Endocarditis is an inflammation of the smooth inner lining of the heart (endocardium), almost always by a bacterial infection.
Infective endocarditis
Infective endocarditis is an infection of the endocardium and heart valves.
Bacteria (or, less commonly, fungi) that enter the bloodstream or rarely contaminate the heart during open heart surgery, they can lodge in the valves of the heart and infect the lining. Abnormal or damaged valves are more prone to infection, but the normal can be infected by some bacteria aggressive, especially when they come in large quantities. The buildup of bacteria and blood clots in the valves (so-called vegetations) can break off and reach vital organs, where they can block the flow of arterial blood. These blockages are very serious and can cause stroke, myocardial infarction, infection and injury to the area are located.
Infective endocarditis can appear suddenly and become fatal within a few days (acute infective endocarditis), or it may develop gradually and almost inapparent over weeks or several months (subacute infective endocarditis).
Causes
Although the blood normally no bacteria, a wound in the skin, inside the mouth or gums (including a wound caused by normal activity such as chewing or brushing teeth) allows a small amount of bacteria entering the bloodstream.
Gingivitis (infection and inflammation of the gums), small skin infections and infections anywhere in the body, allowing the bacteria enter the bloodstream, increasing the risk of endocarditis.
Certain surgical procedures, dental and doctors may also introduce bacteria into the bloodstream, for example, the use of intravenous catheters to administer fluids, nutrients or drugs, a cystoscopy (insertion of a tube to see inside the bladder) or colonoscopy (inserting a tube to look inside the large intestine).
In people with normal heart valves, there is not any damage and white blood cells destroy bacteria. Damaged valves, however, can trap bacteria, which are housed in the endocardium and begin to multiply. Sometimes, during the change of a heart valve with an artificial (prosthetic) can introduce bacteria, which are often resistant to antibiotics. Patients with a birth defect or an abnormality that allows blood to move from side to side of the heart (for example, from one ventricle to the other) also have a higher risk of developing endocarditis.
The presence of certain bacteria in the blood (bacteremia) may not cause immediate symptoms, but it is possible that results in septicemia, ie, a serious blood infection that usually causes fever, chills, tremors, and decreased blood pressure . A person with sepsis has a high risk of developing endocarditis.
The bacteria that cause acute bacterial endocarditis are sometimes aggressive enough to infect normal heart valves, those that cause subacute bacterial endocarditis almost always infect the abnormal valves or injured. It has been shown that the cases of endocarditis usually occurs in people with congenital defects of the heart chambers and valves, in people with artificial valves and valves in older people injured by childhood rheumatic fever or abnormalities of the valve due to age. Those who inject drugs have a high risk of endocarditis because bacteria often are injected directly into the bloodstream through needles, syringes or contaminated drug solutions.
In drug addicts and people who develop endocarditis by prolonged use of a catheter, the inlet valve to the right ventricle (tricuspid valve) is the most often infected. In the other cases of endocarditis, those who become infected are the inlet valve into the left ventricle (mitral valve) or the outlet valve of the ventricle (aortic valve).
In a person with an artificial valve, the risk of infective endocarditis is greatest during the first year after the replacement, after this period, the risk decreases but remains higher than normal. For unknown reasons, the risk is always greater with a valve with an artificial aortic and mitral mechanical valve than with a porcine valve.
Symptoms
Acute bacterial endocarditis usually begins suddenly with high fever (39-40 ° C), rapid heart rate, fatigue, and rapid and extensive lesions of the valves. Fragments of the vegetations arising (emboli) can reach other areas and spread the infection. You can develop pus (abscess) at the base of the infected valve or where it is impacting the pistons.
The valves can be drilled and within days there can be wide leakage of blood through them. In some cases there is shock and kidney and other organs stop functioning (a condition called sepsis syndrome). Finally, arterial infections weaken the walls of blood vessels and cause their destruction. This can be fatal, especially if it occurs in the brain or near the heart.
