1. Infective Endocarditis in
Children: an overview
Dr.B.BALAGOBI

3. Points to ponder...
• IE is infection of the cardiac tissue/related structures -
valves
• Is a complication of congenital and acquired heart
disease → can change the outcome of the heart
disease
• Lesion associated with a high velocity jet of blood or
an intra cardiac prosthesis
• Predisposing factors - dental or surgical procedure,
following cardiac surgery
• Relatively rare in children
• Pre-antibiotic era: mortality was nearly 100%

4. Infective Endocarditis
• Febrile illness
• Persistent bacteremia
• Characteristic lesion of microbial infection
of the endothelial surface of the heart
The vegetation
– Variable in size
– Amorphous mass of fibrin & platelets
– Abundant organisms
– Few inflammatory cells

5. Distinction between Acute and
Subacute Bacterial Endocarditis
Feature Acute Subacute
Underlying Heart Heart may be normal RHD,CHD, etc.
Disease
Organism S. aureus, Pneumococcus viridans
S. pyogenes, Streptococci,
Enterococcus Entercoccus
Therapy Prompt, vigorous and initiated Can often be delayed
on empirical ground until culture reports and
susceptibilities
available

6. Prevention – the underlying lesion
• High risk lesions • Intermediate risk
– Prosthetic valves – MVP with murmur
– Prior IE
– Pure MS
– Cyanotic congenital heart
disease
– Tricuspid disease
– PDA – Pulmonary stenosis
– AR, AS, MR,MS with MR – ASH
– VSD – Bicuspid Ao valve with no
– Coarctation hemodynamic significance
– Surgical systemic-pulmonary
shunts
Lesions at highest risk

7. Prevention – the underlying lesion
• Low/no risk
– MVP without murmur
– Trivial valvular regurg.
– Isolated ASD
– Implanted device
(pacer, ICD)
– CAD
– CABG

8. Culprits...
• Viridans group of streptococci (α haemolyti
strep) - flora of mouth
• Enterococci - gastrointestinal tract
• Staphylococcus aureus
• Fungi

9. Pathophysiology
• Embolization
• Clinically evident 11 – 43% of patients
• Pathologically present 45 – 65%
• High risk for embolization
» Large > 10 mm vegetation
» Hypermobile vegetation
» Mitral vegetations (esp. anterior leaflet)
• Pulmonary (septic) – 65 – 75% of i.v. drug abusers
with tricuspid IE

10. When to suspect…?
• Congenital/acquired • Murmur - failure,
heart lesion changing murmurs
• Continued fever • Splenomegaly
• Anorexia, weight loss, • Embolic phenomena
malaise to lungs/kidneys/brain
• Pallor - demonstrate a limbs (rare since use
drop in Hb% of antibiotics)
• Clubbing, petechiae • Urine - microscopic
• Splinter haematuria (immune
haemorrhages etc - complex)
not usually found

14. The echocardiogram in IE

20. Splinter Hemorrhage

21. Roth’s Spots

25. Sequelae
• Neurologic manifestations, 20%
– Cerebral emboli, mycotic aneurysms,
cerebritis, brain abscess, hemorrhage, etc.
• Peripheral embolization
– Ischemia, infarction, mycotic aneurysms, etc
• Pulmonary infarction
• Renal insufficiency
• Congestive heart failure

28. Prophylaxis...
• Any procedure likely
to cause bacteriaemia • Dental procedures -
• dental treatment Amoxycillin/Erythromycin
• abdominal surgery • GU/GI procedures,
• surgery or previous endocarditis,
instrumentation of intracardiac prostheses -
upper respiratory or Ampicillin and Gentamicin
genitourinary tract • Vancomycin and Gentamicin
following burns •
IV alimentation

29. T/F Infective endocarditis?
A. Diagnosis is based on Duckett Jone’s
criteria
B. ASD is a common cause
C. Cause firm splenomegaly
D. Associated with Streptococcus Viridans
infection
E. Vegetations are sterile
F. Never cause embolisation

30. T/F features of Infective
endocarditis?
A. Clubbing
B. Haematuria
C. Fever
D. Arthralgia
E. Chorea

31. T/F Regarding Infective
endocarditis?
A. Normal WBC count exclude the diagnosis
B. 2D echocardiography is not useful in
diagnosis
C. Blood for culture is taken at the peak of
the fever
D. Macroscopic haematuria is common
E. Clubbing is an early feature.

32. T/F Diastolic murmur in 7 year
old?
A. Mitral stenosis
B. Anaemia
C. Infective endocarditis
D. Tetralogy of fallot
E. Acute Rheumatic carditis

33. T/F Infective endocarditis in
children?
A. Is often caused by Streptococcal
pneumonia
B. Is seen in child with PDA
C. Cause haematuria
D. Cause clubbing during first week
of the illness
E. IV antibiotics is given for 2 weeks