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Posts Tagged ‘minor infective endocarditis’

Infective endocarditis continues to be a challenge for the cardiac physicians.

While we have innovated too much( More than what is required !)  in the interventional arena little is progressed in the last few decades on  this vital  area  of  “Infections of heart”.

Globally , deaths continue to occur in prime ages due to rampant infections of the heart valves.

Prevention of IE was recently deglamorised by diluting the criteria for prophylaxis by ACC/AHA (Cost issues ,  overwhelming science ? )

So, what is left in the war against IE ?

Early diagnosis and recognition

How to diagnose it early ?

Suspicion is the key  . . .

When to suspect ?

Suspect in all with fever and h/o heart disease . So far  no case of afebrile IE reported !

Get rid of the common myths

  • You don’t require vegetations to diagnose IE
  • Blood culture need not be positive
  • Fever can be low grade
  • Rarely severe fatigue is the only sign

This effectively means , one can diagnose IE without a major criteria of Dukes.

One can diagnose IE with 5 minor criterias

If you wait for a major criteria to develop to start treatment , it could be a  costly miss .

So have a open mind, suspect IE, treat early.

Do not unduly worry about , overuse of antibiotics in case of  false diagnose of IE.This  attempt is worth in weight  of gold !


Million ton of antibitics are used indiscrininately in this world by all walks of physcinas for simple cold and surgeions  non existing peripopertaive infections .

While , the global medical community has  accepted this concept with total submission (Intentional harm condoned !) , it is funny to ask for 100% appropriateness in the therapy for a  deadly infection of heart.

It is absolute necessity  to  inject an  anticipatory antibiotic in all cases of suspected IE with high risk valve lesions. (Of course ,  it need to be a reasonably appropriate antibiotic with microbiologists consultation to avoid interference in the subsequent culture evaluation !)

Minor only infective endocarditis.

Please note IE can be diagnosed with the following 5 minor criteria

  1. Predisposing lesion
  2. Fever >38c
  3. Immunological / Vascular lesion
  4. Culture eqivocal
  5. No clear cut vegetation , but high suggestion of vegetaion, New valve regurgitation

A related article in this blog

Vegetation negative infective endocarditis .

Final message

Never hesitate to start empirical antibiotic therapy in suspected high risk IE

Let us err . . . for the patient’s sake  !

Fever + New murmur*= IE until proven otherwise (Oxford handbook of  clinical medicine  P 136 7th Edition )

*It can be read as , presumably new murmur to increase the sensitivity.

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Yes , we can .         Abstract : Link to Indian heart journal

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Vegetation Negative Infective-Endocarditis

S Venkatesan, G Gnanavelu, G Karthikeyan, V Jaganathan,  R Alagesan,
M Annamalai, S Shanmugasundaram, S Geetha, A Balaguru, G Anuradha

Madras Medical College, Chennai


The definitive diagnosis of infective endocartitis (IE) remains a contentious clinical issue. Many diagnostic criteria have been advanced. However, none has withstood the test of time. Currently Duke’s criteria is considered as de facto standard. Documentation of vegetation within the cardiac chambers and positivity of blood culture is the sine qua non of IE and evidently they constitute the major criteria. Ironically, according to Duke’s criteria, IE could still be diagnosed in the absence of vegetation, provided it fulfils other major criteria of culture positivity. In this context, we report our analysis of patients with IE without vegetation. Out of 24 patients admitted between 2004-2005 in our hospital with the diagnosis of IE, 4 patients failed to show vegetations. All had rheumatic heart disease (RHD) and presented with prolonged fever. All had severe eccentric mitral regurigitation (MR). One had severe aortic regurgitation (AR) also. One had flail posterior mitral leaflet (PML). All had blood culture positive – 3 for staphylococcus auerus 1 for pseudomonas. None had vegetations on the first echocardiographic examination. Transesophageal echcardiography (TEE) also failed to detect a vegetation or abscess. The diagnosis of IE was made on the basis of Duke’s criteria (1 major and 3 minor features). Treatment was started based on culture positivity and sensitivity. All patients underwent serial echocardiography every week for 6 weeks. New mobile vegetation was detected in 1 patient in anterior mitral leaflet (AML) measuring 12 mm after 2 weeks. Three patients never showed any evidence of vegetation. One patient developed cerebral vasculitis and another renal insufficiency during the course of treatment. Two patients stabilized with medical management. One expired and other had refractory cardiac failure and was referred for emergency surgery. The mechanism of absence of vegetation in IE could be varied. Simple temporal dissociation between appearance of vegetation and the clinical syndrome should be the first possibility. Further, vigorous antimicrobial treatment might have prevented the formation of vegetation. But, as we have seen in few patients, it never appeared. This was possibly due to layered vegetation like that of a thrombus on the surface of the valve or adjacent myocardium. The process of vegetation formation need not be endoluminal, it can burrough into the tissue plane intramurally without projecting into the cavity. Spontaneous rupture of chordae secondary to inflammation without any vegetation is another possibility.

We conclude , even though vegetations are considered sine quo non of IE in many clinical situations, IE occurs without vegetation. The mechanisms could be varied.

Download full  PPT presentation

infective-endocarditis-csi-2005

infective-endocarditis-csi-2005

infective-endocarditis-vegetation-csi-2005

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