INFECTIVE ENDOCARDITISINFECTIVE ENDOCARDITIS

It is the colonization or invasion of the heart valves or It is the colonization or invasion of the heart valves or the mural endocardium by a the mural endocardium by a microbemicrobe, leading to the , leading to the formation of bulky, friable formation of bulky, friable vegetationsvegetations

Other sites of colonization- Aorta, aneurysmal sacs & Other sites of colonization- Aorta, aneurysmal sacs & blood vessels blood vessels

Vegetations are composed of thrombotic debris & Vegetations are composed of thrombotic debris & organismsorganisms

Most cases are bacterial , others- fungi, rickettsiae (Q Most cases are bacterial , others- fungi, rickettsiae (Q fever) & Chlamydiae fever) & Chlamydiae

Acute endocarditisAcute endocarditis Frequently affects a previously normal heart Frequently affects a previously normal heart

valvevalve

Highly virulent organismsHighly virulent organisms

Mortality high despite treatment (> 50% )Mortality high despite treatment (> 50% )

Lesions produced- Necrotizing, ulcerative, Lesions produced- Necrotizing, ulcerative, invasive valvular infectionsinvasive valvular infections

Subacute endocarditisSubacute endocarditis Insidious onset & even if untreated pursue a protracted Insidious onset & even if untreated pursue a protracted

course course

Organisms of low virulence Organisms of low virulence

Previously abnormal heart, particularly on deformed valvesPreviously abnormal heart, particularly on deformed valves Most patients recover after appropriate antibiotic therapyMost patients recover after appropriate antibiotic therapy

Vegetations often show evidence of healingVegetations often show evidence of healing

ETIOPATHOLOGYETIOPATHOLOGYPredisposing factorsPredisposing factors- RHD RHD - Myxomatous mitral valveMyxomatous mitral valve- Degenerative calcific valvular stenosisDegenerative calcific valvular stenosis- Bicuspid aortic valveBicuspid aortic valve- Prosthetic valvesProsthetic valves- Host factors (Neutropenia, immunodeficiency, Host factors (Neutropenia, immunodeficiency,

malignancy, therapeutic immunosuppression, DM, malignancy, therapeutic immunosuppression, DM, alcohol or IV drug abuse alcohol or IV drug abuse

- Indwelling vascular cathetersIndwelling vascular catheters

Bacterial endocarditis- Mitral valveBacterial endocarditis- Mitral valve

Causative organisms Causative organisms Streptococcus viridansStreptococcus viridans -Native but previously -Native but previously

damaged /abnormal valves -50% to 60% damaged /abnormal valves -50% to 60%

S. aureusS. aureus organisms- Either healthy or deformed organisms- Either healthy or deformed valves & IV drug abusers (10% to 20%)valves & IV drug abusers (10% to 20%)

Enterococci & HACEK group Enterococci & HACEK group

Prosthetic valve endocarditis -Coagulase-negative Prosthetic valve endocarditis -Coagulase-negative Staphylococci (Staphylococci (S. epidermidisS. epidermidis))

Gram-negative bacilli and fungiGram-negative bacilli and fungi

Culture-negative" endocarditis- 10% of casesCulture-negative" endocarditis- 10% of cases

Seeding of the blood with microbes Seeding of the blood with microbes

The portal of entry of bloodstreamThe portal of entry of bloodstream- Obvious infection elsewhereObvious infection elsewhere

- Dental or surgical procedure that causes a transient Dental or surgical procedure that causes a transient bacteremiabacteremia

- Injection of contaminated material directly into the Injection of contaminated material directly into the bloodstream by IV drug usersbloodstream by IV drug users

- Occult source from the gut, oral cavity or trivial injuries Occult source from the gut, oral cavity or trivial injuries

MORPHOLOGYMORPHOLOGYGROSSGROSSHeartHeart Friable, bulky vegetationsFriable, bulky vegetations

Vegetations may be single or multiple and may Vegetations may be single or multiple and may involve more than one valveinvolve more than one valve

Vegetations if erode into the underlying Vegetations if erode into the underlying myocardium produce an abscess cavity myocardium produce an abscess cavity (ring (ring abscess)abscess)

Systemic Systemic Emboli may cause infarcts in the brain, kidneys, Emboli may cause infarcts in the brain, kidneys,

myocardium & other tissues (septic infarcts)myocardium & other tissues (septic infarcts)

MicroscopicallyMicroscopically Vegetations are composed of thrombotic debris & Vegetations are composed of thrombotic debris &

organisms organisms

Vegetations of SABE often have granulation tissue Vegetations of SABE often have granulation tissue at their bases ,fibrosis, calcification & MNICs at their bases ,fibrosis, calcification & MNICs

