Andersons pediatric cardiology 1487

implanted>3monthsago)

Fordefiniteclinicaldiagnosis:2majorcriteriaor1majorand3minorcriteriaor5minorcriteria.
Forpossibleclinicaldiagnosis:1majorand1minorcriterionor3minorcriteria.
AmendedESCandAHA2015guidelines(seereferences1and2).
CT,Computedtomography;FDG,fluorodeoxyglucose;HACEK,Haemophilusspp.,
Aggregatibacterspp.,Cardiobacteriumspp.,Eikenellacorrodens,Kingellaspp.;IE,infective
endocarditis;PET,positronemissiontomography;SPECT,single-photonemissioncomputed
tomography.
ModifiedfromLiJS,SextonDJ,MickN,etal.ProposedmodificationstotheDukecriteriaforthe
diagnosisofinfectiveendocarditis.ClinInfectDis.2000;30:633–638.

Thecriteriaareveryhelpful,buttheyshouldbeusedfordiagnosisinaddition
toclinicaljudgement.

DifferentialDiagnosis
Itmayrequiredifferentialdiagnosiswithchronicinfection,rheumatologic,and
autoimmunediseasesortumors.

IntracardiacMasses
Tumors,althoughrare,shouldalwaysbeconsidered.Itshouldbenotedthat
cardiacmyxomasquiteoftenmanifestwithlow-gradefever,immune
phenomena,andpositivemarkersofinflammationandmimicIEtoagreat
extent.Thenonbacterialthromboticendocarditis(NBTE)describedasa
paraneoplasticprocessformultipleadultcancers44seemsnottobecharacteristic
ofpediatrictumors.However,theremightbedirectextensionintotherightheart
byhepatoblastoma,neuroblastoma,andWilmstumor.45–47Extensiontotheleft
heartviathepulmonaryveinforpulmonarymetastasisofhepatoblasoma48or
Wilmstumor,49aswellasdirectmetastasistotheleftventricleof
neuroblastoma,50havealsobeendescribed.
Granulomatouspolyangiitis(GPA,previouslyWegenergranulomatosis)is

reportedtocauseintracardiacthrombus,52aswellasvalveperforations,51which
mightmimicIE.
Liebmann-Sachsendocarditismaybethefirstmanifestationofsystemiclupus
erythematosus(SLE)inchildren53:itusuallyinvolvesthemitraloraorticvalve
butmayinvolveboth54ormayalsobelocatedonthetricuspidvalve.55,56
Althoughitmayhaveafavorableevolutionafterstartingtreatment,itmay


requireurgentsurgerybecauseexcessivegrowthmaycreateobstruction.57
InChurg-Strausseosinophilicpolyangiitis,cardiacmanifestationsusually
occurwithseveremyocarditisbutintracardiacthrombihavealsobeen
reported.58
Hypereosinophilicsyndromeinchildhoodmayhavecardiacmanifestations
thatareparticularlynotoriousforinitialinfiltration,includingmuralandapical,
thatprogressesquicklytofibrosis,thusleadingtoworseningregurgitationwith
littlepossibilityforrepairandalmostuniversalneedofreplacement.59,60Itmight
alsocausemyocardialinfiltrationwithrestrictivecardiomyopathyasa
concomitantfeature.61Biopsymightnotalwaysbehelpful:echocardiograms
andendomyocardialbiopsiesagreeforpresenceorabsenceofcardiac
involvement60%ofthetime.62
HyperhomocysteinemiaduetoaheterozygousC677Tpolymorphisminthe
methylenetetrahydrofolatereductasegeneisawell-recognizedthrombophilia
conditionthatisphenotypicallymostwellexpressedinthehomozygous
recessivelyinheritedmetabolicdisorderthathasseverehyperhomocysteinemia
andmaypotentiateintracardiacandvalvarthrombiformation.63Itshouldbe
takenintoaccountthatforunknownreasonspatientswithIEmayhavemild
hyperhomocysteinemiawithoutnecessarilyhavingthepolymorphismitself;this
doesnotrelatetobiggervegetationsorincreasedembolicrisk.64Fromtheother
thrombophiliasstudied,ithasbeenconfirmedthatmutationsG20210Aofthe
prothrombingeneandG1691AoffactorVLeidengenedonotcontributetothe

susceptibilitytoIE.65

PeriaorticThickening
Surgicallyrelatedechocardiographicfindingscanappearlikeglueaftervalve
replacement66orhyperechogenicityofhomografts(unpublished).Chronic
periaortitishasbeenstudiedindetailanddescribedinGPA,eosinophilic
granulomatouspolyangiitis,andpolyarteritisnodosa,67–75anditmightverywell
mimicaorticrootabscess.

Pyrexia
LineinfectionsarethemostfrequentcauseofechorequestforrulingoutIE.
Pyrexiaofunknownoriginandbacteremiahavebecomemajorindicationsfor


echotoruleoutIE.Thenumberofrequestshasrisenexponentiallyinthepast2
decades.Differenttoolshavebeendesignedtoindicatewhenanurgentechois
required.Anapproximately20%and10%positiveyieldforIEdiagnosisin
communityandnosocomialacquiredstaphylococcalbacteremia,respectively,
justifiesechoasascreeningtool76,77;thepercentageofpediatricIEcasesamong
childrenwithS.aureusbacteremiaisapproximately12%.78Itshouldbe
underlinedthatoneofthemostfrequentcausesofpersistentbacteremiabesides
IEandlineinfectionisosteomyelitis;toothabscesshasalsobeendescribed.
DifferentialdiagnosisisshownonBox56.4.


Box56.4

DifferentialDiagnosisofInfective
Endocarditis
IntracardiacMasses

Tumors
■Myxomas
■Extensionviatheinferiorvenacava(neuroblastomaandWilmstumor)
■Nonbacterialthromboticendocarditisindistanttumors(notcharacteristicof
pediatricage)
NoninfectiousIntracardiacThrombi
■Acuterheumaticfever
■Autoimmunediseases(GPA,SLE,APS,Churge-StrausseosinophilicGPA)
■Hypereosinophilicsyndrome(acuteleukemia,parasiticdisease)
■Thrombophilia(homocystinemia)

PeriaorticMasses
■Surgical(glue)