonspecific symptoms, including persistent fever, fatigue, weakness, muscle aches, night sweats, and unexplained weight loss, and physical examination may reveal a new or changed heart murmur, petechiae, splinter hemorrhages, Janeway lesions, Osler nodes, and splenomegaly. The diagnosis of endocarditis is based on the modified Duke criteria, which include major criteria such as blood cultures positive for infective endocarditis (IE) and evidence of endocardial involvement, and minor criteria such as predisposition, fever, vascular phenomena, microbiological evidence, and immunologic phenomena 1. Some patients present with complications of endocarditis, including heart failure symptoms, embolic events, or acute kidney injury. Risk factors that should raise suspicion include intravenous drug use, presence of prosthetic heart valves, recent dental procedures, or known valvular heart disease. Diagnostic workup should include:

• Blood cultures (at least three sets from different sites before starting antibiotics)
• Complete blood count (showing anemia and elevated white blood cells)
• Elevated inflammatory markers (ESR, CRP)
• Echocardiography Empiric antibiotic therapy should be initiated promptly after blood cultures are drawn, typically with vancomycin plus ceftriaxone to cover both Staphylococcus and Streptococcus species, the most common causative organisms, while awaiting culture results 1. It is also important to consider the epidemiological factors, history of prior infections, exposure to antimicrobials, clinical course, severity, and extracardiac sites of infection of the current infection when choosing empirical therapy 1. Surgery may be indicated in certain cases, such as heart failure, uncontrolled infection, or prevention of embolism, and the timing of surgery depends on the specific indication and the patient's condition 1.

From the Research

Signs and Symptoms of Endocarditis

The signs and symptoms of endocarditis that would present to the Emergency Room (ER) include:

• Flu-like illness, which makes diagnosis difficult 2
• Fever and murmur, although they may not be present at the time of initial presentation 2
• Roth spots, Janeway lesions, Osler nodes, etc., although these are not common 2
• Consideration of risk factors, such as:
  • Prior endocarditis 2
  • Structural heart damage 2
  • IV drug use (IVDU) 2, 3
  • Poor immune function (vasculitis, HIV, diabetes, malignancy) 2
  • Nosocomial (surgical hardware placement, poor surgical technique, hematoma development) 2
  • Poor oral hygiene 2
• Multiple sites of infection, poor dentition, and abnormal culture results with atypical organisms 2

Diagnostic Approach

Diagnosis of endocarditis is based on:

• Positive blood culture results with identical microorganisms and the demonstration of endocardial involvement 4
• Use of an integrated diagnostic schema, such as the modified Duke criteria 3, 5
• Transthoracic or transesophageal echocardiography should be performed promptly for all suspected IE cases 5
• Consideration of clinical, laboratory, and echocardiographic findings 3

Treatment and Management

Treatment and management of endocarditis include:

• Antibiotic treatment, which depends on whether the involved valve is native or prosthetic, as well as the causative microorganism and its antibiotic susceptibilities 3
• Surgical consultation is warranted in patients with aggressive or persistent infections, emboli, and valvular compromise or rupture 3, 5
• Promptly administered intravenous antimicrobial therapy is essential 5
• Deciding whether to undertake cardiac surgery for the treatment of IE can be extremely difficult, with principal indications including the development of heart failure from acute, severe aortic or mitral regurgitation, or perivalvular extension of infection 5