Endocarditis

Endocarditis is an inflammation of the endocardium ( endocardial ) that lines the cavities of the heart and heart -related share of the arteries and veins and also forms the structure of the heart valve leaflets. Basically, every person is at risk for endocarditis, and untreated course of the disease is usually fatal. In Western Europe, endocarditis has become rare in heart healthy people and since the introduction of antibiotics also treatable. An increased risk of developing endocarditis, however, while people with congenital or acquired heart defects (particularly after heart valve replacement ).

• 4.1 High risk
• 4.2 Medium Risk
• 4.3 Low risk

Morphological classification

• Verrucous endocarditis
• Ulcerative endocarditis
• Endocarditis polyposa / ulceropolyposa
• Endocarditis fibroplastica

Clinical classification

Nonbacterial endocarditis

• Endocarditis verrucosa rheumatica (complication of rheumatic fever )
• Endocarditis thrombotica: concomitant disease caused by tumors or even with marasmus ( then called endocarditis marantica )
• Libman -Sacks endocarditis thrombotica (complication of systemic lupus erythematosus )
• Endocarditis in carcinoid
• Parietal endocarditis Löffler fibroplastica

Bacterial endocarditis

• High acute running bacterial endocarditis ( pathogens: Staphylococcus aureus, Streptococcus, Enterococcus )
• Subacute bacterial endocarditis endocarditis lenta = ( pathogens: Streptococcus viridans usually ( S. sanguis, S. bovis, S. mutans, S. mitis) )

The endocarditis in congenital heart disease

For all heart defects in which the blood flow in the heart is not " normal", it can make the same points come in very minor damage to the endocardium caused by turbulence of blood flow to again and again. These points are then susceptible to inflammation when (mostly) bacteria come into the blood and from there starts from an infection that spreads to other portions of the endocardium and one or more heart valves.

Triggering germs

The most common triggering germs of endocarditis are bacteria ( streptococci, staphylococci, enterococci, bacteria of the so-called HACEK group, etc.), and occasionally mushrooms. References to the possibility of a viral endocarditis, there are not less outside studies in experimental animals.

Possibilities of infection

By wounds ( including invasive medical measures) violations within the oral cavity, febrile illness (eg bronchitis, pneumonia, tonsillitis, urinary tract infections ), bacteria can enter the bloodstream and form the basis for endocarditis, the lymphoreticular in heart healthy people through the system (liver, spleen, lymph nodes, macrophages ) is prevented in time.

Often endocarditis occur in intravenous drug addicts, which then usually a highly acute bacterial endocarditis can be found.

Prophylaxis

With predictable procedures ( dental, endoscopy, surgery so) is at increased risk of endocarditis in patients to think of a prophylaxis, a few hours for example, consists of the administration of an antibiotic for about an hour before treatment and if necessary a second dose after that. Good oral hygiene is always beneficial; it reduces the number of bacteria constantly and not just in dental visits.

New Guidelines for the prophylaxis of bacterial endocarditis, including a comprehensive discussion of the emergence of opportunities have been published by the American Heart Association ( AHA) 2007. The AHA assessed the risk of Endokarditisinfektion much more reserved than before and held the previously experienced prophylaxis in the majority of cases to be expendable. The European Society of Cardiology limited in its guidelines in 2009, prophylactic administration of antibiotics to high risk patients.

Treatment of febrile illness

For all diseases (see above) were caused by a bacterial infection, a treatment with an antibiotic sufficient long time is required to prevent the formation of endocarditis in addition or as a result of the underlying disease. Even with a primary viral infection ( against an antibiotic does not work ) can be an antibiotic to prevent bacterial superinfection sense.

Endocarditis risk

The risk of infective endocarditis is specified as follows:

High risk

• Artificial heart valves
• Implantation of artificial vascular connections (even transplants from human tissue )
• Aorto - pulmonary shunts
• Already made ​​by endocarditis
• Cyanotic heart defect

Medium risk

• All congenital heart defect with abnormalities of large vessels (except see below)
• " Mitral valve prolapse " with leakage of the flap
• Operations using foreign material
• Hypertrophic obstructive cardiomyopathy

Low risk

• ASD II ( atrial septal defect from secundum )
• Pacemakers
• Operations without use of foreign material ( suture closure of an ASD, VSD or a PDA ligation six to twelve months after surgery )
• Mitral valve prolapse without mitral regurgitation ( leakage of the valve)

Patients with intermediate and high risk of endocarditis have got as a rule of her cardiologist a Endokarditispass they submit in dental treatments, for example.

Diagnosis

• Clinical signs: intermittent fever in 90 % of cases
• General symptoms: weakness, loss of appetite, weight loss, arthralgia
• Cardiac Symptoms: Heart Murmurs (new or changed in the sound ), heart failure signs ( water retention, liver enlargement ), ECG: Non-specific, block images: AV block, left bundle branch block ( at Myokardabszess ), T wave inversion
• Cutaneous symptoms: petechiae ( in 30 % of cases), Osler nodules = lentil-sized painful reddish nodules, especially on fingers and / or toes ( = immune complex -induced vasculitis) Janeway lesion: Hemorrhagic lesions of the palm / sole of the foot (not painful)
• Spleen ( CAVE: septic splenic rupture! )
• Renal involvement: hematuria, proteinuria, glomerular almost regularly Herdnephritis ( Löhlein ), microscopic hematuria ( = traces of blood in urine)
• Eyes: Roth 's spots Roth = Patch: retinal hemorrhage

• Increased signs of inflammation, ESR and CRP
• Anemia (anemia ) in 80 % of cases
• Detection of bacteria in blood cultures

• Sonography: Possibly. are vegetations ( = " growths and deposits ", which forms the body at the inflamed site in the heart as a " repair process " ) visible.

Complications

• Destruction of heart valves
• Vegetations (see above) to be ripped off by the pumping heart and clog in their flow through the bloodstream blood vessels in the organs. The dreaded complications This may lead to a stroke, kidney embolism, pulmonary embolism, where especially the stroke is feared because with him is a great risk of inflammation of the brain or the meninges.
• Spread of germs to other organs, where then can form abscesses.

In the course of blood poisoning (sepsis) and septic or toxic shock in toxic -forming bacteria can lead to acute organ failure occur (renal failure, so-called shock kidney and / or lung failure, so-called shock lung ).

Diagnostics and Therapy

A central role in the diagnosis of endocarditis assume the Duke criteria. For the diagnosis of endocarditis echocardiography, blood culture and clinical examination are available, some with other imaging methods. Evidence of cardiac valvulopathy or newly occurring vegetation in the heart or the detection of pathogens in blood culture are sure signs. Both detections are but sometimes difficult to establish, because have not yet formed valvulopathy / vegetations despite the existence of endocarditis or evidence of germs in the blood culture is not possible because the patient has previously received antibiotics. Succeed the detection of bacteria in blood culture not (5 to 10 % of cases), then it must be "blind" treated in the presence of clinical signs. It leads clinically initially strict bed rest, a broad-spectrum intravenous antibiotic therapy over a period of four to six weeks. This is followed by a one-to two -week critical observation. Nevertheless, once made ​​endocarditis remains an increased risk of further disease. Therefore, the prophylaxis should be ( so ) taken very seriously.