Endocarditis pathophysiology: Difference between revisions

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Revision as of 19:46, 21 September 2015

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

The turbulent blood flow around the heart valves is a risk factor for the development of endocarditis. The valves may be damaged congenitally, from surgery, by auto-immune mechanisms, or simply as a consequence of old age. The damaged endothelium of these areas becomes a site for attachment of infectious agents in infectious endocarditis. Dental procedures, colorectal cancer, urinary tract infections and intravenous drug use are the most common routes of introducing the infectious agent into the bloodstream. The three most common pathogens are strepotococcus viridans, staphylococcus and enterococcus. In non-bacterial thrombotic endocarditis (NBTE), the damaged part of a heart valve becomes covered with a blood clot which organizes.

Pathophysiology

Pathogenesis

Infective Endocarditis

The pathogenesis of infective endocarditis includes:^[1]^[2]


Pathogenic Factors	Mechanism

Valvular Damage	Altered and turbulent flow Catheters, electrodes, and other intracardiac devices Solid particles from repeated intravenous injections Chronic inflammation
Bacteremia	Dental procedures Intravenous drug use Complicated urinary tract infections Colorectal cancer
Lack of blood supply to valves	Blunted immune response Therapeutic drugs have difficulty reaching infected valves

Nonbacterial thrombotic endocarditis

Nonbacterial thrombotic endocarditis (NBTE), also called marantic endocarditis is most commonly found on previously undamaged valves.^[2] As opposed to infective endocarditis, the vegetations in NBTE are small, sterile, and tend to aggregate along the edges of the valve or the cusps.^[2] Also unlike infective endocarditis, NBTE does not cause an inflammation response from the body.^[2] NBTE usually occurs due to hypercoaguable states such as systemic bacterial infection or pregnancy.^[2] NBTE may also occur in patients with cancer, particularly mucinous adenocarcinoma.^[2] Libman-Sacks endocarditis is another form of sterile endocarditis; this form occurs more often in patients with lupus erythematosus and is thought to be due to the deposition of immune complexes. Libman-Sacks endocarditis involves small vegetations, while infective endocarditis is composed of large vegetations.^[2] These immune complexes precipitate an inflammatory reaction, which helps to differentiate it from NBTE.^[2] Also unlike NBTE, Libman-Sacks endocarditis does not seem to have a preferred location of deposition and may form on the undersurfaces of the valves or even on the endocardium.^[2]

Gross Pathology

Microscopic Pathology

Pathology

Image courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology

Heart; Breast intraductal papilloma metastasis. Thrombotic Nonbacterial Endocarditis (Infected): Gross mitral valve natural color vegetations well illustrated these were secondarily infected with staphylococcus case of 8 year survival breast intraductal papillary adenocarcinoma with extensive metastases. Aortic valve also involved
Thrombotic Nonbacterial Endocarditis Infected: Micro low mag H&E fibrin vegetation with masses of staphylococci and inflammatory cells in valve secondarily infected case 8 year survival breast papillary intraductal adenocarcinoma with extensive metastases gross is aortic valve lesions.

References

↑ Infective endocarditis. Wikipedia (2015). URL=https://en.wikipedia.org/wiki/Infective_endocarditis#Pathogenesis Accessed on September 21, 2015
↑ ^2.0 ^2.1 ^2.2 ^2.3 ^2.4 ^2.5 ^2.6 ^2.7 ^2.8 Endocarditis. Wikipedia (2015). URL= https://en.wikipedia.org/wiki/Endocarditis Accessed on September 21, 2015

Template:WH Template:WS

[abc-1] Infective endocarditis. Wikipedia (2015). URL=https://en.wikipedia.org/wiki/Infective_endocarditis#Pathogenesis Accessed on September 21, 2015

[endo-2] 2.0 ^2.1 ^2.2 ^2.3 ^2.4 ^2.5 ^2.6 ^2.7 ^2.8 Endocarditis. Wikipedia (2015). URL= https://en.wikipedia.org/wiki/Endocarditis Accessed on September 21, 2015

