Clinical presentation and diagnosis

The clinical presentation for IE is quite variable and often nonspecific. A fever is the most frequent and persistent symptom in patients but may be blunted with previous antibiotic use, congestive heart failure, chronic liver or renal failure, or infection caused by a less virulent organism (i.e., subacute disease). Other signs and symptoms that also may occur are listed in the Clinical Presentation box with some discussed further in detail below.

Heart murmurs are heard frequently on auscultation (over 85% of cases), but a new murmur or change in murmurs is only found in 5% to 10% or 3% to 5%, respectively.1 Additionally, over 90% of patients who have a new murmur will develop congestive heart failure, which is a major cause of morbidity and mortality. Splenomegaly and mycotic aneurysms are also noted in many cases of IE.

This disease is also characterized by the following peripheral manifestations. Some of these clinical findings are found in up to one-half of patients with IE, although recently the prevalence has been decreasing.10

• Skin: Petechiae are very small (usually less than 3 mm) pinpoint flat red spots beneath the skin surface caused by microhemorrhaging. They occur in 20% to 40% of chronic IE, often found on the buccal mucosa, conjunctivae (Fig. 74-3A), and extremities.1 Splinter hemorrhages appear as small dark streaks beneath the finger-or toenails and occur most commonly proximally with IE, typically occurring as a result of local vasculitis or microemboli occurring in about 20% of patients (Fig. 74-3B). Osler's nodes are small (usually 2-15 mm), painful, tender subcutaneous nodules located on the pads of the fingers and toes (Fig. 74-3D) caused primarily by either septic emboli or vasculitis. These nodes are rare in acute disease but are also nonspecific for IE despite occurring in 10% to 25% of all patients.1 Janeway's lesions are small, painless hemorrhagic macular plaques on the palms of the hands or soles of the feet due to septic emboli (in approximately 5% of patients) and more commonly associated with acute S. aureus IE (Fig. 74-3E).

• Extremities: Clubbing of the finger tips typically occurs in long-standing illness and is present in approximately 10% to 20% of patients (Fig. 74-3C).1

• Eye: Roth S spots are rarely occurring (in less than 5% of IE cases), oval-shaped retinal hemorrhages with a pale center near the optic disc (Fig. 74-3F).

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