DRH A2 gave us a great case today about infective endocarditis manifesting as septic emboli to the brain, here are nice take-home points and cool pics from today’s case

1-Suspect endocarditis in a patient with high fevers (>38C) and risk factors either cardiac (prior IE, prosthetic valve, cardiac device, congenital or valvular heart disease) or non-cardiac risk factors (indwelling vascular catheter, IVDU, immunosuppression…)

2-Signs and symptoms can include:

A- Fever (90% of patients) 

B- New cardiac murmur (85% of patients) 

C-Relatively uncommon clinical manifestations that are highly suggestive of IE include:

Janeway lesions – Nontender erythematous macules on the palms and soles

Osler nodes – Tender subcutaneous violaceous nodules mostly on the pads of the fingers and toes, which may also occur on the thenar and hypothenar eminences

Roth spots – Exudative, edematous hemorrhagic lesions of the retina with pale centers

D-Endocarditis can manifest by its complications, namely cardiac (valvular insufficiency, conduction abnormality, heart failure) or neurologic (embolic strokes, brain abscess, mycotic aneurysms)

3-To diagnose: Remember Duke’s Criteria 


Typical bacteria associated with IE from two separate blood cultures, or persistently positive blood cultures (two > 12 hrs apart)

Echocardiogram positive for IE


Predisposition: Intravenous drug use or presence of a predisposing heart condition

Fever: Temperature ≥38.0°C (100.4°F)

Vascular phenomena: Major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, or Janeway lesions

Immunologic phenomena: Glomerulonephritis, Osler nodes, Roth spots, or rheumatoid factor

Microbiologic evidence: Positive blood cultures that do not meet major criteria OR serologic evidence of active infection with organism consistent with IE

Definitive endocarditis: two major criteria/One major and three minor criteria/five minor criteria

4-Your workup: You are looking for

  • Blood cultures: At least three should be obtained prior to antibiotic initiation. Staphylococcus aureus, viridans streptococci, Streptococcus gallolyticus (formerly S. bovis), HACEK (Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, Kingella) organisms
  • TTE, if negative then choose TEE to check out for vegitation
  • Of note, endocardiatis complications (septic emboli, to the brain in our patient case) will require separate workup (MRI brain….)



  • Duration: 4-6 weeks in left sided endocarditis, 2 weeks in uncomplicated right sided endocarditis 
  • Choice of agents: Cover initially with vancomycin and narrow spectrum based on pathogen grown from blood cultures 
  • Indication for surgery: Persistent vegetation (Anterior mitral leaflet vegetation, particularly with size >10 mm as in our patient case), Valvular dysfunction (acute AR or MR with signs of ventricular failure, heart failure unresponsive to medical therapy), valve perforation or rupture 


Images were taken intra-op of our patient’s valvular lesion


  • Our patient received antibiotic prophylaxis with penicillin (as she had a rheumatic fever as a kid, she knew she had a “heart murmur” but unsure of cardiac disease), that should clue us in that she already had valvular complications of her rheumatic fever


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