Endocarditis natural history, complications and prognosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Maliha Shakil, M.D. [2]

Overview

If left untreated, patients with endocarditis may progress to develop congestive heart failure. Complications of endocarditis can occur as a result of the locally destructive effects of the infection. These complications include perforation of valve leaflets causing congestive heart failure, abscesses, and disruption of the heart's conduction system. Endocarditis may also cause embolization to the brain (causing a stroke), to the coronary artery (causing a heart attack), to the lung (causing pulmonary embolism), to the spleen (causing a splenic infarct), and to the kidney (causing a renal infarct). Prognosis of endocarditis is generally poor and the overall mortality rate for both native and prosthetic valve endocarditis ranges from 20-25%. The mortality rate for right-sided endocarditis in injection drug users is approximately 10%. The 5-year survival rate for native valve endocarditis is 70-80% and 50-80% for prosthetic valve endocarditis.

Natural History

• If left untreated, patients with endocarditis may progress to develop congestive heart failure.

Complications

Complications of infective endocarditis include:

Cardiac

1. Murmur
2. A new aortic diastolic murmur suggests dilatation of the aortic annulus or eversion, rupture, or fenestration of an aortic leaflet
3. The sudden onset of a loud mitral pansystolic murmur suggests rupture of chorda tendineae or fenestration of a mitral valve leaflet
4. Congestive heart failure
5. Cardiac rhythm disturbances including AV block
6. Pericarditis (uncommon)

Cutaneous

1. Petechiae of the conjunctiva, oropharynx, skin, and legs
2. Linear subungual splinter haemorrhages of the lower or middle nail bed
3. Osler’s nodes
4. Janeway lesions

Musculoskeletal

1. Myalgias
2. Arthralgias
3. Arthritis
4. Low back pain
5. Rheumatoid factor is elevated in up to 50% of patients with endocarditis for >6 weeks
6. Clubbing of fingers is present in < 15% of patients

Ocular

1. Petechial hemorrhages
2. Flame-shaped hemorrhages
3. Roth's spots
4. Cotton-wool exudates in the retina

Embolic

1. Significant arterial emboli occur in 30%–50% of patients, causing the following:
   • Stroke
   • Monocular blindness
   • Acute abdominal pain, ileus, and melena
   • Pain and gangrene in the extremities
2. CNS emboli are common
3. Coronary emboli, often asymptomatic, can cause myocardial infarction
4. Pulmonary emboli are common in right-sided endocarditis, causing pulmonary infarcts or focal pneumonitis

Splenic

1. Splenomegaly is observed in 15%–30% of patients
2. Splenic infarcts occur in up to 40% of patients
3. Splenic abscesses occur in ~ 5% of patients

Renal

1. Microscopic hematuria occurs in ~ 50% of patients
2. Embolic renal infarction
3. Diffuse membranoproliferative glomerulonephritis

Mycotic Aneurysms

Occur in any artery in 2%–8% of patients, causing the following:

1. Pain or headache
2. Pulsatile mass
3. Fever
4. Sudden expanding hematoma
5. Signs of major blood loss

Neurologic

1. Neurologic complications occur in 25%–40% of cases
2. Strokes caused by cerebral embolisms in ~15% of cases, causing the following:

   • Altered level of consciousness
   • Seizures
   • Fluctuating focal neurologic signs

3. Cerebral aneurysms occur in 1%–5% of cases, causing the following:

   • Headache
   • Focal signs
   • Acute intracerebral or subarachnoid hemorrhage caused by rupture
   • Mild meningeal irritation resulting from slow leakage

4. Brain abscesses may occur in acute endocarditis caused by Staphylococcus aureus
5. Seizures

Monitoring for Complications of Infectious Endocarditis

Among those patients at high risk, careful monitoring should be undertaken to detect the early development of complications such as:

1. Valvular dysfunction, usual insufficiency of the mitral or aortic valves
2. Myocardial or septal abscesses
3. Congestive heart failure
4. Metastatic infection
5. Embolic phenomenon

Prognosis

• The prognosis of endocarditis is generally poor and the overall mortality rate for both native and prosthetic valve endocarditis ranges from 20-25%.
• The mortality rate for right-sided endocarditis in injection drug users is approximately 10%.
• The 5-year survival rate for native valve endocarditis is 70-80% and 50-80% for prosthetic valve endocarditis.