Endocarditis

• Fever
• Chills
• A new or changed heart murmur — abnormal heart sounds made by blood rushing through your heart
• Fatigue
• Aching joints and muscles
• Night sweats
• Shortness of breath
• Paleness
• Persistent cough
• Swelling in your feet, legs or abdomen
• Unexplained weight loss
• Blood in your urine (either visible or found in a doctor's viewing of your urine under a microscope)
• Tenderness in your spleen — an infection-fighting abdominal organ on your left side, just below your rib cage
• Osler's nodes — red, tender spots under the skin of your fingers
• Petechiae— tiny purple or red spots on the skin, whites of your eyes, or inside your mouth

Causes

Endocarditis occurs when germs enter your bloodstream, travel to your heart, and attach to abnormal heart valves or damaged heart tissue. Bacteria cause most cases, but fungi or other microorganisms also may be responsible.

Sometimes the culprit is one of many common bacteria that live in your mouth, throat or other parts of your body. In other cases, the offending organism may enter your bloodstream through:

• Common activities. Everyday activities such as brushing your teeth or chewing food can allow bacteria to enter your bloodstream — especially if your teeth and gums are in poor condition.
• An infection or other medical condition. Bacteria may spread from an infected area, such as a skin sore. Gum disease, a sexually transmitted disease or an intestinal disorder — such as inflammatory bowel disease — also may give bacteria the opportunity to enter your bloodstream.
• Catheters or needles. Bacteria can enter your body through a catheter — a thin tube that doctors sometimes use to inject or remove fluid from the body. The bacteria that can cause endocarditis can also enter your bloodstream through the needles used for tattooing or body piercing. Contaminated needles and syringes are a concern for people who use intravenous (IV) drugs.
• Certain dental procedures. Some dental procedures that can cut your gums may allow bacteria to enter your bloodstream.

Typically, your immune system destroys bacteria that make it into your bloodstream. Even if bacteria reach your heart, they may pass through without causing an infection.

Most people who develop endocarditis have a diseased or damaged heart valve — an ideal spot for bacteria to settle. This damaged tissue in the endocardium provides bacteria with the roughened surface they need to attach and multiply.

Risk factors

If your heart is healthy, you're unlikely to develop endocarditis. Even most types of heart disease don't increase the risk of endocarditis. The germs that cause infection tend to stick to and multiply in damaged or surgically implanted heart valves.

Those at highest risk of endocarditis are those who have:

• Artificial heart valves. Germs are more likely to attach to an artificial (prosthetic) heart valve than to a normal heart valve. The risk of infection is highest in the first year after implantation.
• Congenital heart defects. If you were born with certain types of heart defects, your heart may be more susceptible to infection.
• A prior history of endocarditis. An episode of endocarditis damages heart tissue and valves, increasing the risk of a future heart infection.
• Damaged heart valves. Certain medical conditions — such as rheumatic fever or infection — can damage or scar one or more of your heart valves, making them more prone to endocarditis.
• History of intravenous (IV) illegal drug use. People who use illegal drugs by injecting them are at a greater risk of endocarditis. The needles used to inject drugs are often contaminated with the bacteria that can cause endocarditis.

If you have a known heart defect or heart valve problem, ask your doctor about your risk of developing endocarditis. Even if your heart condition has been repaired or hasn't caused symptoms, you may still be at risk.

Complications

Endocarditis can cause several major complications:

• Stroke and organ damage. In endocarditis, clumps of bacteria and cell fragments (vegetations) form in your heart at the site of the infection. These clumps can break loose and travel to your brain, lungs, abdominal organs, kidneys or extremities. This may cause various problems, including stroke or damage to other organs or tissues.
• Infections in other parts of your body. Endocarditis can cause you to develop pockets of collected pus (abscesses) in other parts of your body, including the brain, kidneys, spleen or liver. An abscess may develop in the heart muscle itself as well, causing an abnormal heartbeat. Severe abscesses may require surgery to treat them.
• Heart failure. Left untreated, endocarditis can damage your heart valves and permanently destroy your heart's inner lining. This can cause your heart to work harder to pump blood, eventually causing heart failure — a chronic condition in which your heart is unable to pump enough blood to meet your body's needs. If the infection progresses untreated, it's usually fatal.

Diagnosis

Your doctor may suspect endocarditis based on your medical history and physical signs and symptoms, such as fever. Using a stethoscope to listen to your heart, your doctor may hear a new heart murmur or a change in a previous heart murmur — possible signs of endocarditis.

