31. Infectious endocarditis

• Fever and chills

• Tachycardia

• General malaise, weakness, weight loss, night sweats

• Dyspnea, cough, pleuritic chest pain

• Arthralgias, myalgias

• Development of a new heart murmur or change in a preexisting murmur

  • Tricuspid valve regurgitation

    • Holosystolic murmur that is loudest at the left sternal border

    • Seen in persons who inject drugs, immunocompromised individuals, patients with congenital heart disease, and patients with instrumentation in the right heart (e.g., central venous catheters) [2]

  • Aortic valve regurgitation: early diastolic murmur that is loudest at the left 3rd and 4thintercostal spaces and along the left sternal border [4]

  • Mitral valve regurgitation: holosystolic murmur that is loudest at the heart's apex and radiates to the left axilla

• Heart failure (e.g., dyspnea, lower limb edema) due to valve insufficiency

• Arrhythmias: Suspect a perivalvular abscess in patients with IE who develop a new conduction abnormality (e.g., heart block).

Extracardiac manifestations are typically caused by septic microemboli and/or immune complex precipitation and are more commonly seen in left-sided IE, with the exception of pulmonary embolic manifestations, which are more common in right-sided IE

• Peripheral embolic and immunologic phenomena: seen in only 5–10% of patients. [1][15]

  • Petechiae, especially splinter hemorrhages (hemorrhages underneath fingernails)

  • Janeway lesions

    • Small, nontender, erythematous macules on palms and soles

    • Microabscesses with neutrophilic capillary infiltration and areas of hemorrhage caused by septic microemboli from valve vegetations

  • Osler nodes: painful nodules on pads of the fingers and toes caused by immune complex deposition

  • Roth spots: round retinal hemorrhages with pale centers

• Emboli to intraabdominal organs

  • Acute renal injury

    • Including hematuria and anuria

    • Due to renal artery occlusion or glomerulonephritis

  • Splenomegaly and possible LUQ pain

    • Due to splenic artery occlusion or splenic abscess

    • May lead to splenic rupture

• Neurological manifestations (e.g., seizures, paresis): due to septic embolic stroke, hemorrhage, meningitis, encephalitis, and/or abscess

• Pulmonary manifestations: caused by septic emboli resulting from tricuspid valve involvement

  • Signs of pulmonary embolism (e.g., dyspnea)

  • Signs of pulmonary infection, e.g., multifocal pneumonia, lung abscess, and/or empyema. [