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Endocarditis
Classification and external resources
Bartonella henselae bacilli in cardiac valve of a patient with blood culture-negative endocarditis. The bacilli appear as black granulations.
ICD-10 I33.
ICD-9 421
DiseasesDB 4224
MedlinePlus 001098
eMedicine emerg/164  med/671 ped/2511
MeSH D004696

Endocarditis is an inflammation of the inner layer of the heart, the endocardium. The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify Diseases The International Statistical Classification of Diseases and Related Health Problems 10th Revision ( ICD -10) is a coding of diseases and signs symptoms abnormal findings I00-I99 - Diseases of the Circulatory system (I00-I02 Acute rheumatic fever ( Rheumatic fever without mention of Heart The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify Diseases The following is a list of codes for International Statistical Classification of Diseases and Related Health Problems. The Diseases Database is a free Website that provides information about the relationships between medical conditions Symptoms, and Medications. MedlinePlus, with the MedlinePlus Medical Encyclopedia, is a website network containing Health information from the world's largest medical Library eMedicine is an online clinical medical knowledge base that was founded in 1996 by Scott Plantz and Richard Lavely two medical doctors Medical Subject Headings ( MeSH) is a huge Controlled vocabulary (or metadata system for the purpose of indexing journal articles and books Inflammation ( Latin, inflamatio, to set on fire is the complex biological response of vascular tissues to harmful stimuli such as Pathogens The heart is a muscular organ in all Vertebrates responsible for pumping Blood through the Blood vessels by repeated rhythmic The endocardium is the innermost layer of tissue that lines the chambers of the heart It usually involves the heart valves (native or prosthetic valves). In Anatomy, the heart valves are Valves in the Heart that maintain the unidirectional flow of blood by opening and closing depending on the difference Other structures which may be involved include the interventricular septum, the chordae tendinae, the mural endocardium, or even on intracardiac devices. Interventricular septum (or ventricular septum, or during development septum inferius) abbreviated IVS is the stout wall separating the lower chambers (the The chordae tendineae, or heart strings, are cord-like Tendons that connect the Papillary muscles to the Tricuspid valve and the

Endocarditis is characterized by a prototypic lesion, the vegetation, which is a mass of platelets, fibrin, microcolonies of microorganisms, and scant inflammatory cells. [1]

There are multiple ways to classify endocarditis. The simplest is classifying based on etiology: either infective or non-infective, depending on whether a microorganism is the source of the inflammation. A microorganism (also spelled micro organism or micro-organism and also called a microbe) is an Organism that is Microscopic (usually Regardless, diagnosis of this disease is based on the clinical features, investigations such as echocardiogram, as well as any blood cultures exhibiting the existence of microorganisms commonly causing endocarditis. An echocardiogram is a Sonography of the Heart. Also known as a cardiac ultrasound it uses standard ultrasound techniques to image two-dimensional slices of Blood culture is Microbiological culture of Blood. It is employed to detect Infections that are spreading through the bloodstream ( Bacteremia, A microorganism (also spelled micro organism or micro-organism and also called a microbe) is an Organism that is Microscopic (usually

Contents

Infective endocarditis

As the valves of the heart do not actually receive any supply of their own, defensive immune mechanisms (such as white blood cells) cannot approach the valves. So if an organism (such as bacteria) establishes a hold on the valves forming a vegetation, the body cannot get rid of them. The Bacteria ( singular: bacterium) are a large group of unicellular Microorganisms Typically a few Micrometres in length bacteria have Also, the lack of blood supply to the valves has implications on treatment, since drugs also have difficulty reaching the infected valve.

Normally, blood flows smoothly through these valves. If they have been damaged (for instance in rheumatic fever) bacteria can have a chance to take hold. Rheumatic fever is an Autoimmune inflammatory Disease which may develop two to three weeks after a Group A streptococcal infection (such as

Classification

Traditionally, infective endocarditis has been clinically divided into acute and subacute (because the patients tend to live longer in subacute as opposed to acute) endocarditis. This classifies both the rate of progression and severity of disease. Thus subacute bacterial endocarditis (SBE) is often due to Streptococci of low virulence and mild to moderate illness which progresses slowly over weeks and months and has low propensity to hematogenously seed extracardiac sites, while acute bacterial endocarditis (ABE) is a fulminant illness over days to weeks, and is more likely due to Staphylococcus aureus which has much greater virulence, or disease-producing capacity and frequently causes metastatic infection. Streptococcus is a Genus of spherical Gram-positive bacteria belonging to the phylum Firmicutes and the Staphylococcus aureus (ˌstæfɨləˈkɒkəs ˈɔriəs literally "Golden Cluster Seed" and also known as golden staph) is the most common cause of

This terminology is now discouraged. The terms short incubation (meaning less than about six weeks), and long incubation (greater than about six weeks) are preferred.

