Endocarditis in Children

EndocarditisMany conditions may present subtly in children (ex, Inborn Errors of Metabolism, HUS, Pneumonia), but the subtle presentations of cardiac disease are often the most attention grabbing. We have previously discussed Subtle Signs of Heart Failure and Myocarditis.  Let us take a moment to appreciate another significant cardiac condition that may present in subtle fashions and requires our vigilance: Endocarditis in Children.

 

Endocarditis in Children: Basics

  • Rare, but deadly!
    • Difficult to know the exact occurrence of infective endocarditis in children.
    • Estimates range from 0.05 to 0.78 cases per 1,000 pediatric admissions. [Baltimore, 2015]
    • Overall frequency of endocarditis in children is increasing, though.
    • Unfortunately, mortality remains high: 5-10% [Tseng, 2014; Day, 2009]
  • Epidemiology has changed over past 80 years. [Baltimore, 2015; Elder, 2015; Tseng, 2014]
    • Rheumatic Heart Disease was once a significant factor, but now relatively rare.
    • Post-operative Congenital heart disease is now the leading associated condition in endocarditis cases.
      • Much improved survival for children with CHD leads to longer timespans for children to be affected.
      • Postoperative infective endocarditis is a long-term risk after correction of complex CHD, especially if there are residual defects or prosthetic material.
      • Increased prevalence of septal or vascular occluders and coils increases risk also.
    • Central Indwelling Lines also used more commonly now and increase risk.
  • S. aureus has become more prevalent over the past few decades. [Baltimore, 2015; Esposito, 2015; Yock-Corrales, 2013; Wei, 2010; Day, 2009]
  • Streptococci viridans group still remains an important cause.

 

Infective Endocarditis: Presentation

  • Symptoms are often vague and indolent: [Baltimore, 2015]
    • Prolonged fever
    • Rigors, diaphoresis
    • Fatigue, weakness
    • Arthralgias, myalgias
    • Weight loss
  • Occasionally, may present with acute illness with rapidly developing symptoms.
  • Clinical findings relate to 4 underlying phenomena: [Baltimore, 2015]
    1. Bacteremia / Fungemia
      • >85% of cases present with fever [Wei, 2010]
    2. Valvulitis
      • New murmur may be appreciated.
      • May develop overt heart failure.
      • In children with CHD, may not appreciate change in murmur, but there may be decreased oxygenation.
    3. Immunologic Responses
    4. Embolic
      • Extra-cardiac findings (Janeway lesions, Roth Spots, Osler Nodes, etc) are less commonly found in children than adults.
      • May see renal abnormalities (ex, glomerulonephritis, infarct).
        • Hematuria is one of the more common findings. (~53% of cases had microscopic hematuria) [Wei, 2010]
        • Can be due to embolic or immune complex deposition.
      • Embolic disease can also lead to injury to brain, lung, GI tract, or heart. [Wei, 2010]
      • Mycotic aneurysms have also been reported.
  • The Modified Duke Criteria
    • The current recommendations to help make the diagnosis of endocarditis is to use the Modified Duke Criteria. [Baltimore, 2015Baddour, 2005]
    • Divides cases into 3 categories and has Major and Minor Criteria:
      • Definite Infective Endocarditis
      • Possible Infective Endocarditis
      • Rejected
    • See TABLE 3 and TABLE 4 in Circulation 2015 for Modified Duke Criteria (too complex to replicate here).

 

Endocarditis in Children w/ Normal Hearts

  • While less common, endocarditis can occur in structurally normal hearts (~8-10% of cases) [Baltimore, 2015; Day, 2009]
    • One study had much higher percentage of previously healthy children developing endocarditis (35.4%) [Lin, 2012]
    • Average interval from symptom onset to diagnosis in these children was 18-31 days. [Lin, 2012]
  • Usually involves the aortic or mitral valves
  • Indwelling intravascular catheters are major risk factor for many of these patients.
  • Staphylococcus aureus bacteremia is the leading culprit. [Day, 2009]
  • Methicillin-resistant S. aureus has also become a common causative agent. [Esposito, 2015]
  • Neonates and Premature infants with normal hearts who develop endocarditis are at high risk for mortality. [Day, 2009]

 

Moral of the Morsel

  • Persistent fever always warrants our appreciation and contemplative minds! Don’t just dismiss it as another Virus.
  • Fever in child with structurally abnormal heart should absolutely grab your attention, even long after any repair. May need to discuss specific lesion and repair and potential risk of endocarditis with the cardiologist.
  • Central lines are useful, but come with a lot of risk as well.
  • Got hematuria? Don’t just blame the kidney… think about the heart also!

