Endocarditis

endocardium- Thin innermost layer composed of simple squamous epithelium

overlying a layer of connective tissue).
The heart’s endocardium is a smooth tissue layer that lines its chambers.
endocardium covers and forms the surface of the four heart valves.it is a delicate,
tissue layer with a composition that is structurally similar to the endothelium that
lines the interior surface of blood vessels.
Infective endocarditis is an infection of the inner surface of the heart, usually the 
valves
• Endocarditis generally occurs when bacteria(The bacterial most
commonly involved are streptococci or staphylococci.) or other germs ,
occurs when germs (usually bacteria) enter the blood stream and attach
to and attack the lining of the heart valves. Infective endocarditis causes
growths (vegetations) on the valves, produces toxins and enzymes
which kill and break down the tissue to cause holes on the valve, and
spreads outside the heart and the blood vessels. The resulting
complications are embolism of material from the vegetations, leaky
valve, heart block and abscesses around the valve. Without treatment,
endocarditis is a fatal disease.
•
• Subacute bacterial endocarditis (SBE) is often due to
streptococci of low virulence (mainly viridans streptococci)
and mild to moderate illness which progresses slowly over
weeks and months (>2 weeks) and has low propensity to
hematogenously seed extracardiac sites.
• Acute bacterial endocarditis (ABE) is a fulminant illness
over days to weeks (<2 weeks), and is more likely due to
Staphylococcus aureus, which has much greater virulence or
disease-producing capacity and frequently causes metastatic
infection.
Bacteria cause most cases, but
fungi or other microorganisms
also may be responsible. Left
untreated, endocarditis can
damage or destroy heart valves
and can lead to life-threatening
complications
The tricuspid valve is most
commonly affected (50%),
whereas involvement of the
mitral and aortic valves is less
common (20% each). The
involvement of multiple valves
is common. Pulmonary valve
endocarditis is rare.
• Fungal endocarditis rarely occurs in
healthy individuals and is associated
with immunocompromised states,
intravenous drug use, prolonged
antibiotic use, and long-term
parenteral nutrition use. Individuals
with prosthetic heart valves or with
a history of reconstructive cardiac
surgery also have a higher risk of
fungal endocarditis. Native valve
fungal endocarditis can occur in
organ transplants recipients who are
on immunosuppressive agents,
Bacteria, fungi or other germs that cause endocarditis might enter your
bloodstream through:
• Normally, bacteria can be found in the mouth(Streptococci, Neisseria..), on the skin,
in the intestines(Streptococcus, Enterococcus ), respiratory system(, Staphylococcus
Streptococcus) and in the urinary tract. Enterococcus.

• Some of these bacteria may be able to get into the bloodstream when eating, during teeth
brushing and when passing stools and cause endocarditis. Normal heart valves are very
resistant to infection, but diseased valves have defects on the surface where bacteria may
attach. Valve prosthesis (replacement heart valves) are more prone to infection than
normal valves. The bacteria rapidly form colonies, grow vegetations and produce
enzymes, destroying the surrounding tissue and opening the path for invasion.
• Causes
• Everyday oral activities. Activities such as
brushing teeth, or other activities that could
cause gums to bleed, can allow bacteria to
enter bloodstream —
• skin sore. - Bacteria may spread from an
infected area,
• gum disease,
• Sexually transmitted infections (STIs),
such as chlamydia or gonorrhea
• inflammatory bowel disease — increased
permeability (penetrability) of the damaged
mucosa for bacteria and the therapeutic
immunosuppression in patients with active
inflammatory bowel disease.can also give
bacteria the opportunity to enter the
bloodstream.
• Catheters. Bacteria can enter body through
a catheter — a thin tube that doctors
sometimes use to inject or remove fluid from
the body. This is more likely to occur if the
catheter is in place for a long period of time.
•Needles used for tattoos and body piercing. The bacteria that can
cause endocarditis can also enter bloodstream through the needles used
for tattooing or body piercing.
•Intravenous (IV) illegal drug use. Contaminated needles and syringes
are a special concern for people who use illegal intravenous (IV) drugs,
such as heroin or cocaine. Often, individuals who use these types of drugs
don't have access to clean, unused needles or syringes.
•Certain dental procedures. Some dental procedures that can cut gums
may allow bacteria to enter your bloodstream.
Bacteria can more easily attach to the lining of heart (endocardium), if the
lining's surface is rough or faulty, diseased or damaged heart valves.
However, endocarditis does occasionally occur in previously healthy
individuals.endoscopic examinations
Risk factors
Artificial heart valves. Germs are more
likely to attach to an artificial (prosthetic)
heart valve than to a normal heart valve.
•Congenital heart defects.  certain
types of heart defects, such as an irregular
heart or abnormal heart valves, may be
more susceptible to infection.
•A history of endocarditis. Endocarditis
can damage 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. This can make them more
prone to endocarditis.
A 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 can be
contaminated with the bacteria that can cause
endocarditis.
Clinical Manifestations
Most common
• Flu-like symptoms, such as fever
and chills
• A new or changed heart murmur,
which is the heart sounds made
by blood rushing through heart
• Fatigue
• Aching joints and muscles
• Night sweats
• Shortness of breath
• Chest pain when breathe
• Swelling in feet, legs or
abdomen
Clinical Manifestations
uncommon
 petechiae on the body
 Osler nodes -Small, painful
nodules may be present in
the pads of fingers or toes
 Janeway lesions -Irregular,
red or purple, painless, flat
macules may be present on
the palms, fingers, hands,
soles, and toes
 Roth spots-A hemorrhage in
clusters of petechiae
the retina with a white center.
 Blood in your urine,
 Tenderness in spleen,