Infective endocarditis may also be classified as culture-positive or culture-negative. Culture-negative endocarditis can be due to micro-organisms that require a longer period of time to be identified in the laboratory, such organisms are said to be 'fastidious' because they have demanding growth requirements, or due to absence of an organism as in marantic endocarditis. A growth medium or culture medium is a liquid or gel designed to support the growth of Microorganisms or cells There are different types of media for Some pathogens responsible for culture-negative endocarditis include Aspergillus species, Brucella species, Coxiella burnetii, Chlamydia species, and HACEK bacteria. Aspergillus is a Genus of around 200 Molds found throughout much of nature worldwide Brucella is a Genus of Gram-negative bacteria. They are small (0 Coxiella burnetii is a species of Intracellular, pathogenic bacteria, and is the causative agent of Q fever. A HACEK organism is one of a set of slow-growing Gram negative bacteria that form a normal part of the Human flora.

Patients who inject narcotics intravenously may introduce infection which will travel to the right side of the heart classically affecting the tricuspid valve, and most often caused by Staphylococcus aureus. The term narcotic (ναρκωτικός is believed to have been coined by the Greek physician Galen to refer to agents that benumb or deaden causing loss The tricuspid valve (also known as the right atrioventricular valve) is on the right side of the heart between the Right atrium and the Right ventricle Staphylococcus aureus (ˌstæfɨləˈkɒkəs ˈɔriəs literally "Golden Cluster Seed" and also known as golden staph) is the most common cause of In other patients without a history of intravenous exposure, endocarditis is more frequently left-sided.

Another form of endocarditis is nosocomial endocarditis which is when the patient is diagnosed with endocarditis and has had hospital care one month prior to the incident and is usually secondary to IV catheters, TPN lines, pacemakers, etc. Nosocomial infections are Infections which are a result of treatment in a Hospital or a healthcare service unit but secondary to the patient's original condition For other uses see Pacemaker (disambiguation A pacemaker (or artificial pacemaker, so as not to be confused with the heart's natural pacemaker [1]

Finally, the distinction between native-valve endocarditis and prosthetic-valve endocarditis is clinically important. Prosthetic valve endocarditis can be early (< 2 months of valvular surgery) or late (> 2 months of valvular surgery). Early prosthetic valve endocarditis is usually due to intraoperative contamination or a postoperative bacterial contamination which is usually nosocomial in nature. Nosocomial infections are Infections which are a result of treatment in a Hospital or a healthcare service unit but secondary to the patient's original condition Late prosthetic valve endocarditis is usually due to community acquired microorganisms. A microorganism (also spelled micro organism or micro-organism and also called a microbe) is an Organism that is Microscopic (usually [1]

Etiology and pathogenesis

As previously mentioned, altered blood flow around the valves is a risk factor in obtaining endocarditis. The valves may be damaged congenitally, from surgery, by auto-immune mechanisms, or simply as a consequence of old age. Surgery (from the χειρουργική cheirourgikē, via chirurgiae meaning "hand work" is a medical specialty that uses operative manual and instrumental Autoimmunity is the failure of an organism to recognize its own constituent parts as self, which results in an immune response against its own cells and tissues The damaged part of a heart valve becomes covered with a blood clot, a condition known as non-bacterial thrombotic endocarditis (NBTE).

In a healthy individual, a bacteremia (where bacteria get into the blood stream through a minor cut or wound) would normally be cleared quickly with no adverse consequences. Bacteremia ( Bacteræmia in British English is the presence of bacteria in the Blood. If a heart valve is damaged and covered with a piece of a blood clot, the valve provides a place for the bacteria to attach themselves and an infection can be established.

