Sunday, January 15, 2006

endocarditis

Endocarditis is an inflammatory alteration of the heart valves and of the membranes lining the heart. Infective endocarditis includes all presentations (acute, subacute) and causes (bacterial, fungal) of infectious complications of cardiovascular disease.
Depending on the virulence of the infecting organism, the symptoms of endocarditis may be insidious (as in subacute) or fulminant (as in acute). Typical symptoms are fever, which may be low grade, sweating, weakness, weight loss, complications of infarcts, arthralgias (joint pain), skin lesions such as petechiae (pinpoint, intradermal, or submucous hemorrhage), Osler's nodes (tender areas found in the pads of fingers, toes, or soles of feet), and splinter hemorrhages. Acute bacterial endocarditis may have sudden onset of chills, fever, and congestive heart failure. Endocarditis is frequently seen in intravenous drug users and patients undergoing hemodialysis (the artificial filtering of impurities from the blood). Examination shows signs of heart disease, fever, skin lesions of mucosal surfaces and the distal extremities, splenomegaly (enlargement of the spleen). Laboratory testing may reveal anemia, an elevated sedimentation rate, gross or microscopic hematuria (bloody urine), pyuria (pus in urine), proteinuria (protein in urine), elevated gamma globulin levels, and renal dysfunction. Blood cultures are positive in 85 percent to 90 percent of patients.
In the last 20 years there has been an increase in the number of elderly cases of endocarditis. Because of the nonspecific nature of the symptoms, this illness tends to be overlooked in the elderly. Also, fever is less prominent in this age group and heart murmurs may be absent in as many as 30 percent of the cases. The mortality rate is over 60 percent in those over age 70. Antibiotics are the primary mode of treatment in infective endocarditis. When possible, bactericidal drugs (penicillins, cephalosporins, vancomycin) should be used because bacteriostatic drugs (tetracyclines, sulfonamides, chloramphenical) usually fail. Because of decreased renal function in the elderly, these regimens may produce more toxicity.
The patient with congestive heart failure may require immediate surgery with valve replacement. In infections of prosthetic devices, surgical debridement, or replacement is usually indicated.
Covington, T., and Walker, J. Current Geriatric Therapy. Philadelphia: W. B. Saunders, 1984.

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