VEGETATION NEGATIVE INFECTIVE ENDOCARDITIS

A VIEW POINT . . .

S.Venkatesan,G.Gnanavelu,G.Karthikeyan,V.Jaganathan,R.AlagesanM.Annamalai,S.Shanmugasundaram, S.Geetha,A.Balaguru .G.Anuradha

Madras Medical College. Chennai.India

Mumbai Dec 2005

Annual scientificsessions

Infective endocarditis

Still a dreaded clinical entity

Mortality & morbidity is more than MI or UA

Equals that of a malignancy if not diagnosed &treated early

Many diagnostic criteria has been advanced .

None had withstood the test of time.

Currently Dukes criteria is considered as de factostandard.

Von Reyn 1981 Clinical ,Autopsy

Duke 1994 Stressed Echo evidence

Modified Duke (Li 2000) TEE included

IE is a Criteria syndrome

New valvular regurgitation

New partial dehiscence of prosthetic valve

Abscess

Vegetation on valve or supporting structure

Positive echocardiogram (TEE recommended in prosthetic valves, rated atleast possible IE by clinical criteria, or complicated IE; TTE as the first test inother patients):

Evidence of endocardial involvement

1 positive BC for C. brunetii or antiphase-I immunoglobulin G antibody titer>1:800

2 positive BCs drawn >12 hours apart or 4 positive BCs irrespective of thetiming

2 separate positive BCs consistent with IE (V. streptococci, Streptococcus bovis,HACEK group, S. aureus, and enterococci) in the absence of a primary focus

Positive blood culture (BC)Majorcriteria

Echocardiographic minor criteria eliminated

Microbiological evidence: positive BC that does not meetmajor criteria or serological evidence of infection

Immunologic phenomena

Vascular phenomena

Fever

PredispositionMinorcriteria

Which comes first ?

Echocardiography

Microbial

Clinical

Colonisation

Adhesion

Vegetation

Invasion

It needs of Millions of bacteria anddebri to form 3mm sized vegetation that is detectedby Echo

It has been our observation some ofthe patients with RHD , and severe regurgitantlesions with febrile spells that indicated highdegree of suspicion of IE but withoutdocumentation of vegetation .

Back ground

“In this context we report our analysis of patientswith IE without vegetations. Out of 24 patientsadmitted between 2004-2005 in our hospital with thediagnosis of IE 4 patients failed to showvegetations”

NoClass 3MR/TRM 18

NoClass 2MR/ARF 20

YesClass 3MR/ARM 22

YesClass 4MR/MS/TRM 18

CHFFunctional class

LesionPatient

Baseline data

Clinical features

NoNil+M 18

YesNil+F 20

NoNil+M 22

YesNil+M 18

vascular

ImmunologicalFeverPatient

Microbiology

-PseudomonasStaph aureus4

Staph auerusStaph auerusStaph aureus3

-Staph auerusStaph aureus2

Streptococcusviridans

-StreptococcusViridans

1

Blood culture 3Blood culture 2Blood culture 1

No vegetationNo vegetationNo vegetationNo vegetation4

12mm11mm--3

No vegetationNo vegetationNo vegetationNo vegetation2

No vegetationNo vegetationNo vegetationNo vegetation1

Echo 4 wEcho- 2 wEcho-1 wBase lineEcho

TTE Vegetation

Echocardiography

yesnil-both severeMR/AR4

yesyesnil-severe/moderate

MR/AR3

--nilYesBoth severeMR/AR2

yesyesnilyesSevereEccentric

MR/MS/TR

1

LVdysfunction

WorseningMR/AR

Echo Geneicmass

Flailvalve

JetMorphology

Valvelesion

Trans Esophageal echocardiography done

at least once in all patients

Failed to detect vegetations

Therapy

Standard therapy first week

Followed by Culture guided therapy

Drugs used Ceftrixone , Amikacin , Vancomycin

Course & complications

One patient developed cerebral vasculits andanother renal insufficiency during the course oftreatment.

Two patients stabilized with medical management.

One expired .

Other had refractory cardiac failure and was referredfor emergency surgery

Nomenclature of the syndrome

How do you call IE without Culture positivity ?

How shall we label IE without vegetation ?

Culture negative endocarditis

Vegetation negative endocardits

Incidence of Vegetation Negative IE

Vegetation Negative Vs vegetation positive

Comparison not possible due to small series

But trend towards more staphylo coccal

infection in veg negative IE

Mortality 1 out of 4

Mechanisms for absenceof visible vegetation

Resolution of power Ultrasound

TTE vs TEE5mm /2mm

65 % - 90%

Negative TEE Does notexclude IE if suspicion is high

Temporal dissociation between appearance ofvegetation and the clinical syndrome.

Vigorous antimicrobial treatment might haveprevented the formation of vegetation

Classical Endoluminal ,Mobile

Intramuralboroughing

Layered

Chordal rupture as a

Sole manifestation

of IE.

Is diffuse Endocardial involvement possible ?

Some think CHF by itself is a evidence forendocarditis

Conclusion

•Even though vegetations are considered sine quanon of IE in many clinical situations IE occurs without vegetation.

•The incidence is 16% in our series.

•The mechanisms are varied.

Echocardiography per se has significantlimitation in ruling out Infectiveendocarditis

Over reliance on ECHO to rule out IE hasthe potential to delay in starting therapyAnd Could have adverse outcome

One should attempt to diagnose IE in thepre vegetation phase itself

IMPLICATIONS

Good judgement comes fromexperience . . .

Experience comes from badjudgement.