of Janeway lesions, Osler’s nodes (20% of cases) (132). The patient may present with symptoms
of myocarditis or pericarditis.
It is important to note the susceptibility of prosthetic valves to becoming infected during
HCBSI or health care associated fungemia. Sixteen percent of patients with mechanical or
bioprosthetic valves in place develop PVE during HCBSI. Sixty-one percent of the BSIs
originated from intravascular catheters (33%) or skin and wound (28%) assays infections.
Staphylococcal and gram-negative BSI infected 55% and 33%, respectively, of prosthetic
valves (135).
PMIE
PM infections and PMIE may be classified as primary, those infections in which the pacemaker
or its pocket is the source of infection or as secondary infections in which the leads (rarely the
pacemaker itself or its pocket) are seeded from a BSI (109–113,136). The clinical presentation of
PM infections and PMIE is dependent on the site of infection and its origin. Infections within a
few months of placement are either acute or subacute infections of the pulse-generator pocket
acquired during implantation. There may be associated bacteremia. Thirty-three percent of
patients are febrile. Late infections of the pocket are caused by erosion of the overlying skin.
They always indicate infection of the generator and possibly of the leads themselves.
Generally PMIE presents with more systemic signs and symptoms than do infections of
the pacemaker pocket. Despite the fact thatS. aureus and CoNS are the most frequent
pathogens, PMIE is usually subacute in nature. Fever occurs in 84% 100% of patients.
However, absence of fever does not rule out the presence of PMIE. Forty-five percent of cases
of PMIE suffer from symptoms of septic pulmonary emboli (dyspnea, pleuritic pain).
IVDA IE
Approximately 5% to 8% of IVDA who present with fever have IE. The signs and symptoms of
IVDA IE are related not only to the nature of the pathogen but also by the particular cardiac
valves that are infected. The clinical course of left-sided IVDA is quite similar to that of
valvular infections in non-drug users. However there is a high rate of neurological findings
(panopthalmitis and cerebral mycotic aneurysms) and persistence of bacteremia whenP.
aeruginosais involved (38,137,138). Fifty-three percent of cases of IVDA IE present with coughs,
pleuritic pain, and hemoptysis due to right-sided involvement. There is low rate of systemic
embolization. The pulmonary signs and symptoms may be due to septic emboli, pneumonia
and/or empyema. Emboli may also involve the central nervous system, bones, and joints. The
high rate of concurrent infection with HIV does not effect the clinical presentation of IVDA IE.
HCIE
HCIE clinically differs from valvular infection that is acquired in the community. It much more
often presents as a nonspecific picture of sepsis with hypotension, metabolic acidosis, and
multiple organ failure. Hypotension and pulmonary edema are also more frequent in HCIE
(53% vs. 23% and 27% vs. 9%, respectively). It presents itself less often with fever/chills and
leukocytosis (55% vs. 25% and 82% vs. 61%, respectively). These features are dependent on the
host’s mounting an effective inflammatory response. There is a lower rate of the
dermatological manifestations of IE such as Osler’s nodes and Janeway lesions. The older
age and the greater rate of valvular abnormalities of the patient with iatrogenically produced
IE may explain these differences (69,139,140).
Although in the recent past, up to 45% of cases of HCIE involved prosthetic valves, in the
last 20 years the percentage of native valves infected in health care facilities has been on the
increase. It is important to repeat that prosthetic valves are very susceptible to being infected
by BSIs. This may occur despite the patients having been given an appropriate antibiotic
regimen for more than two weeks at the onset of the bacteremia 34% of these infections were
caused by gram-negative and fungi (135). The presentation of fungal HCIE of prosthetic valves
is quite indolent and contributes, along with the difficulty in isolating fungi from the
bloodstream, to the failure to make an expeditious diagnosis (141).
Infective Endocarditis and Its Mimics in Critical Care 231