(ii) determining the source of sepsis; and (iii) starting empiric antibiotics that cover the
predictable pathogens and have a low resistance potential and good safety profile (38,39).
Bacterial Endocarditis
Infective endocarditis is described as acute or subacute based on the tempo and severity of the
clinical presentation (40). Categories of infective endocarditis include native valve infective
endocarditis, prosthetic valve endocarditis, infective endocarditis associated with intravenous
drug abuse, and nosocomial infective endocarditis (41). The characteristic lesion is vegetation
composed of platelets, fibrin, microorganisms, and inflammatory cells on the heart valve.
Conditions associated with endocarditis include injection drug use, poor dental hygiene, long-
term hemodialysis, diabetes mellitus, HIV infection,long-term indwelling venous catheters, mitral
valve prolapse with regurgitation, rheumatic heart disease, other underlying valvular diseases,
and prosthetic valves (42–44). Organisms associated with endocarditis includeStaphylococcus
aureus, viridans streptococci, enterococci, gram-negative bacilli (including the HACEK organisms;
Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella), and fungi.
Nonspecific symptoms and signs of endocarditis include fever, arthralgias, wasting,
unexplained heart failure, new heart murmurs, pericarditis, septic pulmonary emboli, strokes,
and renal failure (45). Skin lesions occur less frequently today than they once did but aid in the
diagnosis if present (45). Cutaneous manifestations of endocarditis include splinter
hemorrhages (Fig. 3), petechiae, Osler’s nodes, and Janeway lesions.
Petechiae are the most common skin lesions seen during endocarditis. The petechiae are
small, flat, and reddish brown and do not blanch with pressure. They frequently occur in small
crops and are usually transient. They are often found on the heels, shoulders, legs, oral mucous
membranes, and conjunctiva.
Osler’s nodes may be seen in patients with subacute bacterial endocarditis. These
nodules are tender, indurated, and erythematous. They occur most commonly on the pads of
the fingers and toes, are transient, and resolve without the development of necrosis. The
histology of these lesions demonstrates microabscesses and microemboli.
Janeway lesions are small, painless, erythematous macules that are found on the palms
and soles. These lesions can be seen with both acute and subacute endocarditis. Histological
analysis reveals microabscesses with neutrophil infiltration.
Disseminated Gonococcal Infection
Disseminated gonococcal infections (DGI) result from gonococcal bacteremia and occur in 1%
to 3% of patients with untreatedN. gonorrhea–associated mucosal infection (46–48). DGI is most
Figure 3 Subungual hemorrhages in an
adult patient with group B streptococcal
endocarditis.Source: Courtesy of Dr Lee
S. Engel.Fever and Rash in Critical Care 27