Endocarditis

Since being in Japan on this occasion, I have seen at least 4 cases of endocarditis and heard of at least one other.

One case I picked up myself in my first week, and the only complaint was a fever in a very well looking patient sitting in his bed in front of me. The look of his poor dentition and a loud systolic murmur led me to the diagnosis, whereas the 'full body CT' performed on admission, had failed to elucidate the cause. Goal directed testing e.g. echocardiography picked up the vegetation and the patient received valve-saving reconstruction surgery.

More recently, two young female patients developed IE and one was found to have a 'floppy mitral valve' with regurgitation and blood cultures growing streptococcus salivarius (alpha-haemolytic strep) with the only contributing cause being dental work performed several months before; a classical case of subacute bacterial endocarditis. But for the experience and expertise of my colleague in the outpatient clinic, this diagnosis could have been missed- well done to him!

The second female patient presented with a rapidly progressive multifocal pneumonia and it was initially considered, by myself and others, to be a post-influenzal staphylococcal pneumonia on clinical grounds alone before any microbiological data were available. It was unsurprising to find all 4 blood culture bottles had grown S. aureus. However, an echocardiogram was performed and this revealed a Ventricular Septal Defect (VSD) with a large vegetation (2cm!!).

Another case of suspected IE was found on a patient with terminal cardiac failure who presented to ER with a fever. He had been developing worsening dyspnoea at rest and rapidly progressive renal failure. The fact that his fingers and toenails had the most splinter haemorrhages I have ever seen (plus Beau's line: arrest of nail growth), a loud cardiac murmur and blood in the urine convinced me he also had IE.

He was transferred to another hospital and so it was not possible to get confirmation of the suspected diagnosis.

Where is all this leading?? Well, in the UK, the diagnosis of infective endocarditis is extremely uncommon. I have personally only seen two cases in seven years and hence, to hear of at least 4-5 cases in under a year has been an eye opener to me.

A patient with a fever, young or old, should always have their finger nails examined for splinter haemorrhages, finger pulps for Osler's nodes, the palms forJaneway Lesions, and if you can do retinal fundoscopy, Roth's spots.

A cardiac murmur may be absent, but in most cases I have seen, they have been present and usually are consistent with regurgitation (systolic or diastolic) from an incompetent destroyed valve. Finding blood in the urine should alert the physician to possible renal infarcts from septic thromboemboli derived from the vegetation. The usual 3 sets of blood cultures must be taken even in the absence of a fever and an high ESR e.g. 80mm/hour, can provide useful clues for making the diagnosis.

A transthoracic echo can sometimes reveal the vegetation, if large enough, but for the small millimeter size vegetations, only an oesophageal echo will do.

The junior doctors need to bear this diagnosis in mind for causes of fever, because if missed, the results can be catastrophic. Examining the hands (particularly the nails) can give the doctor the clue they need to make the diagnosis on physical examination alone, which a CT scan would never see.