Differentials
Rheumatic fever
SIGNS / SYMPTOMS
Patients with rheumatic heart disease may present very similarly with predominantly constitutional symptoms. Jones criteria are diagnostic and consist of carditis, polyarthritis, chorea, erythema marginatum, subcutaneous nodules, and evidence of preceding streptococcal infection.[46]
INVESTIGATIONS
Positive antistreptolysin O antibodies or anti-DNAase B.
Echocardiogram may demonstrate evidence of congestive heart failure with globalised carditis, but generally lacks specific vegetations seen with IE.
Endomyocardial biopsy will reveal pathognomonic Aschoff bodies, which are persistent local inflammatory lesions.
Atrial myxoma
SIGNS / SYMPTOMS
Patients may present with constitutional symptoms secondary to cytokine release or may have systemic disease secondary to embolic phenomenon.
Often patients will describe waxing and waning symptoms as opposed to the subacute progressive nature of IE.
INVESTIGATIONS
CXR may demonstrate characteristic calcifications within the heart or a small atrium.
Echocardiography with subsequent histological examination is the most specific and sensitive test for diagnosis of atrial myxoma.
Libman-Sacks endocarditis
SIGNS / SYMPTOMS
Patients are commonly asymptomatic, and have history suggestive of a diagnosis of systemic lupus erythematosus.
Patients with a positive antiphospholipid antibody may report repeated miscarriages, venous thrombosis, or thrombocytopenia.
INVESTIGATIONS
Often will have positive auto-antibody profile including antinuclear antibody, antidouble-stranded DNA antibody, and anticardiolipin antibody with associated valvular disease.
Immunohistochemical staining will demonstrate a lack of neutrophil and characteristic anti-inflammatory response seen in IE.
Non-bacterial thrombotic endocarditis (NBTE; marantic endocarditis)
SIGNS / SYMPTOMS
Endocarditis in which sterile vegetations are deposited on cardiac valves. The most common tumours producing NBTE are pancreatic, lung, and colon, so patients may report signs and symptoms consistent with those underlying conditions.
Other associations include systemic lupus erythematosus (Libman-Sacks endocarditis) and other chronic diseases such as tuberculosis and AIDS.
Also may report symptoms of underlying hypercoagulable state such as recurrent deep venous thrombosis, accelerated atherosclerosis, premature coronary artery disease, myocardial infarction, or stroke.[47]
INVESTIGATIONS
There is no destruction of the affected valve and no associated bacteraemia. Patients often have underlying carcinomas or hypercoagulable state, so CT scan of chest, abdomen and pelvis may demonstrate a primary tumour responsible for underlying pathology, which is thought to be secondary to mucin production with subsequent embolic phenomenon.
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