Janeway lesions
Diagnostics
Blood cultures -A blood culture test is used to identify any bacteria or
fungi in blood stream.
CBC test -.Elevated white blood cell.Anemia  low red blood cells
 Positive rheumatoid factor

Elevated C-reactive protein test

Doppler echocardiography
 Chest X-ray.t-o see if endocarditis has caused heart to enlarge or if
any infection has spread to lungs.
Computerized tomography (CT) scan or magnetic resonance
imaging (MRI). of your brain, chest or other parts of body if
infection has spread to these areas.
 Prevention
Antibiotic prophylaxis is recommended for high-risk patients
immediately before and sometimes after the following procedures:
 Dental procedures that involve manipulation of gingival tissue or
the periapical area of the teeth or perforation of the oral mucosa
 Tonsillectomy or adenoidectomy
 Surgical procedures that involve respiratory mucosa
 Bronchoscopy with biopsy or incision of respiratory tract mucosa
 Cystoscopy or urinary tract manipulation
 Surgery involving infected skin or musculoskeletal tissue

2 g of amoxicillin (Amoxil) orally 2 hour before and after the

procedure. If patients are allergic to penicillin, clindamycin
(Cleocin), cephalexin (Keflex), cefazolin, ceftriaxone, azithromycin
(Zithromax) . . . may be used.
 Medical Management
 Eradicate the invading organism through adequate doses of an appropriate
antimicrobial agent (IV infusion for 2 to 6 weeks)
 Numerous antimicrobial regimens are in use, but penicillin is usually the medication
of choice
 Blood cultures are taken periodically to monitor the effect of therapy
 In fungal endocarditis, an antifungal agent, such as amphotericin B is the usual
treatment
 In addition, the patient’s temperature is monitored at regular intervals because
the course of the fever is one indication of the effectiveness of treatment
 Surgical intervention may be required if the infection does not respond to
medications, the patient has a prosthetic heart valve endocarditis, has a
vegetation larger than 1 cm, or develops complications such as a septal
perforation
Complications
In endocarditis, clumps of bacteria and cell fragments form in
heart at the site of the infection. These clumps, called
vegetations, can break loose and travel to brain, lungs,
abdominal organs, kidneys or limbs. As a result, endocarditis
can cause several major complications, including:
• heart murmur, heart valve damage and heart failure
•Stroke
•Seizure
•Paralysis-Loss of the ability to move part of all of your body
•abscesses -Pockets of collected pus that develop in the
heart, brain, lungs and other organs
•Pulmonary embolism — an infected vegetation that travels to
the lungs and blocks a lung artery
•Kidney damage-emboli causing renal infarction,
glomerulonephritis
•Enlarged spleen
Myocarditis
Myocarditis-an inflammatory process involving the myocardium-

