A 70-year-old lady presents to her GP with recurrent fevers, fatigue, confusion and shortness of breath on exertion, which started a few weeks earlier. On examination she is febrile with a temperature of 38.4C. The GP notes that she has a newly discovered early diastolic heart murmur. Chest examination is normal and there is mild, bilateral ankle oedema. Her past medical history includes type 2 diabetes and hypertension.
The GP suspects endocarditis and urgently refers her to A&E.
Endocarditis is defined as an infection that affects the inner lining of the heart (the endocardium), including the heart valves. Its a rare condition but it carries a risk of mortality and can cause significant cardiac damage. It requires early diagnosis and treatment.
Risk factors for developing endocarditis include:
Endocarditis can have a non-specific and insidious onset. Symptoms can develop acutely or slowly over weeks or sometimes months.
The most common features are non-specific flu-like symptoms including fever, myalgia, fatigue, rigors, headache, cough and a sore throat. Unexplained weight loss might be noted, along with the presence of a new heart murmur.
Endocarditis is caused by infective organisms, such as bacteria and fungi, which colonise the endothelial surfaceof the heart. It has a predilection forthe heart valve leaflets (native or prosthetic), where vegetations (an accumulation of platelets in which microorganisms and inflammatory cells embed) form. This may be visible on echocardiography and may embolise, leading to strokes and peripheral or pulmonary emboli, or systemic dispersion of infection.
Other features can include:
Other signs include:
These stigmata are less frequent in earlier presentations of the disease.
Consider the diagnosis in patients with:
And in patients with the following symptoms:
Consider especially if there is:
The spectrum of clinical presentation is wide and can depend on what the causative organism is, where the infection occurs, the presence of underlying heart disease and whether the patient is immunocompromised. The greatest risk is in patients who have had heart surgery or have used drugs intravenously.
As a result, endocarditis can present acutely with sepsis, heart failure and evidence of systemic embolisation, or more insidiously with persistent fever and fatigue.
Acute endocarditis is usually caused by Staphylococcus aureus, but if the presentation is subacute, commonly implicated organisms include viridans streptococci, enterococci, coagulase-negative staphylococcus or gram-negative coccobacilli.1
Early-stage infection can masquerade as other illnesses, making it hard to seal a diagnosis. Some of the red flags that might point you towards the diagnosis are highlighted below. The Duke criteria are commonly used in clinical practice, to accompany clinical judgment.2
Investigations that may be helpful include:
The most important management aspect if a GP suspects endocarditis is to avoid giving antibiotics. It is important that blood cultures are taken first so proper treatment can be given, using antibiotics to which the organism is sensitive.
Therefore, if endocarditis is suspected, the GP should:
Prolonged courses of IV antibiotics are often required and liaison with the hospital is important. Further investigations might be needed, or even heart surgery.
Early characterisation of the implicated organism and sensitivities allows tailoring of therapy, particularly as resistance is becoming an increasing issue.3 Regimens are recommended by the European Society of Cardiology.4 Most regimens include a penicillin for four to six weeks, combined with gentamicin for up to two weeks.
The European Society of Cardiology supports the use of prophylactic antibiotics in high-risk patients undergoing dental surgery, as decided by the specialist.4
Dr Louise Tulloh is a GP at Mendip Vale Medical Group, north Somerset.Professor Robert Tulloh is a consultant congenital cardiologist at Bristol Heart Institute.
