A 17 Year Old Girl Admitted With 6 Month History Of Weight loss And A Murmur On Auscultation

A 17 year old girl was admitted in the hospital with a 6 month history of generalized body pains, loss of weight and night sweats. Over the past 6 weeks she has started to become breathless on mild exertion. At the time of admission she had a temperature of 101 F and on examination she had a early diastolic murmur on the left sternal border on auscultation of the precordium. On doing a fundoscopic examination following was seen:

Roth spots in the retina ( hemorrhagic area with a pale center)

On examination of her hands subungal splinter hemorrhage was seen in one of the finger nails. The picture is shown below:

What is the most likely diagnosis?

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Infective Endocarditis ( Fever, diastolic murmur, history of weight loss, Roth spots and splinter hemorrhages all point towards the diagnosis of Infective endocarditis)

Case Discussion:
Infective Endocarditis also known as Bacterial Endocarditis is an infection caused by the bacterial of the endocardial surfaces of the heart which may include one or more of the heart valves, a mural endocardiaum or a septal defect.

Signs And Symptoms: include some or more of the following:

• Fever
• Malaise
• Fatigue
• A new or a changing heart murmur
• Weight loss
• Cough
• Septic embolism that may cause thromboembolitic problems such as stroke 
• Janeway lesions: painless hemorrhagic cutaneous lesions on the palms and soles.
• Intracranial hemorrhage
• Conjuctival hemorrhage. 
• Splinter hemorrhage: dark red linear lesions in the nail bed
• Osler nodes: tender subcutaneous nodules in the distal pads of the digits
• Roth Spots: retinal hemorrhages with small, clear centers.
• Splenomegaly
• Pallor with anemia
• Generalized body aches and pains

Diagnosis: The Duke's criteria is to be fulfilled for the diagnosis and the criteria combines the clinical, microbiological, pathological and echocardiographic characteristics in a particular patient. 

Major echocardiographic criteria include the following:

• Echocardiogram positive for IE, documented by an oscillating intracardiac mass on a valve or on supporting structures, in the path of regurgitant jets, or on implanted material, in the absence of an alternative anatomic explanation
• Myocardial abscess
• Development of partial dehiscence of a prosthetic valve
• New-onset valvular regurgitation

Minor criteria for IE include the following:

• Predisposing heart condition or intravenous drug use
• Fever of 38°C (100.4°F) or higher
• Vascular phenomenon, including major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhage, or Janeway lesions
• Immunologic phenomenon such as glomerulonephritis, Osler nodes, Roth spots, and rheumatoid factor
• Positive blood culture results not meeting major criteria or serologic evidence of active infection with an organism consistent with IE
• Echocardiogram results consistent with IE but not meeting major echocardiographic criteria

A definitive clinical diagnosis can be made based on the following:

• 2 major criteria
• 1 major criterion and 3 minor criteria
• 5 minor criteria