(The myocardium is the muscle tissue of the heart, and forms a
thick middle layer between the outer epicardium layer and the inner
endocardium layer.) reducing heart's ability to pump and causing
rapid or abnormal heart rhythms (arrhythmias)
Myocarditis usually results from viral, bacterial, fungal, parasitic,

metazoal, protozoa infection
It also may be immune related, occurring after acute systemic infections

such as rheumatic fever
Myocarditis may result from an inflammatory reaction to toxins such as

pharmacologic agents used in the treatment
of other diseases ethanol, or radiation

Viral infection is the most common cause of myocarditis

most patients with myocarditis resolve the disease relatively quickly. Only

certain susceptible individuals progress from acute to chronic myocarditis
and dilated cardiomyopathy. The term “chronic myocarditis” is used if
acute myocarditis does not disappear quickly or if symptoms reappear later
after an episode of acute myocarditis.
 Clinical Manifestations

 mild case of myocarditis or are in the early stages, you might

have no symptoms or mild ones, such as chest pain or
shortness of breath.
In serious cases, the signs and symptoms of myocarditis vary,
depending on the cause of the disease. Common myocarditis
signs and symptoms include:
Chest pain-A sharp or stabbing chest pain or pressure, which
may spread to neck and shoulders. due to inflammation of the
blood vessels supplying the heart. Chest pain that is worse
with leaning backwards and better leaning forward scan
signify inflammation of the pericardium . Pericarditis
frequently accompanies myocarditis of the outside layers of
heart muscle.
Arrhythmias-Rapid or abnormal heart rhythms
Dyspnea-Shortness of breath, at rest or during physical
activity
Fluid retention with swelling of your legs, ankles and feet
Fatigue
 flu like-and symptoms of a viral infection, such as a
headache, body aches, joint pain, fever, a sore throat or
diarrhea
Causes
viruses are one of the most common causes of infectious myocarditis.
The most common viruses to cause myocarditis include
• Epstein-Barr virus (EBV)
• Cytomegalovirus (CMV)
• Hepatitis C
• Herpes
• HIV
• Parvovirus
• Covid 19
•
•
•Bacteria. 
•Chlamydia (a common sexually transmitted disease)
•Mycoplasma (bacteria that cause a lung infection)
•Streptococcal (strep) bacteria
•Staphylococcal (staph) bacteria
•Treponema (the cause of syphilis)