Read the original post:
'I've had this temperature for weeks' | Feature - Pulse
- Best 30 Cardiology in Secaucus, NJ with Reviews - YP.com [Last Updated On: April 12th, 2018] [Originally Added On: April 12th, 2018]
- Cardiology | Weill Cornell Medicine [Last Updated On: April 14th, 2018] [Originally Added On: April 14th, 2018]
- Cardiology Conferences 2018 | Cardiology Meetings 2018 ... [Last Updated On: April 26th, 2018] [Originally Added On: April 26th, 2018]
- Dr. Anil Goel, MD - Birmingham, MI - Cardiology & Clinical ... [Last Updated On: April 26th, 2018] [Originally Added On: April 26th, 2018]
- Clinical Physiology (Cardiology) MSc/PGDip | Middlesex ... [Last Updated On: May 15th, 2018] [Originally Added On: May 15th, 2018]
- Cardiology Conferences 2018 | Upcoming Cardiology ... [Last Updated On: May 16th, 2018] [Originally Added On: May 16th, 2018]
- Clinical Cardiology Section | Cleveland Clinic [Last Updated On: May 27th, 2018] [Originally Added On: May 27th, 2018]
- Journal of Clinical and Experimental Cardiology - Open ... [Last Updated On: June 6th, 2018] [Originally Added On: June 6th, 2018]
- Cardiology Summit 2018 | Cardiology Conferences | Heart ... [Last Updated On: June 23rd, 2018] [Originally Added On: June 23rd, 2018]
- Cardiology Clinical and Research Faculty Members ... [Last Updated On: June 26th, 2018] [Originally Added On: June 26th, 2018]
- Cardiology Conferences 2018 | Cardiology Congress 2018 ... [Last Updated On: June 26th, 2018] [Originally Added On: June 26th, 2018]
- About Us - New Jersey Cardiology Associates [Last Updated On: July 8th, 2018] [Originally Added On: July 8th, 2018]
- About Us - Ventura Clinical Trials [Last Updated On: August 16th, 2018] [Originally Added On: August 16th, 2018]
- Clinical Cardiology Made Ridiculously Simple: Michael A ... [Last Updated On: August 22nd, 2018] [Originally Added On: August 22nd, 2018]
- Clinical Cardiology - American Society of Preventive Cardiology [Last Updated On: October 2nd, 2018] [Originally Added On: October 2nd, 2018]
- Heart Surgery Hospital in india | Cardiology Treatment ... [Last Updated On: October 7th, 2018] [Originally Added On: October 7th, 2018]
- Clinical Cardiology - American Society of Preventive ... [Last Updated On: December 3rd, 2018] [Originally Added On: December 3rd, 2018]
- Guideline Clinical App - American College of Cardiology [Last Updated On: December 7th, 2018] [Originally Added On: December 7th, 2018]
- Journal of Clinical and Experimental Cardiology- Open ... [Last Updated On: December 12th, 2018] [Originally Added On: December 12th, 2018]
- Clinical Cardiology - Baptist Health [Last Updated On: December 30th, 2018] [Originally Added On: December 30th, 2018]
- Cardiology at Cancun: Topics in Clinical Cardiology [Last Updated On: February 5th, 2019] [Originally Added On: February 5th, 2019]
- Department of Cardiovascular Medicine, KU School of Medicine [Last Updated On: March 10th, 2019] [Originally Added On: March 10th, 2019]
- Towards Health Equality: Improving the Management of Cardiovascular Diseases in Women - International Atomic Energy Agency [Last Updated On: September 21st, 2019] [Originally Added On: September 21st, 2019]
- Lifetime Risk of PAD Varies by Race, but All Are Vulnerable to Traditional Risk Factors - TCTMD [Last Updated On: September 21st, 2019] [Originally Added On: September 21st, 2019]
- DEFINE-HF: Dapagliflozin Improves Function and QoL, but Not Biomarkers, in HFrEF - TCTMD [Last Updated On: September 21st, 2019] [Originally Added On: September 21st, 2019]
- Combining Nature and Technology, Luye Medical and Cleveland Clinic Join to Build a Future Hospital in Shanghai - Yahoo Finance [Last Updated On: September 21st, 2019] [Originally Added On: September 21st, 2019]
- Will Renal Denervation for Hypertension Rise Again? - Medscape [Last Updated On: September 21st, 2019] [Originally Added On: September 21st, 2019]
- Obstructive Sleep Apnea, Sleep Symptoms, and their Association with Cardiovascular Disease - DocWire News [Last Updated On: September 21st, 2019] [Originally Added On: September 21st, 2019]
- CNE expands pulmonary, sleep services with Brigham & Women's physicians - Warwick Beacon [Last Updated On: September 21st, 2019] [Originally Added On: September 21st, 2019]
- What I Am Most Looking Forward to at TCT 2019 - TCTMD [Last Updated On: September 21st, 2019] [Originally Added On: September 21st, 2019]