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 *Catheters, electrodes, and other intracardiac devices
 *Solid particles from repeated intravenous injections
 *Chronic inflammation
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 [[Nonbacterial thrombotic endocarditis]] (NBTE), also called '''marantic endocarditis''' is most commonly found on previously undamaged valves.<ref name=endo> Endocarditis. Wikipedia (2015). URL=https://en.wikipedia.org/wiki/Endocarditis Accessed on September 21, 2015</ref>  As opposed to infective endocarditis, the vegetations in NBTE are small, sterile, and tend to aggregate along the edges of the valve or the cusps.<ref name=endo> Endocarditis. Wikipedia (2015). URL=https://en.wikipedia.org/wiki/Endocarditis Accessed on September 21, 2015</ref>  Also unlike infective endocarditis, NBTE does not cause an inflammation response from the body.<ref name=endo> Endocarditis. Wikipedia (2015). URL=https://en.wikipedia.org/wiki/Endocarditis Accessed on September 21, 2015</ref>  NBTE usually occurs due to hypercoaguable states such as systemic bacterial infection or pregnancy.<ref name=endo> Endocarditis. Wikipedia (2015). URL=https://en.wikipedia.org/wiki/Endocarditis Accessed on September 21, 2015</ref>  NBTE may also occur in patients with cancer, particularly mucinous adenocarcinoma.<ref name=endo> Endocarditis. Wikipedia (2015). URL=https://en.wikipedia.org/wiki/Endocarditis Accessed on September 21, 2015</ref> [[Libman-Sacks endocarditis]] is another form of sterile endocarditis; this form occurs more often in patients with [[lupus erythematosus]] and is thought to be due to the deposition of immune complexes. Libman-Sacks endocarditis involves small vegetations, while infective endocarditis is composed of large vegetations.<ref name=endo> Endocarditis. Wikipedia (2015). URL=https://en.wikipedia.org/wiki/Endocarditis Accessed on September 21, 2015</ref>  These immune complexes precipitate an inflammatory reaction, which helps to differentiate it from NBTE.<ref name=endo> Endocarditis. Wikipedia (2015). URL=https://en.wikipedia.org/wiki/Endocarditis Accessed on September 21, 2015</ref>  Also unlike NBTE, Libman-Sacks endocarditis does not seem to have a preferred location of deposition and may form on the undersurfaces of the valves or even on the endocardium.<ref name=endo> Endocarditis. Wikipedia (2015). URL=https://en.wikipedia.org/wiki/Endocarditis Accessed on September 21, 2015</ref>
-===Associated Conditions===
 ===Gross Pathology===
 ===Microscopic Pathology===
-==Causes of Bacteremia==
-===Dental Procedures===
-The bacteremia is often caused by [[dentistry|dental]] procedures, such as a cleaning or [[Extraction (dental)|extraction]] of a [[tooth]]. It is important that a [[dentist]] or a [[dental hygienist]] therefore be  told of any heart problems before beginning the procedure. [[Endocarditis antibiotic prophylaxis|Prophylactic antibiotics]] are administered to patients with certain heart conditions as a precaution.
-===Entrance of Bacteria Into the Bloodstream===
-Another cause of [[infective endocarditis]] is a scenario in which an excess number of bacteria enter the bloodstream. [[Colorectal cancer]], serious [[urinary tract infection]]s, and [[IV drug]] use can all introduce large numbers of such bacteria. When a large burden of bacteria are introduced, a normal heart valve may be infected. A more virulent organism (such as ''[[Staphylococcus aureus]]'', but see [[#Micro-organisms_responsible|below]] for others) is often responsible for infecting a normal valve.
-===Intravenous Drug Use===
-Infections of the [[tricuspid valve]] and less frequently the [[pulmonic valve]] tend to occur in intravenous drug users given the high pathogen burden from their introduction in the [[vein]]. The diseased valve is most commonly affected when there is a pre-existing disease. In rheumatic heart disease this is the [[aortic valve]] and the [[mitral valve]]s, on the left side of the heart.
 ==Pathology==