Fungal and parasitic- (Trypanosome cruzi and toxoplasma, including

some that are transmitted by insects and can cause a condition called
Chagas disease). infections can also cause it.
Other causes include certain chemicals or allergic
reactions to medications or toxins like:
• Alcohol
• Medications or illegal drugs -that might cause
an allergic or toxic reaction. These include
drugs used to treat cancer; antibiotics, such as
penicillin and sulfonamide drugs; some anti-
seizure medications; and some illegal
substances, such as cocaine.
• Spider bites
• Snakebites
• Chemotherapy and radiation therapy
• An autoimmune disease that causes
inflammation throughout your body, like lupus
or rheumatoid arthritis, may also lead to
myocarditis.
complications
Severe myocarditis can permanently damage your heart
muscle, possibly causing:
•Heart failure. Untreated, myocarditis can damage r
heart's muscle so that it can't pump blood effectively. can't
pump blood, the blood that pools in heart can form clots. If
a clot blocks one of heart's arteries, a heart attack
occures If a blood clot in heart travels to an artery leading
to brain before becoming lodged, you can have a stroke.
•Rapid or abnormal heart rhythms
(arrhythmias). Damage to your heart muscle can cause
arrhythmias.
•Sudden cardiac death. Certain serious arrhythmias can
cause heart to stop beating (sudden cardiac arrest). It's
fatal if not treated immediately.
Prevention
prevention
There's no specific prevention for myocarditis. However,
taking these steps to prevent infections might help:
•Avoid people who have a viral or flu-like illness until
they've recovered. If you're sick with viral symptoms, try to
avoid exposing others.
•Follow good hygiene. Regular hand-washing can help
prevent spreading illness.
•Avoid risky behaviors. To reduce your chances of getting
an HIV-related myocardial infection, practice safe sex and
don't use illegal drugs.
•Minimize exposure to ticks. If you spend time in tick-
infested areas, wear long-sleeved shirts and long pants to
cover as much of your skin as possible. vaccines, including
those that protect against rubella and influenza — diseases
that can cause myocarditis
Diagnostics
 Blood tests- elevated -C-reactive protein(CRP) and/or 
erythrocyte sedimentation rate (ESR), increased IgM (serology) against
viruses known to affect the myocardium. Markers of myocardial damage
(troponin or creatine kinase cardiac isoenzymes) are elevated.[10]
 The ECG findings most commonly seen in myocarditis are diffuse 
T wave inversions; saddle-shaped ST-segment elevations may be present
(these are also seen in pericarditis).[10]
 The gold standard is still biopsy of the myocardium
 Chest X-ray. An X-ray image shows the size and shape of your heart, as
well as whether you have fluid in or around the heart that might indicate
heart failure.
 Echocardiogram. Sound waves create moving images of the beating
heart. An echocardiogram might detect enlargement of your heart, poor
pumping function, valve problems, a clot within the heart or fluid around
heart.
Medical Management
 specific treatment for the underlying cause if it is
known (eg, penicillin for hemolytic streptococci)
 bed rest to decrease cardiac workload-
Angiotensin- converting enzyme (ACE)
inhibitors- lisinopril , enalaprilAngiotensin II
receptor blockers (ARBs). Beta blockers-
bisoprolol, carvedilol Diuretics.-relieve sodium and
fluid retention.
Pericarditis is an inflammation of the pericardium,
the thin saclike membrane surrounding the heart.
• The pericardium is a thin, two-layered,
(the parietal pericardium, and
• the visceral pericardium), fluid-filled sac that
covers the outer surface of the heart. It provides
lubrication for the heart, shields the heart from
infection and malignancy, and contains the heart in
the chest wall. It also keeps the heart from over-
expanding when blood volume increases, which
keeps the heart functioning efficiently
Pericarditis usually begins suddenly but and may last
up to several months. The condition usually clears up
after 3 months. Most cases are mild and usually
improve on their own. When symptoms develop more
gradually or persist, pericarditis is considered chronic
and attacks can come and go for years. the membrane
around heart is red and swollen, like the skin around
a cut that becomes inflamed. Sometimes there is extra
fluid in the space between the pericardial layers, which
is called pericardial effusion
constrictive pericarditis-The pericardium is the sac around the heart. In people with
constrictive pericarditis, to shrinkage of the pericardium .Inflammation in this part of the
heart causes scarring, thickening, and muscle tightening, or contracture. Over time, the
pericardium loses its elasticity and becomes rigid . The condition is rare in adults, and it’s
even less common in children.
The symptoms of constrictive pericarditis include:
• breathing difficulty that develops slowly and becomes worse
• fatigue
• a swollen abdomen
• chronic, severe swelling in the legs and ankles
• weakness
• a low-grade fever
• chest pain
The cause of constrictive pericarditis isn’t always known. However, possible causes may
include:
• heart surgery
• radiation therapy to the chest
• tuberculosis
• Some of the less common causes are:
• viral infection
• bacterial infection
• mesothelioma, is a type of cancer that develops from the thin layer of tissue that covers
many of the internal organs (known as the mesothelium)which is an uncommon type of
cancer caused by asbestos exposure
• A pericardial effusion is excess fluid between the heart
and the sac surrounding the heart, known as the
pericardium. Most are not harmful, but they sometimes
can make the heart work poorly.
• Normally, 2 to 3 tablespoons of clear, yellow pericardial
fluid are between the sac's two layers. That fluid helps
the heart move easier within the sac.
• a pericardial effusion, much more fluid sits there. Small
ones may contain 100 milliliters of fluid. Very large ones
may have more than 2 liters.
• If the fluid builds up quickly, it can cause cardiac
tamponade. This is a sudden build-up of fluid in between
the layers of the pericardium that keeps heart from
working like it should and can cause your blood pressure
to drop. Cardiac tamponade is life-threatening and
requires immediate drainage of the fluid
A pericardial effusion
causes
In most cases, inflammation of the sac, a condition called pericarditis, leads to the effusion. As
it becomes inflamed, more fluid is produced.
Viral infections are one of the main causes of the
• Coxsackieviruses
• Echoviruses
• HIV
• Covid 19
Other conditions that can cause these effusions include:
• Cancer
• Injury to the sac or heart from a medical procedure
• Heart attack
• Severe kidney failure, also called uremia
• Autoimmune disease (lupus, rheumatoid arthritis, and others)
• Bacterial infections, including tuberculosis
In many cases, no cause can be found.
 A pericardial effusion
Diagnosis
• weak or distant heart sounds
• liver swelling
• fluid in the belly area
Imaging test
• Electrocardiogram-Irregularities
• Echocardiogram-It can detect fluid or
thickening in the pericardium.
• CT scan and MRI can detect thickening in
the pericardium and blood clots.
Treatment
• Diuretics
• (analgesics) to control pain
• corticosteroids