- Serelaxin Not Linked to CV Mortality Reduction in Patients Hospitalized for Acute HF - The Cardiology Advisor [Last Updated On: September 21st, 2019] [Originally Added On: September 21st, 2019]
- Sacubitril-Valsartan Not Linked to Lower Hospitalization Risk, CV Death in HFpEF - The Cardiology Advisor [Last Updated On: September 21st, 2019] [Originally Added On: September 21st, 2019]
- FDA clears multiuse angiography systems from Siemens Healthineers - DOTmed HealthCare Business News [Last Updated On: September 21st, 2019] [Originally Added On: September 21st, 2019]
- Balloon Pulmonary Angioplasty Effective for Chronic Thromboembolic PH - The Cardiology Advisor [Last Updated On: September 21st, 2019] [Originally Added On: September 21st, 2019]
- RWJBarnabas Health, St. Luke's University Health launch clinical affiliation - FierceHealthcare [Last Updated On: September 21st, 2019] [Originally Added On: September 21st, 2019]
- Bilirubin: A Novel Indicator of Infective Endocarditis Adverse Outcomes - The Cardiology Advisor [Last Updated On: September 21st, 2019] [Originally Added On: September 21st, 2019]
- Major Bleeding Mostly Early, Not Severe With Rivaroxaban Plus Aspirin in COMPASS - TCTMD [Last Updated On: September 21st, 2019] [Originally Added On: September 21st, 2019]
- Community-based Care Model Reduces CVD Risk - Managed Healthcare Executive [Last Updated On: September 21st, 2019] [Originally Added On: September 21st, 2019]
- American College of Cardiology Steps Up: Equal Pay, Opportunities for All - TCTMD [Last Updated On: September 21st, 2019] [Originally Added On: September 21st, 2019]
- FDA Approves Novo Nordisk's Oral Semaglutide, First GLP-1 in Pill Form - AJMC.com Managed Markets Network [Last Updated On: September 21st, 2019] [Originally Added On: September 21st, 2019]
- A New Drug for HF? DEFINE-HF Bolsters Dapagliflozin Cardio Cred - Medscape [Last Updated On: September 21st, 2019] [Originally Added On: September 21st, 2019]
- Seeking Synergy: Bringing Cardiology into Your Enterprise Imaging Strategy - Health Imaging [Last Updated On: September 21st, 2019] [Originally Added On: September 21st, 2019]
- TCT 2019 Day Two: Transcatheter Valves, New and Old - TCTMD [Last Updated On: September 30th, 2019] [Originally Added On: September 30th, 2019]
- Transcatheter Options Best for Tricuspid Regurgitation in Matched Registry Analysis - TCTMD [Last Updated On: September 30th, 2019] [Originally Added On: September 30th, 2019]
- Bypass Surgery and Coronary Stenting Yield Comparable 10-Year Survival - Diagnostic and Interventional Cardiology [Last Updated On: September 30th, 2019] [Originally Added On: September 30th, 2019]
- TAVR Improves Health Status Over Surgery in Low-Risk Patients at 1 Year: PARTNER 3 - TCTMD [Last Updated On: September 30th, 2019] [Originally Added On: September 30th, 2019]
- Eidos Therapeutics to Present Interim Analysis of the Ongoing Phase 2 Open-Label Extension Study of AG10 in Patients with TTR Amyloid Cardiomyopathy... [Last Updated On: September 30th, 2019] [Originally Added On: September 30th, 2019]
- Off Script: The New Gatekeepers of Procedural Education - TCTMD [Last Updated On: September 30th, 2019] [Originally Added On: September 30th, 2019]
- Study Shows Safety and Efficacy of Near Infrared Spectroscopy (NIRS) Imaging to Identify Patients and Plaques at an Increased Risk for MACE - BioSpace [Last Updated On: September 30th, 2019] [Originally Added On: September 30th, 2019]
- The Heart of the Matter: Cardiovascular Fitness in Horses - United States Eventing Association [Last Updated On: September 30th, 2019] [Originally Added On: September 30th, 2019]
- Google parent Alphabet hires former FDA head Robert Califf to lead health strategy and policy - FierceHealthcare [Last Updated On: September 30th, 2019] [Originally Added On: September 30th, 2019]
- Inclisiran Benefits Patients With Familial Hypercholesterolemia and ASCVD - The Cardiology Advisor [Last Updated On: September 30th, 2019] [Originally Added On: September 30th, 2019]
- AUGUSTUS: Best Benefit With Apixaban, P2Y12 Inhibitor Dual Therapy - Medscape [Last Updated On: September 30th, 2019] [Originally Added On: September 30th, 2019]
- New TAVR System Safe and Effective for High-Risk Surgical Patients with Severe Aortic Stenosis - Newswise [Last Updated On: September 30th, 2019] [Originally Added On: September 30th, 2019]
- Dapagliflozin Improves Heart Failure-Related Health Status in HFrEF - The Cardiology Advisor [Last Updated On: September 30th, 2019] [Originally Added On: September 30th, 2019]
