Symptoms of infective endocarditis

Infective endocarditis has local and systemic symptoms.

Local changes in infective endocarditis include the formation of abscesses in the myocardium with destruction of the tissue and (sometimes) disorders of the conduction system (usually with abscesses of the lower part of the septum). Severe valvular regurgitation can develop suddenly, causing heart failure and death (usually with a mitral or aortic valve). Aortitis can be a consequence of contact spread of the infection. Infection of the prosthetic valves is most likely to cause valve-ring abscesses, vegetation leading to obstruction, myocardial abscesses and mycotic aneurysms that manifest valve obstruction, lamination, and cardiac conduction abnormalities.

Systemic symptoms of infective endocarditis develop primarily due to the embolism of the infected material from the heart valve and, mainly with chronic infection, immunosuppressed reactions. Right-side lesions usually cause the emergence of infected pulmonary emboli, which can lead to the formation of a lung infarction, pneumonia or pleural empyema. Left-sided lesions can cause embolism in any organ, especially the kidneys, spleen and CNS. Mycotic aneurysms can form in any large artery. Skin and retinal embolisms are often found. Diffuse glomerulonephritis can be the result of the deposition of immune complexes.

[1], [2]

Classification of infective endocarditis

Infective endocarditis can have an asymptomatic, subacute, acute course, as well as a fulminant course with a high probability of rapid decompensation.

[3], [4], [5], [6], [7], [8], [9],

Subacute infectious endocarditis 

Despite the fact that this pathology is serious, it usually proceeds asymptomatically, progressing slowly (within weeks or months). Often the source of infection or the entrance gate is not detected. PIE is usually caused by streptococci (especially S. viridans, microaerophil, anaerobic and non-enterococcal streptococci of group D and enterococci), less often with Staphylococcus aureus, epidermal staphylococcus and hemophilic rod. PIE often develops on altered valves after asymptomatic bacteremia due to periodontitis, gastrointestinal and urogenital infections.

Acute infective endocarditis (OIE)

Usually develops suddenly and rapidly progresses (within a few days). The source of the infection or the entrance gate is often obvious. If bacteria are virulent or bacteremia is massive, it is possible to damage normal valves. Usually, OIE is caused by Staphylococcus aureus, group A haemolytic streptococcus, pneumococcus or gonococcus.

[10], [11], [12],

Endocarditis of prosthetic valves (EPA)

It develops in 2-3% of patients within 1 year after valve replacement, then at 0.5% per year. It is more common after prosthetic aortic than mitral valve, and equally affects mechanical and bioprotic valves. Early infections (less than 2 months after surgery) are caused mainly by contamination during the operation by antibiotic-resistant bacteria (eg, epidermal staphylococcus, diphtheria, intestinal bacteria, Candida fungi , Aspergillus). Late infections are mainly caused by infection with malovirulent microorganisms during surgery or transient asymptomatic bacteremia. The most common are streptococci, epidermal staphylococcus, diphtheria, gram-negative bacilli, hemophilic rod, Actinobacillus actinomycetem comitans and Cardiobactehum hominis.

[13], [14], [15], [16], [17]

Subacute infectious endocarditis

Initially, the symptoms are uncertain: moderate fever (<39 ° C), night sweats, fast fatigue, malaise and weight loss. Symptoms of colds and arthralgia may appear. Manifestations of valvular insufficiency can be the first finding. Initially up to 15% of patients have a fever or noise, but in the end almost all of them have both signs. Data from a physical examination can be normal or include pallor, fever, changes in the existing noise, or the development of new regurgitation noise and tachycardia.

Embolism in the retina can lead to the appearance of round or oval hemorrhagic retinal lesions with a small white center (Roth spots). Cutaneous manifestations include petechiae (on the upper part of the trunk, conjunctiva, mucous membranes and distal limbs), painful erythematous subcutaneous nodules on the fingers (Osler's nodules), unstressed hemorrhagic maculae on the palms or soles (Janeway's symptom), and hemorrhages under the feet. Approximately 35% of patients have CNS lesions, including transient ischemic attacks, stroke, toxic encephalopathy and (with rupture of mycotic central aneurysm) a cerebral abscess and subarachnoid-distant bleeding. Renal embolisms can cause pain in one half of the trunk and sometimes in the hematuria. Splenic emboli can be accompanied by pain in the upper left quadrant of the abdomen. Prolonged infection can cause splenomegaly or thickening of the terminal phalanges of the fingers and toes.

Acute infective endocarditis and endocarditis of prosthetic valves

Symptoms are similar to PIE, but the flow is more rapid. Fever is almost always present initially, it gives the impression of severe intoxication, septic shock sometimes develops. Noise in the heart is present initially in approximately 50-80% of patients, and ultimately - more than 90%. Sometimes purulent meningitis develops.

[18], [19], [20]

Right-sided endocarditis

Septic pulmonary emboli can cause coughing, pleural pain in the chest and sometimes hemoptysis. With tricuspid insufficiency, the noise of blood regurgitation is typical.