Restrictive cardiomyopathy is characterized by a nondilated rigid ventricle, resulting

in severe diastolic dysfunction and restrictive filling that produces hemodynamic
changes similar to those in constrictive pericarditis.
 Pericarditis
Pericarditis refers to an inflammation of the pericardium, the
membranous sac enveloping the heart.
It may be a primary illness or it may develop during various
medical and surgical disorders.
Classification:
subacute- (>6 weeks to 6 months)
acute -  (<6 weeks)
Chronic - (>6 months)
Exudative- Pericardial effusion ("fluid around the heart") is
an abnormal accumulation of fluid in the pericardial cavity.
Noneffusive
Constrictive
serous (serum), purulent (pus), (calcium deposits), fibrinous
(clotting proteins), or sanguinous (blood).
Constrictive pericarditis is a medical condition
characterized by a thickened, fibrotic pericardium
 limiting the heart's ability to function normally
Signs and symptoms of constrictive pericarditis are
consistent with the following: fatigue, swollen abdomen,
difficulty breathing (dyspnea), swelling of legs and
general weakness. Related conditions are bacterial
pericarditis, pericarditis and pericarditis after a heart
attack
Causes
Tuberculosis[, Incomplete drainage of purulent 
pericarditis. Chronic pericarditis[,Postsurgical[..
Causes of Pericarditis:

 Idiopathic or nonspecific causes

 Infection: viral, bacterial, fungal
 Hypersensitivity states: immune reactions, medication
reactions, serum sickness
 Disorders of adjacent structures: myocardial infarction,
dissecting aneurysm . .
 Neoplastic disease: caused by metastasis from lung cancer or
breast cancer, leukemia
 Radiation therapy of chest and upper torso
 Trauma: chest injury, cardiac surgery, cardiac catheterization
 Renal failure and uremia
 Tuberculosis
Clinical Manifestations:
 Pericarditis may be asymptomatic.
most common symptom
 chest pain -that Is sharp and stabbing (caused by the heart rubbing against the
pericardium) .May get worse when cough, swallow, take deep breaths or lie flat
Feels better when sit up and lean forward .You also may feel the need to bend
over or hold your chest to breathe more comfortably.
Other symptoms include:
 Pain in your back, neck or left shoulder Trouble breathing when you lie down
 A dry cough or hiccough

 Anxiety or fatigue
 shortness of breath,swelling in feet, legs and ankles. water retention, heart
palpitations, and severe swelling of the abdomen may be a symptom of
constrictive pericarditis
 creaky or scratchy friction rub heard most clearly at the left lower sternal border.

mild fever, increased WBC count, anemia, and
an elevated ESR or C-reactive protein level

Dyspnea and other signs and symptoms of

heart failure may occur as the result of
pericardial compression due to constrictive
pericarditis or cardiac tamponade.- Cardiac
tamponade, also known as pericardial
tamponade, is when fluid in the
pericardium (the sac around the heart) builds
up and results in compression of the heart
Diagnostic:
 The diagnosis is most often made on the basis of the history,
signs, and symptoms.
 Echocardiography
 Computed tomography may be the best diagnostic tool for
determining the size, shape, and location of pericardial
effusions and may be used to guide pericardiocentesis.
 MRI may assist with detection of inflammation and adhesions.
 Biopsy
 12-lead ECG may show concave ST elevations in many, if not
all, leads and may show depressed PR segments or atrial
dysrhythmias.
Medical Management
 bed rest until the fever, chest pain, and friction rub have subsided
 Analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs)
such as aspirin or ibuprofen
 Corticosteroids (eg, prednisone) may be prescribed if the
pericarditis is severe or if the patient does not respond to
NSAIDs.
 Colchicine may also be used as alternative therapy.
 Pericardiocentesis, a procedure in which some of the
pericardial fluid is removed, is rarely necessary
 Surgical removal of the pericardium (pericardiectomy) may
be necessary to release both ventricles from the constrictive
and restrictive inflammation and scarring.