The bacteremia is often caused by dental procedures (in most cases due to viridans streptococci, which reside in oral cavity), such as a cleaning or extraction of a tooth. Dentistry' is the "evaluation diagnosis prevention and/or treatment (nonsurgical surgical or related procedures of diseases disorders and/or conditions of the oral cavity It is important that a dentist or a dental hygienist is told of any heart problems before commencing. Dentistry' is the "evaluation diagnosis prevention and/or treatment (nonsurgical surgical or related procedures of diseases disorders and/or conditions of the oral cavity A dental hygienist is a licensed Dental auxiliary who specializes in preventive dental care typically but not limited to focusing on techniques in Oral hygiene. Antibiotics are administered to patients with certain heart conditions as a precaution, although in the UK this practice has changed as of March 2008 due to new NICE guidelines. In modern usage an antibiotic is a Chemotherapeutic agent with activity against Microorganisms such as Bacteria, fungi or Protozoa

Another group of causes result from a high number of bacteria getting into the bloodstream. Colorectal cancer (mostly Streptococcus bovis), serious urinary tract infections (mostly enterococci), and IV drug (Staphylococcus aureus) use can all introduce large numbers of bacteria. Colorectal cancer, also called colon cancer or large bowel cancer, includes Cancerous growths in the colon, Rectum and A urinary tract infection ( UTI) is a bacterial Infection that affects any part of the Urinary tract. With a large number of bacteria, even a normal heart valve may be infected. A more virulent organism (such as Staphylococcus aureus, but see below for others) is usually responsible for infecting a normal valve.

Intravenous drug users tend to get their right heart valves infected because the veins that are injected enter the right side of the heart. In the Circulatory system, a vein is a Blood vessel that carries Blood back toward the Heart (as opposed to Artery, a blood vessel The injured valve is most commonly affected when there is a pre-existing disease. (In rheumatic heart disease this is the aortic and the mitral valves, on the left side of the heart. )

Clinical and pathological features

Diagnosis

The most important investigation is Blood culture. Fever of unknown origin (FUO, pyrexia of unknown origin (PUO or febris e causa ignota (febris E An echocardiogram is a Sonography of the Heart. Also known as a cardiac ultrasound it uses standard ultrasound techniques to image two-dimensional slices of Murmurs are abnormal Heart sounds that are produced as a result of turbulent blood flow which is sufficient to produce audible noise A stroke is the rapidly developing loss of brain functions due to a disturbance in the blood vessels supplying blood to the brain The parietal lobe is a lobe in the Brain. It is positioned above (superior to the Occipital lobe and behind (posterior to the Frontal lobe. The brain is the center of the Nervous system in animals All Vertebrates and the majority of Invertebrates have a brain Please do not add warnings to this page about the pictures Wikipedia is not censored for taste and has a guideline preventing such warnings - WikipediaNo disclaimers in articles Janeway lesions are non- Tender, small Erythematous or Haemorrhagic macular or nodular lesions on the Palms or soles Glomerulonephritis, also known as glomerular nephritis, abbreviated GN, is a renal disease characterized by Inflammation of the glomeruli Osler's nodes are painful red raised lesions on the Finger pulps indicative of the heart disease subacute Infective Endocarditis. A lesion is any abnormal tissue found on or in an organism usually damaged by disease or trauma Roth's spots are Retinal Hemorrhages with white or pale centers composed of Coagulated Fibrin. The vertebrate retina is a light sensitive part inside the inner layer of the Eye. Rheumatoid factor (RF or RhF is an Autoantibody ( Antibody direct against an organism's own tissues most relevant in Rheumatoid arthritis. In general, a patient should fulfill the Duke Criteria[2] in order to establish the diagnosis of endocarditis.

As the Duke Criteria relies heavily on the results of echocardiography, research has addressed when to order an echocardiogram by using signs and symptoms to predict occult endocarditis among patients with intravenous drug abuse[3][4][5] and among non drug-abusing patients [6][7]. An echocardiogram is a Sonography of the Heart. Also known as a cardiac ultrasound it uses standard ultrasound techniques to image two-dimensional slices of Unfortunately, this research is over 20 years old and it is possible that changes in the epidemiology of endocarditis and bacteria such as staphylococcus make the following estimates incorrectly low. Staphylococcus (in Greek σταφυλη staphyle means bunch of grapes and κοκκος coccos means granule is a genus of Gram-positive

Among patients who do not use illicit drugs and have a fever in the emergency room, there is a less than 5% chance of occult endocarditis. Mellors [7] in 1987 found no cases of endocarditis nor of staphylococcal bacteremia among 135 febrile patients in the emergency room. Staphylococcus (in Greek σταφυλη staphyle means bunch of grapes and κοκκος coccos means granule is a genus of Gram-positive The upper confidence interval for 0% of 135 is 5%, so for statistical reasons alone, there is up to a 5% chance of endocarditis among these patients. In contrast, Leibovici [6] found that among 113 non-selected adults admitted to the hospital because of fever there were two cases (1. 8% with 95%CI: 0% to 7%) of endocarditis.