CLINICAL FEATURESCLINICAL FEATURES Fever is the most consistent sign of IEFever is the most consistent sign of IE

Nonspecific fatigue, loss of weight & a flulike syndromeNonspecific fatigue, loss of weight & a flulike syndrome Murmurs are present in 90% of patients with left-sided Murmurs are present in 90% of patients with left-sided lesionslesions

Complications generally begin within the first weeks of the Complications generally begin within the first weeks of the onset of the diseaseonset of the disease

-Immunologically mediated - glomerulonephritis -Immunologically mediated - glomerulonephritis

Secondary to microemboli -UncommonSecondary to microemboli -Uncommon Petechiae in the nail bed of the digits (Petechiae in the nail bed of the digits (splinter or subungual splinter or subungual

hemorrhages)hemorrhages)

Erythematous/ hemorrhagic nontender lesions on the palms Erythematous/ hemorrhagic nontender lesions on the palms or soles or soles (Janeway lesions)(Janeway lesions)

Subcutaneous nodules in the pulp of the digits Subcutaneous nodules in the pulp of the digits (Osler nodes(Osler nodes) )

Retinal hemorrhages Retinal hemorrhages (Roth spots(Roth spots) )

DUKE CRITERIA for diagnosis of DUKE CRITERIA for diagnosis of IEIE

Requires either pathologic or clinical criteriaRequires either pathologic or clinical criteria

If clinical criteria are used, then for diagnosisIf clinical criteria are used, then for diagnosis 2 major2 major 1 major + 3 minor1 major + 3 minor 5 minor 5 minor

Pathologic criteriaPathologic criteria1.1. Microorganisms demonstrated by culture/ Microorganisms demonstrated by culture/

histologic exam in a vegetation/ embolus from histologic exam in a vegetation/ embolus from vegetation or intracardiac abscessvegetation or intracardiac abscess

2.2. Histologic confirmation of active endocarditis in Histologic confirmation of active endocarditis in vegetation of intracardiac abscessvegetation of intracardiac abscess

MajorMajor MinorMinor

1. Positive blood culture 1. Positive blood culture indicating characteristic indicating characteristic organismorganism

1. Predisposing heart lesion/ 1. Predisposing heart lesion/ IV drug abuseIV drug abuse

2. Echo- Valve related mass/ 2. Echo- Valve related mass/ abscessabscess

2.Fever2.Fever3.Valvular lesion3.Valvular lesion

3. New valvular regurgitation3. New valvular regurgitation 4.Immunological phenomena4.Immunological phenomena

5. Microbiologic evidence- 5. Microbiologic evidence- Uncharacteristic organismUncharacteristic organism

6. Echo- New valvular 6. Echo- New valvular regurgitation/ pericarditisregurgitation/ pericarditis

NONINFECTED NONINFECTED

VEGETATIONSVEGETATIONS

Nonbacterial Thrombotic Endocarditis (NBTE)Nonbacterial Thrombotic Endocarditis (NBTE) / Marantic / Marantic endocarditisendocarditis

Characterized by the deposition of) on the leaflets of the Characterized by the deposition of) on the leaflets of the cardiac valves small masses of fibrin, platelets & other cardiac valves small masses of fibrin, platelets & other blood components (Vegetationblood components (Vegetation

Valvular lesions are sterile Valvular lesions are sterile

Seen in debilitated patients (cancer or sepsis)Seen in debilitated patients (cancer or sepsis)

May produce emboli and resultant infarcts in the brain, May produce emboli and resultant infarcts in the brain, heart or elsewhereheart or elsewhere

Marantic endocarditisMarantic endocarditis

MorphologyMorphology GrossGrossVegetations are sterile, nondestructive & small (1 to 5 Vegetations are sterile, nondestructive & small (1 to 5

mm)mm)Single or multiple along the line of closure of the Single or multiple along the line of closure of the

leaflets or cusps leaflets or cusps

MicroMicroSmall masses of fibrin, platelets & other blood Small masses of fibrin, platelets & other blood

components components without accompanying inflammation without accompanying inflammation

Pathogenesis of NBTEPathogenesis of NBTEPredisposing conditionsPredisposing conditions

1.Hypercoagulable state1.Hypercoagulable state -DIC-DIC -C-Cancerancer –Mucinous adenocacarcinoma, APML –Mucinous adenocacarcinoma, APML - Hyperestrogenic states- Hyperestrogenic states- Extensive burns or sepsis - Extensive burns or sepsis

2.Endocardial trauma-2.Endocardial trauma- an indwelling catheter an indwelling catheter

Endocarditis of SLE (Libman-SacksEndocarditis of SLE (Libman-Sacks ) ) SLESLE Valvulitis with small, sterile vegetations (Valvulitis with small, sterile vegetations (Libman-Sacks Libman-Sacks

endocarditisendocarditis ) )

