The cl inical manifestations of infective endocarditis are diverse and may involve almost any organ system. Symptoms of endocarditis usu¬ally occur within 2 wk of the inciting bacteremia, although diagnosis may take much longer. Fever is the single most common finding. Non¬specific generalized complaints of anorexia, fatigue, confusion, weight loss, and night sweats are also common. Because the presentation is sometimes atypical (eg. without fever), infective endocarditis in the el¬derly may not be recognized and treated until it has progressed to a late stage. In these cases, it has an extremely poor prognosis.
On physical examination, cardiac murmurs are found in > 90% of patients, due to a predisposing valvular abnormality or to the infection itself. Murmurs are no! found in most patients with tricuspid valve en¬docarditis. New or changing cardiac murmurs are described in 36% to 52% of infective endocarditis cases diagnosed by strict clinical criteria, although these murmurs are heard less frequently in the elderly. The symptoms and signs of heart failure may also be presenl. occurring sec¬ondary to underlying heart disease or valvular destruction. Splenic en¬largement occurs in 25% to 60% of patients, correlating with longer durations of infection.
About 50% of patients with infective endocarditis have cutaneous or peripheral manifestations. Petechiaearc most common, arising in crops and found on the conjunctivae, palate, buccal mucosa, extremities, and skin above the clavicles. Splinter hemorrhages appear as linear, dark streaks beneath the fingernails or toenails; however, these lesions are also common in noninfected elderly persons and in those with occupa¬tion-related trauma. Osier’s nodes—small, tender subcutaneous nod¬ules that develop in the pulp of Ihe digits or on the thenar eminences— contrast with Janeway lesions—small, hemorrhagic, or erythematous nonlender macules on the palms or soles. Janeway lesions are due to septic emboli and are associated more often with acute endocarditis, especially that caused by 5. aureus. Ophthalmologic examination may reveal pale-centered, oval hemorrhages {Roth spots) on the retina. Al-

Infective Endocarditis   497
though Roth spots are highly suggestive of infective endocarditis, they are also seen in patients with collagen-vascular and hematologic dis¬orders.
Other clinical manifestations may involve other organ systems as a result of thromboembolic phenomena. Rmboli to the spleen may cause left upper quadrant abdominal pain radiating to the shoulder, a splenic friction rub, or signs of a left pleural effusion. Rmboli to Ihe kidney may cause flank or back pain, suggesting renal infarction. Patients with tricuspid valve endocarditis may develop pulmonary emboli and pre¬sent with dyspnea, cough, pleuritic chest pain, and hemoptysis, espe¬cially if pulmonary infarction has occurred.
Cerebral embolism and rupture of an intracranial mycotic aneurysm are devastating complications, and the palient may present with the signs of a cerebrovascular accident; (his may distract the clinician from Ihe infectious cause of the disease. Fever and a stroke syndrome in any patient should warrant consideration of Ihe possibility of infective en¬docarditis. Most cerebral emboli involve the distribution of the middle cerebral artery or one of its branches. Clinical signs of emboli include hemiparesis. cranial nerve palsies, corticosensory loss, aphasia, ataxia, alterations in mental status, or a combination thereof. Persistent headache may be the only symptom signifying an intracranial mycotic aneurysm before rupture.