Among patients who do use illicit drugs and have a fever in the emergency room, there is about a 10% to 15% prevalence of endocarditis. This estimate is not substantially changed by whether the doctor believes the patient has a trivial explanation for their fever[5]. Weisse[3] found that 13% of 121 patients had endocarditis. Marantz [5] also found a prevalence of endocarditis of 13% among such patients in the emergency room with fever. Samet [4] found a 6% incidence among 283 such patients, but after excluding patients with initially apparent major illness to explain the fever (including 11 cases of manifest endocarditis), there was a 7% prevalence of endocarditis.

Among patients with staphylococcal bacteremia (SAB), one study found a 29% prevalence of endocarditis in community-acquired SAB versus 5% in nosocomial SAB[8]. However, only 2% of strains were resistant to methicillin and so these numbers may be low in areas of higher resistance.

Echocardiography
The transthoracic echocardiogram has a sensitivity and specificity of approximately 65% and 95% if the echocardiographer believes there is 'probabable' or 'almost certain' evidence of endocarditis[9][10].

[Discussion is needed here, including transthoracic versus transesophageal]

Blood Cultures:-

ECGs (MI)

Chest X-Ray (Pulmonary Embolism at Right sided failure)

Duke's Criteria

Major Criteria

Positive blood culture for Infective Endocarditis Typical microorganism consistent with IE from 2 separate blood cultures, as noted below:

  • 2 positive cultures of blood samples drawn >12 hours apart, or
  • all of 3 or a majority of 4 separate cultures of blood (with first and last sample drawn 1 hour apart)

Evidence of endocardial involvement Positive echocardiogram for IE defined as :

Minor Criteria

Micro-organisms responsible

Many types of organism can cause infective endocarditis. A HACEK organism is one of a set of slow-growing Gram negative bacteria that form a normal part of the Human flora. Glomerulonephritis, also known as glomerular nephritis, abbreviated GN, is a renal disease characterized by Inflammation of the glomeruli In Medicine, an embolism occurs when an object (the embolus, plural emboli) migrates from one part of the Body (through circulation These are generally isolated by blood culture, where the patient's blood is removed, and any growth is noted and identified. Blood culture is Microbiological culture of Blood. It is employed to detect Infections that are spreading through the bloodstream ( Bacteremia,

Alpha-haemolytic streptococci, that are present in the mouth will often be the organism isolated if a dental procedure caused the bacteraemia. Streptococcus is a Genus of spherical Gram-positive bacteria belonging to the phylum Firmicutes and the

If the bacteraemia was introduced through the skin, such as contamination in surgery, during catheterisation, or in an IV drug user, Staphylococcus aureus is common.

A third important cause of endocarditis is Enterococci. Enterococcus is a Genus of Lactic acid bacteria of the phylum Firmicutes. These bacteria enter the bloodstream as a consequence of abnormalities in the gastrointestinal or urinary tracts. Enterococci are increasingly recognized as causes of nosocomial or hospital-acquired endocarditis. This contrasts with alpha-haemolytic streptococci and Staphylococcus aureus which are causes of community-acquired endocarditis.

Some organisms, when isolated, give valuable clues to the cause, as they tend to be specific.

Treatment

High dose antibiotics are administered by the intravenous route to maximize diffusion of antibiotic molecules into vegetation(s) from the blood filling the chambers of the heart. In modern usage an antibiotic is a Chemotherapeutic agent with activity against Microorganisms such as Bacteria, fungi or Protozoa This is necessary because neither the heart valves nor the vegetations adherent to them are supplied by blood vessels. Antibiotics are continued for a long time, typically two to six weeks. Specific drug regimens differ depending on the classification of the endocarditis as acute or subacute (acute necessitating treating for Staphylococcus aureus with oxacillin or vancomycin in addition to gram-negative coverage). Oxacillin sodium (trade name Bactocill) is a narrow spectrum Beta-lactam antibiotic of the Penicillin class Vancomycin ( INN) (ˌvæŋkoʊˈmaɪsɪn is a Glycopeptide Antibiotic used in the Prophylaxis and treatment of infections caused by Gram-negative bacteria are those Bacteria that do not retain Crystal violet dye in the Gram staining protocol Fungal endocarditis requires specific anti-fungal treatment, such as amphotericin B. A fungus (ˈfʌŋgəs is a eukaryotic Organism that is a member of the kingdom Fungi (ˈfʌndʒaɪ Amphotericin B (Fungilin Fungizone Abelcet AmBisome Fungisome Amphocil Amphotec is a Polyene Antifungal drug, often used Intravenously