- Remote Ischemic Conditioning Did Not Improve 12 Month Clinical Outcomes After STEMI - The Cardiology Advisor [Last Updated On: September 30th, 2019] [Originally Added On: September 30th, 2019]
- Insights from the European Society of Cardiology congress | Speaking of Medicine - PLoS Blogs [Last Updated On: September 30th, 2019] [Originally Added On: September 30th, 2019]
- Smokers Have More Pulmonary Emboli, Leading to Higher Hospital Readmission Rates | - Diagnostic and Interventional Cardiology [Last Updated On: October 22nd, 2019] [Originally Added On: October 22nd, 2019]
- AZ's Farxiga gets heart failure prevention okay from FDA - PMLiVE [Last Updated On: October 22nd, 2019] [Originally Added On: October 22nd, 2019]
- Bayer Announces Recipients of the Pulmonary Hypertension Accelerated Bayer (PHAB) Awards at CHEST Annual Meeting 2019 - BioSpace [Last Updated On: October 22nd, 2019] [Originally Added On: October 22nd, 2019]
- The Epidemic Of The Metabolic Syndrome Among The Palestinians In The G | DMSO - Dove Medical Press [Last Updated On: October 22nd, 2019] [Originally Added On: October 22nd, 2019]
- Optina Diagnostics and the Montreal Heart Institute Partner to Develop a New Biomarker for Atherosclerosis - PRNewswire [Last Updated On: October 22nd, 2019] [Originally Added On: October 22nd, 2019]
- Even With Same Diagnosis, Women Get Half the Heart Attack Treatments as Men - AJMC.com Managed Markets Network [Last Updated On: October 22nd, 2019] [Originally Added On: October 22nd, 2019]
- Eva Dickerman, Andrew Weil - The New York Times [Last Updated On: October 22nd, 2019] [Originally Added On: October 22nd, 2019]
- EHR vendor Veradigm and partners creating new shared data tools for researchers - Healthcare IT News [Last Updated On: October 22nd, 2019] [Originally Added On: October 22nd, 2019]
- Evolocumab Well-tolerated as Add-on for Hypercholesterolemia Therapy - DocWire News [Last Updated On: October 22nd, 2019] [Originally Added On: October 22nd, 2019]
- Deborah Heart and Lung Center announces affiliation with Cleveland Clinic Heart & Vascular Institute - Health Essentials from Cleveland Clinic [Last Updated On: October 22nd, 2019] [Originally Added On: October 22nd, 2019]
- New Registry to Provide Insight into STEMI Occurrence, Treatment in North India | - Diagnostic and Interventional Cardiology [Last Updated On: October 22nd, 2019] [Originally Added On: October 22nd, 2019]
- Finding Your Best Fit in Cardiology - TCTMD [Last Updated On: October 22nd, 2019] [Originally Added On: October 22nd, 2019]
- Cardiology team expands to meet community need - The Union of Grass Valley [Last Updated On: October 22nd, 2019] [Originally Added On: October 22nd, 2019]
- Deaths After Ablation of Atrial Fibrillation 'Concerning' in Real-World Analysis - TCTMD [Last Updated On: November 1st, 2019] [Originally Added On: November 1st, 2019]
- Cutler Family gifts $15 million to University Hospitals to transform mens health care - Newswise [Last Updated On: November 1st, 2019] [Originally Added On: November 1st, 2019]
- Troponin Increases After Elective PCI Tied to Complexity, Extent of CAD - TCTMD [Last Updated On: November 1st, 2019] [Originally Added On: November 1st, 2019]
- Caregiving and the Soul of Medicine - Medscape [Last Updated On: November 1st, 2019] [Originally Added On: November 1st, 2019]
- STEMI Mortality Unaffected by Weekend, Weeknight, or Holiday Admission in France - TCTMD [Last Updated On: November 1st, 2019] [Originally Added On: November 1st, 2019]
- Cardiva Medical publishes positive results from the AMBULATE pivotal study Cardiology2.0 - Cardiology2.0 [Last Updated On: November 1st, 2019] [Originally Added On: November 1st, 2019]
- Gaps in Access to TAVR and SAVR: 'Something Needs to Be Done' - TCTMD [Last Updated On: November 1st, 2019] [Originally Added On: November 1st, 2019]
- Cardiva Medical Announces Publication of Data From the AMBULATE Pivotal Study in the Journal of the American College of Cardiology: Clinical... [Last Updated On: November 1st, 2019] [Originally Added On: November 1st, 2019]
- Raymond James 4 Analyst Favorite Health Care Picks With Huge Upside Potential - 24/7 Wall St. [Last Updated On: November 7th, 2019] [Originally Added On: November 7th, 2019]
- Global Computed Tomography (CT) Scanners Devices and Equipment Market Report 2020: Major Players are GE Healthcare, Koninklijke Philips, Hitachi,... [Last Updated On: November 7th, 2019] [Originally Added On: November 7th, 2019]