 

References

Esposito S1, Mayer A1, Krzysztofiak A2, Garazzino S3, Lipreri R4, Galli L5, Osimani P6, Fossali E7, Di Gangi M8, Lancella L2, Denina M3, Pattarino G4, Montagnani C5, Salvini F9, Villani A2, Principi N1, Italian Pediatric Infective Endocarditis Registry. Infective Endocarditis in Children in Italy from 2000 to 2015. Expert Rev Anti Infect Ther. 2016;14(3):353-8. PMID: 26708337. [PubMed] [Read by QxMD]

Baltimore RS, Gewitz M, Baddour LM, Beerman LB, Jackson MA, Lockhart PB, Pahl E, Schutze GE, Shulman ST, Willoughby R Jr; American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young and the Council on Cardiovascular and Stroke Nursing. Infective Endocarditis in Childhood: 2015 Update: A Scientific Statement From the American Heart Association. Circulation. 2015 Oct 13;132(15):1487-515. PMID: 26373317. [PubMed] [Read by QxMD]
Baddour LM, Wilson WR, Bayer AS, Fowler VG Jr, Tleyjeh IM, Rybak MJ, Barsic B, Lockhart PB, Gewitz MH, Levison ME, Bolger AF, Steckelberg JM, Baltimore RS, Fink AM, O’Gara P, Taubert KA; American Heart Association Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young, Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and Stroke Council. Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation. 2015 Oct 13;132(15):1435-86. PMID: 26373316. [PubMed] [Read by QxMD]

Elder RW1, Baltimore RS2. The Changing Epidemiology of Pediatric Endocarditis. Infect Dis Clin North Am. 2015 Sep;29(3):513-24. PMID: 26311357. [PubMed] [Read by QxMD]

Tseng WC1, Chiu SN, Shao PL, Wang JK, Chen CA, Lin MT, Lu CW, Wu MH. Changing spectrum of infective endocarditis in children: a 30 years experiences from a tertiary care center in Taiwan. Pediatr Infect Dis J. 2014 May;33(5):467-71. PMID: 24378945. [PubMed] [Read by QxMD]

Yock-Corrales A1, Segreda-Constenla A, Ulloa-Gutierrez R. Infective endocarditis at Costa Rica’s children’s hospital, 2000-2011. Pediatr Infect Dis J. 2014 Jan;33(1):104-6. PMID: 23989105. [PubMed] [Read by QxMD]

Lin YT1, Hsieh KS, Chen YS, Huang IF, Cheng MF. Infective endocarditis in children without underlying heart disease. J Microbiol Immunol Infect. 2013 Apr;46(2):121-8. PMID: 22727890. [PubMed] [Read by QxMD]

Wei HH1, Wu KG, Sy LB, Chen CJ, Tang RB. Infectious endocarditis in pediatric patients: analysis of 19 cases presenting at a medical center. J Microbiol Immunol Infect. 2010 Oct;43(5):430-7. PMID: 21075710. [PubMed] [Read by QxMD]

Day MD1, Gauvreau K, Shulman S, Newburger JW. Characteristics of children hospitalized with infective endocarditis. Circulation. 2009 Feb 17;119(6):865-70. PMID: 19188508. [PubMed] [Read by QxMD]

Baddour LM, Wilson WR, Bayer AS, Fowler VG Jr, Bolger AF, Levison ME, Ferrieri P, Gerber MA, Tani LY, Gewitz MH, Tong DC, Steckelberg JM, Baltimore RS, Shulman ST, Burns JC, Falace DA, Newburger JW, Pallasch TJ, Takahashi M, Taubert KA; Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease; Council on Cardiovascular Disease in the Young; Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia; American Heart Association; Infectious Diseases Society of America. Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America. Circulation. 2005 Jun 14;111(23):e394-434. PMID: 15956145. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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