Subacute bacterial endocarditis can produce symptoms for months before the valve lesions or stroke can deliver a clear diagnosis.
Symptoms include fatigue, mild fever (37.5 ° C to 38.5 ° C), weight loss, sweating and decreased number of red blood cells (anemia). Endocarditis is suspected in a person with fever without clear evidence of infection, if you have a heart murmur or if a breath has changed existing features. You can feel an enlarged spleen. On the skin may appear very small spots that seem tiny freckles, it is also possible to see the white of the eye or under the fingernails of the hand. These spots are areas of tiny blood spills caused by small emboli that have been shed from the heart valves.
Larger emboli can cause stomach pain, sudden blockage of an artery in an arm or leg, heart attack or stroke.
Other symptoms of acute and subacute bacterial endocarditis are chills, joint pain, paleness, rapid heartbeat, painful subcutaneous nodules, confusion and blood in the urine.
The artificial valve endocarditis may be acute or subacute. Compared to a natural valve infection is more likely that infection of an artificial valve from spreading to the heart muscle at the base of the valve and it falls off. In this case, it is necessary to perform emergency surgery to replace the valve because of heart failure due to leakage of blood through the valve can be fatal. On the other hand, it is possible to interrupt the electrical conduction system of the heart, causing a decrease in the frequency of the heartbeat, which could cause a sudden loss of consciousness or even death.
Diagnosis
In suspected acute bacterial endocarditis, the patient should be hospitalized for diagnosis and treatment. Because the symptoms of subacute bacterial endocarditis are at first vague, the infection can damage heart valves and spread to other places before being diagnosed. Subacute endocarditis is not treated as dangerous as acute.
The diagnosis can be suspected from the symptoms, especially when they appear in someone with a predisposition to the disease. The echocardiogram, which is based on the reflection of ultrasound to create images of the heart, you can identify vegetations on the valves and injuries. To identify the bacteria causing the disease, blood samples are removed to make a crop. Since the release of bacteria into the blood in sufficient quantity to be identified only happens intermittently, taken three or more blood samples at different times to increase the likelihood that at least one of them contains enough bacteria to grow in the cultures in the laboratory. In the same laboratory process, tested several antibiotics to choose the most effective against specific bacteria.
Sometimes, it is not possible to isolate any germ from a blood sample.
The reason may be that special techniques are needed to grow certain bacteria or that the patient had previously received antibiotics that did not heal the infection but reduced the amount of bacteria enough to hide their presence. There is still another possibility, namely that no case of endocarditis, but from some other disease with similar symptoms, such as a tumor.
Prevention and treatment
Patients with abnormalities of the heart valves with artificial valves or congenital defects, are given antibiotics as a preventive measure before dental or surgical procedures. Therefore, dentists and surgeons need to know whether a person has had a valve problem.
Although the risk of outbreaks of endocarditis is not very high in the course of a surgical procedure and preventive antibiotics given are not always effective, the consequences are so severe that, generally, the physician recommends the administration of antibiotics, such as caution before applying these procedures.
Treatment almost always requires hospital admission because the administration of high doses of intravenous antibiotics should be at least two weeks. Antibiotics alone do not always cure an infection in an artificial valve. Therefore, sometimes necessitating heart surgery to repair or replace damaged valves and removing vegetation.
Non-infective endocarditis
The non-infective endocarditis is a disease characterized by the formation of blood clots in damaged valves.
The risk of this disease increases in people with systemic lupus erythematosus (an immune system disease), lung cancer, stomach or pancreas, tuberculosis, pneumonia, bone infection or diseases that cause severe weight loss. Like in infective endocarditis, heart valves may leak blood or open incorrectly. There is a high risk of emboli cause a stroke or a myocardial infarction. Although sometimes given drugs to prevent formation of thrombi, studies have not yet confirmed that this is really beneficial.
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