In acute endocarditis, due to the fulminant inflammation empirical antibiotic therapy is started immediately after the blood has been drawn for culture. This usually includes oxacillin and gentamicin IV infusions until the culture sensitivity report with the minimum inhibitory concentration comes, when the therapy can be modified to tailor to the microorganism. Minimum inhibitory concentration ( MIC) in Microbiology, is the lowest Concentration of an Antimicrobial that will inhibit the visible growth A microorganism (also spelled micro organism or micro-organism and also called a microbe) is an Organism that is Microscopic (usually

In subacute endocarditis, antibiotic treatment is based on the microorganism involved, requiring the culture sensitivity report. A microorganism (also spelled micro organism or micro-organism and also called a microbe) is an Organism that is Microscopic (usually So immediate therapy is mainly focused on symptomatic treatment.

The most common organism responsible for Infective Endocarditis is Streptococcus viridans, which is highly sensitive to Penicillin. Streptococcus viridans is a pseudo-taxonomic term for a large group of generally non-pathogenic Commensal streptococcal bacteria Penicillin (sometimes abbreviated PCN or pen) is a group of Beta-lactam antibiotics used in the treatment of Bacterial Infections High dose IV Crystalline Penicillin 20L every 4hrs for 2 weeks is recommended and still remains the drug of choice. Penicillin (sometimes abbreviated PCN or pen) is a group of Beta-lactam antibiotics used in the treatment of Bacterial Infections Again it is important to note that antibiotic therapy hinges upon the culture sensitivity report.

Another regimen that is followed for endocarditis is the short course treatment[14] which is a 2 week treatment regimen of benzyl penicillin IV which may be sufficient for Streptococcus viridans and Streptococcus bovis so long as the following conditions are met:

‣ Endocarditis of a native valve, not on a prosthetic valve

‣ An MIC ≤ 0. Penicillin (sometimes abbreviated PCN or pen) is a group of Beta-lactam antibiotics used in the treatment of Bacterial Infections Streptococcus viridans is a pseudo-taxonomic term for a large group of generally non-pathogenic Commensal streptococcal bacteria Streptococcus bovis is a Catalase - and Oxidase -negative non-motile non- sporulating, Gram-positive Lactic acid bacterium Minimum inhibitory concentration ( MIC) in Microbiology, is the lowest Concentration of an Antimicrobial that will inhibit the visible growth 1 mg/l

‣ No adverse prognostic factors such as heart failure, aortic valve regurgitation, or conduction defects

‣ No evidence of thromboembolism

‣ No vegetations > 5mm in diameter

‣ Clinical response within 7 days

The short course treatment In patients where the blood culture reveals the causative organism, culture sensitivity reports should be followed to treat the patient, in addition to usage of two bactericidal antibiotics for a minimum of two weeks as a combination therapy. Heart failure is a Cardiac condition that occurs when a problem with the structure or function of the Heart impairs its ability to supply A heart block is a disease in the electrical system of the Heart. Thrombosis is the formation of a blood Clot ( Thrombus) inside a Blood vessel, obstructing the flow of Blood through the Circulatory Blood culture is Microbiological culture of Blood. It is employed to detect Infections that are spreading through the bloodstream ( Bacteremia,

Surgical debridement of infected material and replacement of the valve is necessary in patients who fail to clear micro-organisms from their blood in response to antibiotic therapy, or in patients who develop cardiac failure resulting from destruction of a valve by infection. A removed valve is usually replaced with an artificial valve which may either be mechanical (metallic) or obtained from an animal such as a pig; the latter are termed bioprosthetic valves. Other indications to consider surgery include[14]:

‣ Unstable Prosthetic Valve or Obstruction

‣ Recurrent septic emboli, mycotic aneurysm

‣ Large vegetations

‣ Abscess formation

‣ Early closure of mitral valve

‣ Gram negative species

Infective endocarditis is associated with a 25% mortality. In Medicine, an embolism occurs when an object (the embolus, plural emboli) migrates from one part of the Body (through circulation

Non-infective endocarditis

Non-infective or marantic endocarditis is rare. A rare disease (sometimes known as an orphan disease has such a low Prevalence in a population that a doctor in a busy General practice would not A form of sterile endocarditis is termed Libman-Sacks endocarditis; this form occurs more often in patients with lupus erythematosus and the antiphospholipid syndrome. Libman-Sacks endocarditis is a form of nonbacterial Endocarditis that is seen in systemic lupus erythematosus. Systemic lupus erythematosus ( SLE or lupus,) is a chronic autoimmune disease that can be fatal though with recent medical advances fatalities are becoming Antiphospholipid syndrome (APS or APLS or antiphospholipid antibody syndrome is a disorder of Coagulation, which causes blood clots ( Thrombosis) in both Non-infective endocarditis may also occur in patients with cancers, particularly mucinous adenocarcinoma.

