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Infective Endocarditis: Causes, Risk Factors, Symptoms, Treatment & Prevention

What is Infective Endocarditis?

Endocarditis is an infection of the inner membrane of the heart, muscles of the heart and heart valves. The inner lining of the heart is known as endocardium. Endocarditis is also referred as infective endocarditis or bacterial endocarditis.

Infective Endocarditis

Endocarditis has a tendency to affect any mechanical devices that might be implanted in the heart. Individuals with an artificial heart valve, pacemaker or defibrillator are at a higher risk of developing endocarditis.

A heart valve is a flap-like structure, which acts like a stopper and regulates the flow of blood in the heart.

Infective endocarditis can be classified as acute and sub-acute. The pattern of incidence of IE is changing globally. Previously IE used to occur in 4th decade of life but due to changing pattern of incidences globally the mean age of occurrence is in 6th to 7th decade of life. In India,  the average age of individuals suffering from endocarditis is still less than 40 years, which is far less in comparison to western countries.

Causes and risk factors

Causes

IE is primarily caused by bacteria. In rare cases, fungi or other microbes may be responsible for endocarditis infections. In India, where rheumatic heart disease is more prevalent, Streptococcus viridans is the most important causative organism of IE. In health care associated endocarditis, Streptococcus aureus is the most important organism.

A human body has a lot of bacteria living in it. Our immune system is designed to fight off any infections caused by these bacteria.

If by chance, these bacteria enter the bloodstream and reach the heart, they can attack and damage the inner membrane of the heart and its valve. As a result of the infection, the valve stops functioning properly and may lead to severe complications, if left untreated.

In some cases, where an individual has damaged heart tissues, these bacteria can easily infect those damaged tissues and spread.

There is also a high risk of these bacterial growths clumping together and acting as clots, blocking the flow of blood, resulting in a heart attack.

Endocarditis causing germs can get into the bloodstream and reach the heart in the following ways:

  • Dental treatments: minor injuries incurred during certain dental procedures give an opportunity for bacteria to enter the bloodstream.
  • Brushing, flossing and chewing: sometimes the bacteria travel through the oral cavities into the blood stream. This is commonly seen in individuals suffering from poor dental hygiene.
  • Certain medical conditions: if a person has pre-existing infections of the skin, gum or sexually transmitted diseases like gonorrhoea, it provides easy access to bacteria to enter the bloodstream and reach the heart.
  • Contaminated needles or catheter: Infected needles used for body piercing, tattoo or catheters used in surgeries, allow the bacteria to enter the bloodstream and infect the heart.

Risk Factors

Endocarditis is commonly seen in an individual suffering from some heart disease. Some of the risk factors that make an individual vulnerable to endocarditis infections are:

  • Congenital heart disorders: Individual born with heart defects are more prone to endocarditis infection.
  • History of endocarditis: If an individual has suffered from endocarditis in the past.
  • Heart device implantation: any device implanted in the heart, such as pacemakers or artificial heart valves, increase the risk of endocarditis infection.
  • Faulty or defective heart valve: heart valve defects are a major concern for the development of endocarditis.
  • HIV or other sexually transmitted diseases: Individuals with HIV infections or suffering from sexually transmitted diseases are at a risk of endocarditis.
  • Drug abuse through injections: a drug addict who has been using contaminated needles for injecting drugs is at a high risk of getting endocarditis infection.
  • Cardiac Surgeries: An individual who has undergone cardiac surgery might develop endocarditis later in life.
  • Immunosuppressive therapy

Symptoms and signs

IE presents with a triad of heart murmur, fever and enlargement of spleen(splenomegaly)

Depending on the time taken in the development of symptoms endocarditis can be:

  • Acute endocarditis: Sudden appearance of symptoms, getting severe very rapidly. You will  have flu-like symptoms with fever night sweats, pain in muscles and fatigue
  • Subacute endocarditis: Symptoms appear slowly, taking weeks or sometimes months to develop and may last for months and there would be fatigue, fever with chills, loss of appetite and weight, swelling of feet and breathlessness with red rashes on palms and soles and painful ulcers on tips of fingers and toes.

Some of the common symptoms of endocarditis can be:

  • Fever above 100oF
  • Unexplained weight loss
  • Loss of appetite
  • Fatigue
  • Body pain
  • Chronic cough
  • Swelling in legs
  • Heart murmurs
  • Breathlessness

Diagnosis

Endocarditis diagnosis is made by an individual’s medical history, physical examination and results of the tests that might be advised by the doctor.