The infection can mimic other illnesses in its early stages. Various tests may be necessary to help make the diagnosis:

• Blood tests. The most important test is a blood culture used to identify bacteria in the bloodstream. Blood tests can also help your doctor identify certain conditions, including anemia — a shortage of healthy red blood cells that can be a sign of endocarditis.
• Transesophageal echocardiogram. An echocardiogram uses sound waves to produce images of your heart at work. This type of echocardiogram allows your doctor to get a closer look at your heart valves. It's often used to check for vegetations or infected tissue. During this test, an ultrasound device is passed through your mouth and into your esophagus — the tube that connects your mouth and stomach.
• Electrocardiogram (ECG). Your doctor may order this noninvasive test if he or she thinks endocarditis may be causing an irregular heartbeat. During an ECG, sensors (electrodes) that can detect the electrical activity of your heart are attached to your chest and sometimes to your limbs. An ECG measures the timing and duration of each electrical phase in your heartbeat.
• Chest X-ray. X-ray images help your doctor see the condition of your lungs and heart. Your doctor can use X-ray images to see if endocarditis has caused your heart to enlarge, or if infection has spread to your lungs.
• Computerized tomography (CT) scan or magnetic resonance imaging (MRI). You may need a CT or MRI scan of your brain, chest or other parts of your body if your doctor thinks that infection has spread to these areas.

Treatments and drugs

The first line of treatment for endocarditis is antibiotics. Sometimes, if your heart valve is damaged by your infection, surgery is necessary.

Antibiotics

If you have endocarditis, you may need high doses of intravenous (IV) antibiotics in the hospital. Blood tests may help identify the type of microorganism that's infecting your heart. This information will help your doctor choose the best antibiotic or combination of antibiotics to fight the infection.

You will usually need to take antibiotics for four to six weeks or longer to clear up the infection. Once your fever and the worst of your signs and symptoms have passed, you may be able to leave the hospital and continue IV antibiotic therapy with visits to your doctor's office. You'll need to see your doctor regularly to make sure your treatment is working.

Report to your doctor any signs or symptoms that your infection is getting worse, such as:

• Fever
• Chills
• Headaches
• Joint pain
• Shortness of breath

Diarrhea, a rash, itching or joint pain may indicate a reaction to an antibiotic — another reason to call your doctor.

See your doctor immediately if you experience shortness of breath or swelling in your legs, ankles or feet. These signs and symptoms may indicate heart failure.

Surgery

If the infection damages your heart valves, you may have symptoms and complications for years after treatment. Sometimes surgery is needed to treat persistent infections or replace a damaged valve. Surgery is also sometimes needed to treat endocarditis that's caused by a fungal infection.

Depending on your condition, your doctor may recommend either repairing your damaged valve or replacing it with an artificial valve made of animal tissue or man-made materials. 

Lifestyle remedies

If you're at risk of endocarditis, let all of your health care providers know. You may want to request an endocarditis wallet card from the American Heart Association. Check with your local chapter or print the card from the association's Web site.

To help prevent endocarditis, make sure to practice good hygiene:

• Pay special attention to your dental health — brush and floss your teeth and gums often, and schedule regular dental checkups.
• Avoid procedures that may lead to skin infections, such as body piercings or tattoos.
• Seek prompt medical attention if you develop any type of skin infection or open cuts or sores that don't heal properly.

Prevention

People with the following heart conditions are at risk of more-serious outcomes from endocarditis:

• Artificial (prosthetic) heart valve
• Previous endocarditis infection
• Certain types of congenital heart defects
• Heart transplant complicated by heart valve problems

People with these conditions may need to take preventive antibiotics before certain medical or dental procedures to prevent endocarditis.

Preventive antibiotics

Certain dental and medical procedures may allow bacteria to enter your bloodstream. Antibiotics taken before these procedures can help destroy or control the harmful bacteria that may lead to endocarditis.

Antibiotics are recommended only before the following procedures:

• Certain dental procedures (those that cut your gum tissue or part of the teeth)
• Procedures involving the respiratory tract, infected skin or tissue that connects muscle to bone

Antibiotics are no longer recommended before all dental procedures or for procedures of the urinary tract or gastrointestinal system.

If you've had to take preventive antibiotics in the past before your dental exams, you may be concerned about these changes. In the past, you were likely told to get antibiotics because of a concern that common dental procedures increased your risk of endocarditis. But as doctors have learned more about endocarditis prevention, they've realized that endocarditis is much more likely to occur from exposure to random germs than from a typical dental exam or surgery.

This doesn't mean it's not important to take good care of your teeth through brushing and flossing. There is some concern that infections in your mouth from poor oral hygiene might increase the risk of germs entering your bloodstream. In addition to brushing and flossing, regular dental exams — at least yearly — are an important part of maintaining good oral health. 

References:

https://en.wikipedia.org/wiki/Endocarditis

https://www.nlm.nih.gov/medlineplus/ency/article/001098.htm

http://www.nhs.uk/conditions/endocarditis/Pages/Introduction.aspx

http://www.medicinenet.com/endocarditis/article.htm

http://www.heart.org/HEARTORG/Conditions/More/HeartValveProblemsandDisease/Heart-Valves-and-Infective-Endocarditis_UCM_450448_Article.jsp#.V0wpWVdlnGI