References

  1. ^ a b c Kasper, Dennis L. ; Eugene Brunwald, Anthony S. Fauci, Stephen Hauser, Dan L. Longo, J. Larry Jameson (2005). Harrison's Principles of Internal Medicine. Harrison's Principles of Internal Medicine is an American Textbook of Internal medicine. McGraw-Hill, pp. The McGraw-Hill Companies Inc, ( is a Publicly traded corporation headquartered in Rockefeller Center in New York City. 731-740. ISBN 0-07-139140-1.  
  2. ^ Durack D, Lukes A, Bright D (1994). "New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service. ". Am J Med 96 (3): 200-9. PMID 8154507.  
  3. ^ a b Weisse A, Heller D, Schimenti R, Montgomery R, Kapila R (1993). "The febrile parenteral drug user: a prospective study in 121 patients. ". Am J Med 94 (3): 274-80. PMID 8452151.  
  4. ^ a b Samet J, Shevitz A, Fowle J, Singer D (1990). "Hospitalization decision in febrile intravenous drug users. ". Am J Med 89 (1): 53-7. doi:10.1016/0002-9343(90)90098-X. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document. PMID 2368794.  
  5. ^ a b c Marantz P, Linzer M, Feiner C, Feinstein S, Kozin A, Friedland G (1987). "Inability to predict diagnosis in febrile intravenous drug abusers. ". Ann Intern Med 106 (6): 823-8. PMID 3579068.  
  6. ^ a b Leibovici L, Cohen O, Wysenbeek A (1990). "Occult bacterial infection in adults with unexplained fever. Validation of a diagnostic index. ". Arch Intern Med 150 (6): 1270-2. PMID 2353860.  
  7. ^ a b Mellors J, Horwitz R, Harvey M, Horwitz S (1987). "A simple index to identify occult bacterial infection in adults with acute unexplained fever. ". Arch Intern Med 147 (4): 666-71. PMID 3827454.  
  8. ^ Kaech C, Elzi L, Sendi P, Frei R, Laifer G, Bassetti S, Fluckiger U (2006). "Course and outcome of Staphylococcus aureus bacteraemia: a retrospective analysis of 308 episodes in a Swiss tertiary-care centre. ". Clin Microbiol Infect 12 (4): 345-52. doi:10.1111/j.1469-0691.2005.01359.x. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document. PMID 16524411.  
  9. ^ Shively B, Gurule F, Roldan C, Leggett J, Schiller N (1991). "Diagnostic value of transesophageal compared with transthoracic echocardiography in infective endocarditis. ". J Am Coll Cardiol 18 (2): 391-7. PMID 1856406.  
  10. ^ Erbel R, Rohmann S, Drexler M, Mohr-Kahaly S, Gerharz C, Iversen S, Oelert H, Meyer J (1988). "Improved diagnostic value of echocardiography in patients with infective endocarditis by transoesophageal approach. A prospective study. ". Eur Heart J 9 (1): 43-53. PMID 3345769.  
  11. ^ [http://wordnet.com.au/Products/topics_in_infectious_diseases_Aug01.htm Topics in Infectious Diseases Newsletter, August 2001, Pseudomonas aeruginosa.
  12. ^ Simon S. B. Chew, David Z. Lubowski (2001). Year 2001 ( MMI) was a Common year starting on Monday according to the Gregorian calendar. Clostridium septicum and malignancy.
  13. ^ Mirabelle Kelly, MD (June 7, 2005). Events 1099 - The First Crusade: The Siege of Jerusalem begins Year 2005 ( MMV) was a Common year starting on Saturday (link displays full calendar of the Gregorian calendar. HACEK Group Infections.
  14. ^ a b Boon, Nicholas A. ; Nicki R. Colledge, Brian R. Walker (2006). Davidson's Principles & Practice of Medicine. Churchill Livingstone Elsevier, pp. 629-633. ISBN 0-443-10057-8.  

External links

Dictionary

endocarditis

-noun

  1. (pathology, cardiology) An inflammation of the endocardium and possibly the heart valves.
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