Septic Emboli - Dr. Raper

When should I think about infective endocarditis and septic emboli?
-Consider in patients who raise your suspicion for sepsis and have any of these risk factors:

• age>60
• IVDA
• Poor dentition
• HIV/AIDS
• Immunosuppression
• Indwelling catheters/devices
• Structural Heart Disesase
• Chronic Hemodialysis
• Hx of endocarditis

 
 
What exam findings are suggestive of IE?
-Some are more specific than others.  Roth’s spots, Osler’s nodes, and Janeway lesions are relatively rare but are essentially illness defining.  More sensitive but less specific findings include cardiac murmors, petechiae, splenomegaly, and splinter hemorrhages.
 
Who gets septic emboli?
-Patients with large lesions, unstable/multiple lesions, and left sided lesions are most likely to embolize secondary to higher left sided pressure gradients.
 
Where do the emboli go, and what does that look like?
- Right sided lesions (without PFO) go to the lungs, and typically manifest clinically as:

• >2 imaging findings, often bilateral bilateral
• Cavitary lesions
• Nodules
• Infiltrate
• Empyema

 
-Left Sided lesions

• CNS (45% mortality)
  • Ischemic Stroke/TIA
  • ICH
  • Meningitis/Abscess
  • Mycotic Aneurysms
• Renal
  • Abdominal/Flank pain/Vomiting
  • Acute HTN (renal artery obstruction)
  • Hematuria/Proteinuria
• Spleen
  • Abdominal pain
  • Infarct leads to abscess, which requires drainage
• Mesentery
  • Pain out of proportion to exam
  • Surgical emergency
• Mycotic Aneurysm
  • Infected material embolizes to downstream artery
  • Infection and inflammation extends into vessel, weakening it
  • Leads to spontaneous bleeding and persistent infectious nidus
• Liver, Pancreas, Coronary Vessels, and Extremities are other less common embolic locations

 
Take Home Points

• Appropriately diagnosing and treating IE/SE requires vigilance and a high index of suspicion
• IE/SE is not just the disease of the young IVDA anymore
• Anything is possible, and not in a good way… …take all complaints seriously in suspected sepsis

 

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