Thrombotic heart valve lesions with sterile vegetations - Thrombotic heart valve lesions with sterile vegetations - antiphospholipid syndrome due to circulating antiphospholipid syndrome due to circulating antiphospholipid antibodies antiphospholipid antibodies

The mitral valve is more frequently involved than the aorticThe mitral valve is more frequently involved than the aortic

Regurgitation is the usual functional abnormalityRegurgitation is the usual functional abnormality

MorphologyMorphologyGrossGross Vegetations are small single/ multiple, sterile, Vegetations are small single/ multiple, sterile,

granular pink (1 to 4 mm in diameter)granular pink (1 to 4 mm in diameter)

Located on the undersurfaces of the AV valves/ the Located on the undersurfaces of the AV valves/ the valvular endocardium / cords/ mural valvular endocardium / cords/ mural

Histologically Histologically Finely granular, fibrinous eosinophilic material that Finely granular, fibrinous eosinophilic material that

may contain hematoxylin bodies may contain hematoxylin bodies

RHDRHD IEIE NBTENBTE LSELSE

Row of Row of small, warty small, warty vegetationsvegetations

Along lines Along lines of closure of of closure of valve valve leafletsleaflets

Large, irregular Large, irregular mass of vegetationmass of vegetation

At valve cusps At valve cusps extending into the extending into the chordaechordae

Small, bland Small, bland vegetationsvegetations

Attached at line Attached at line of closureof closure

Small or Small or medium medium sized sized vegetation vegetation

On either On either or both or both sides of sides of valve valve leafletsleaflets

ARTIFICIAL VALVESARTIFICIAL VALVESPrimarily 2 categoriesPrimarily 2 categories (1) (1) mechanical prosthesesmechanical prostheses using nonphysiologic using nonphysiologic

biomaterials biomaterials (caged balls, tilting disks, or hinged semicircular flaps)(caged balls, tilting disks, or hinged semicircular flaps)

(2) (2) tissue valvestissue valves, usually , usually bioprosthesesbioprostheses consisting of consisting of chemically treated animal tissuechemically treated animal tissue

( porcine aortic valve tissue preserved in a dilute ( porcine aortic valve tissue preserved in a dilute glutaraldehyde solution& mounted on a prosthetic glutaraldehyde solution& mounted on a prosthetic frame)frame)

COMPLICATIONS OF ARTIFICIAL COMPLICATIONS OF ARTIFICIAL VALVESVALVES

Approximately 60% of substitute valve recipients Approximately 60% of substitute valve recipients develop complications within 10 years postop.develop complications within 10 years postop.

Frequency of complications is same but the nature is Frequency of complications is same but the nature is different with different types of artificial valvesdifferent with different types of artificial valves

Thrombosis Calcification/ tearThrombosis Calcification/ tear

Cause of failure of cardiac valve Cause of failure of cardiac valve prosthesisprosthesis

Thrombosis/thromboembolismThrombosis/thromboembolism

Anticoagulant-related hemorrhageAnticoagulant-related hemorrhage

Prosthetic valve endocarditisProsthetic valve endocarditis

Structural deterioration -  Wear, fracture, poppet failure in ball valves, Structural deterioration -  Wear, fracture, poppet failure in ball valves, cuspal tear, calcificationcuspal tear, calcification

Nonstructural dysfunction-  Granulation tissue, suture, tissue Nonstructural dysfunction-  Granulation tissue, suture, tissue entrapment, paravalvular leak, disproportion, hemolytic anemiaentrapment, paravalvular leak, disproportion, hemolytic anemia

Prophylactic use of antibiotics in patients withProphylactic use of antibiotics in patients with some form of cardiac anomaly /artificial valve who is some form of cardiac anomaly /artificial valve who is

to undergo a dental, surgical, or other invasive to undergo a dental, surgical, or other invasive procedureprocedure

Prompt diagnosis and effective treatment of IE Prompt diagnosis and effective treatment of IE

QuestionsQuestions

Long QLong Q1.Define rheumatic fever. Discuss the 1.Define rheumatic fever. Discuss the

etiopathogenesis & morphology of it.etiopathogenesis & morphology of it.

2. Define endocarditis. Discuss the 2. Define endocarditis. Discuss the etiopathogenesis, morphology & etiopathogenesis, morphology & complications of infective endocarditis.complications of infective endocarditis.

Short QShort Q1.1. Jones criteriaJones criteria2.2. Rheumatic feverRheumatic fever3.3. Aschoff bodyAschoff body4.4. VegetationsVegetations5.5. Infective endocarditisInfective endocarditis6.6. Libman sack endocarditisLibman sack endocarditis7.7. Maccallum plaqueMaccallum plaque