Presentation

Classic presentation

• Presentation is nonspecific and variable, but the most common symptoms are fever and malaise.
  
• The classic triad of fever, new heart murmur, and anemia is rare.
  
• Patients may present acutely with critical illness, or subacutely with low-grade fever, fatigue, weight loss, and distal emboli.

Critical presentation

• Patients may present in acute or progressive congestive heart failure with dyspnea, frothy sputum, and chest pain. This is the most common complication.
  
• The second most common complication is arterial embolization of valve vegetation fragments. These emboli can affect any body system:
  
  
  
  • Central nervous system (CNS): cerebrovascular accidents (CVA), subarachnoid hemorrhage (SAH), acute monocular blindness.
    
  • Renal: back pain, hematuria, renal failure.
    
  • Pulmonary: pneumonia, infarction, pleural effusion.
    
  • Gastrointestinal (GI): splenic infarction, mesenteric ischemia.
  
  
• Heart blocks and arrhythmias are also possible as the infection may extend through the septum and into the cardiac conduction system.
  
• Patients may present with respiratory compromise, diminished pulmonary capacity, altered mental status, or evidence of sepsis.

Diagnosis and evaluation

• Definitive diagnosis is made by positive blood culture(s), and evidence of valvular injury or vegetations on echocardiogram.
  
• Echocardiography should be performed as soon as possible.
  
• A transesophageal echocardiogram is more sensitive and should be performed in patients with a high clinical suspicion and a normal transthoracic echocardiogram.
  
• Nonspecific laboratory findings include leukocytosis, normocytic anemia, elevated C-reactive protein (CRP), elevated erythrocyte sedimentation rate (ESR), and hematuria.
  
• There are no specific findings on ECG or chest radiography.
  
• Other physical examination findings are due to circulating immune complexes that are embolizing (Table 56.2).
  
• The Duke Criteria are widely used to diagnose infective endocarditis and have a sensitivity of about 90% (Table 56.3). A positive diagnosis consists of
  
  
  
  • Two major criteria, or
    
  • One major criterion and three minor criteria, or
    
  • All five minor criteria.

Table 56.2. Physical findings in infective endocarditis

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