If you have a family history of congenital heart disease, rheumatic fever or valve disease, your doctor will suspect IE. You might have small dark lines under your fingernails which look like splinters of wood. These are called Splinter haemorrhages. You also can have burst red blood vessels in your retina known as Roth’s spot.

Physical examination may reveal a murmur which can be caused by any heart defect or defective heart valves.

Infective Endocarditis

Some of the routine diagnostic tests for endocarditis are:

  • Blood test: This will help in confirming any bacterial infection. Less number of red blood cells can be a sign of endocarditis.Cultures can be done to identify the organism
  • Chest x-ray: It is done to check whether the heart has enlarged due to infections.
  • Echocardiogram or transesophageal echocardiogram: It is done to find out the faulty heart valve, damaged due to infections or to check for infected areas.
  • Electrocardiogram (ECG): It is done to find out heart size, motion of the defective heart valves

Treatment and prevention

Treatment 

Depending on the severity of the bacterial infection and the damage incurred by the heart, your doctor will decide the treatment.

In case the infection has not led to much damage, you will be advised an antibiotic course, preferably given through a drip which may take few weeks to resolve the bacterial infection completely.

Your doctor would recommend surgery  if:

  • The disease has damaged your valve or heart tissue
  • You have moderate to severe congestive heart failure
  • You have an uncontrolled infection.

It is important to repair or replace the defective heart valve, to protect against further complications.

Prevention

Individuals who are at a risk of getting endocarditis infection need to take preventive steps:

  • Practice good oral hygiene.
  • Inform your doctor that you are susceptible to endocarditis before undergoing any surgery or dental treatment. Your doctor may prescribe preventive antibiotics.
  • Avoid getting tattoo and body piercing done at unhygienic places.
  • Say no to drug abuse.

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Complications

If endocarditis is left untreated, it might lead to fatal complications. Some of the major complications can be:

  • Heart attack
  • Risk of other organs getting damaged
  • Heart failure
  • Development of pus in other parts of the body
  • Inefficient heat valve, resulting in poor blood circulation.

Next steps

If you have been diagnosed with endocarditis infection, seek immediate medical consultation. Do not wait for the symptoms to become severe, as they may considerably damage your heart.

It is also important to complete the course of medications as advised by the doctor. Do not stop taking medications by yourself without consulting with your doctor.

Questions to ask your doctor

Make a list of all your queries. You can ask about the diagnosis and the degree of damage incurred to the heart. Get a list of do’s and don’t from your doctor.

Red flags

If you are at a risk of getting endocarditis infection and have been experiencing some of the symptoms mentioned above, contact your doctor immediately.

Watch out for any unusual signs:

  • Unexplained high fever
  • Blood in the urine
  • Murmuring sound in the chest

Consult a top Cardiologist

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References

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  • Endocarditis – Medline Plus – Accessed on 10-February, 2016 https://www.nlm.nih.gov/medlineplus/ency/article/001098.htm
  • Endocarditis – NHS choices – Accessed on 10 February 2016 http://www.nhs.uk/conditions/Endocarditis/Pages/Introduction.aspx
  • Bacterial Endocarditis – American Heart Association –Accessed on 10 February 2016, http://circ.ahajournals.org/content/107/20/e185.full
  • Infective Endocarditis-Cleveland clinic – Accessed on 10 February 2016, http://my.clevelandclinic.org/services/heart/disorders/heart-valve-disease/endocarditis-protection
  • What is Infective Endocarditis? – American Heart Association –Accessed on 10 February 2016, https://www.heart.org/idc/groups/heart-public/@wcm/@hcm/documents/downloadable/ucm_300297.pdf
  • Infective endocarditis: Indian scenario-The association of physician of India-Accessed on 10 February 2016, http://www.apiindia.org/medicine_update_2013/chap29.pdf
  •  Epidemiology of infective endocarditis in Chennai, South India- PubMed-Accessed on 10 February 2016, http://www.ncbi.nlm.nih.gov/pubmed/22718013
  • Infective endocarditis-an Indian perspective- Accessed on 11 February 2016 http://indianheartjournal.com/pdf/July%20Aug2005.pdf

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