Introduction

Infective endocarditis is a rare condition which affects the heart's membrane, where a type of infection occurs in the heart. Bacterial infection can be the main cause with 30% of cases being caused by a bacterium called Staphylococcus aureus, fungi can also cause this condition.

In children, it can be even more rare. Let us understand what happens when it affects children.

What causes infective endocarditis?

Infective endocarditis is considered as a rare condition that affects people assigned male at birth twice to the people assigned female at birth.¹

Most cases of infective endocarditis happen because of bacterial infections (mainly caused by bacteria called streptococci, staphylococci, and enterococci) making about 80 to 90% of all cases and with bacterium Staphylococcus aureus being the major culprit with 30% of cases worldwide.¹

Other bacteria that cause infective endocarditis are a group of bacteria called HACEK (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, and Kingella). These bacteria are less prone to cause infection but can still be a factor.

Other cases can be caused by fungal infection, which is called fungal endocarditis..These cases make up only 1% of overall cases. It can be a complication of Candida or Aspergillus (two fungal organisms) and it can be fatal.¹

What are the risk factors?

Risk factors are usually environments that play a role in causing bacterial infection in children. Common environments of infections can be in healthcare or community (Lack of clarity is there in the previous sentence), but it is most likely to happen in a healthcare setting.

In fact, bacteria can enter the blood through surgical procedures such as in case of heart valve operations, most likely to happen in the first 60 days after the operation, or following cardiac interventions; other common ways in which bacteria enter the bloodstream can include:^1,2

• Dental procedures
• Tonsil or adenoid gland surgery
• Invasive medical procedures, such as the examination of airways or bronchoscopy (a procedure and an instrument cannot be written as alternative)
• Surgery, which includes respiratory, urinary tract, or gastrointestinal surgery

Some children can be more at risk of contracting bacterial endocarditis if they have:

• Congenital heart disease
• Artificial (prosthetic) heart valve
• Heart transplant, with malfunction of heart valve
• Venous caterer
• Rheumatic heart disease
• Past Endocarditis
• Weak immune system¹

How does infective endocarditis start?

Infective endocarditis is usually caused by damage of the heart membrane called the endocardium, this can result from trauma caused by medical procedures such as the insertion of catheters, or placement of electrodes, turbulent, or faulty blood flow around a sick heart or damage from the repetitive injection of drugs which can lead to the growth of bacteria.

Areas of the heart with turbulent blood flow, where there is less blood flow have a higher chances of getting damaged, usually being the point of start of the infection.

After the heart gets damaged because of these factors platelets (blood cells in charge of clotting and scarring, and healing) clump together to form clots in the damaged heart tissue, however this can end up attracting bacteria, in fact bacteria can stick to clots, grow and cause significant infections, damaging even more the tissue.¹

As we said previously, bacteria can enter the body from various procedures or simply be already present in the body, such as bacteria can enter the bloodstream from the mouth, skin, intestines, respiratory, or urinary tract.³

What are the signs and symptoms of infective endocarditis?

Infective endocarditis can be highly influenced by your child's age, with the teenage group having symptoms similar to those of adults, these symptoms can include:

• Fever
• Loss of appetite and general discomfort
• Fatigue
• Growth retardation

In newborns, symptoms can be difficult to detect and not specific, but common symptoms can include:

• Accelerated heartbeat
• Feeding refusal
• Vomiting
• High fever

In children, the younger the age, the harder it can become to reach this diagnosis. Symptoms can change from child to child, and other symptoms that can occur in children of any age are:

• Flu-like symptoms
• Skin changes - bumps on fingers and toes, spots on palms of hands and soles of feet
• Cough
• Shortness of breath
• Small broken blood vessels
• Bloody urine
• Swelling in feet, legs or abdomen^2,4

Which complications can occur in bacterial endocarditis?

As in any disease, bacterial endocarditis can lead to several complications, which can include:

• Blood clots or bacteria traveling to other parts of the body (arms, legs, bowel, spleen. brain, or heart arteries)
• Kidney disease
• Infections in other parts of the heart
• Weak blood vessels in the brain (aneurysm)
• Heart failure
• Death²

How is infective endocarditis diagnosed?

The doctor asks about the child’s symptoms and health history, conducts a physical examination, and listens to their heart. Common tests may also be conducted.

• Echocardiogram, looks at the structure of the heart and its function, using sound waves to create a moving picture of heart and heart valves
• Complete blood count, looks at cell in the blood
• Blood culture, infections in blood
• Electrocardiogram (also known as ECG or EKG), a painless procedure to measure the electrical activity of the heart. It is not specific to endocarditis but can show abnormalities affecting the heart
• X-Ray, It can help the doctor understand if there is swelling in the lungs and heart or the infection has spread to lungs
• Computerized tomography CT scan or magnetic resonance imaging MRI are only used if the infection is suspected to have spread in other body parts⁵

The symptoms of this infection can be very similar to those of common conditions making its diagnosis very difficult (exemplify the common conditions).

Because of the complexity of the diagnosis of infective endocarditis in children, the Duke criteria can be used, this method can combine lab findings with imaging studies. This diagnostic method is usually used in adults, and it might be useful for teens, but it might be less indicated for younger children.

How can infective endocarditis be treated?

Treatment of infective endocarditis can depend on your child’s symptoms, age, health condition and the severity of his condition. Treatments can include:

• Antibiotics- antibiotics can be given through IV (intravenous) for a few weeks (2 to 6 weeks). This needs the patient to be kept under doctor’s supervision. In case of fungal infection child is prescribed antifungal medicine⁵
• Surgery - some children could need a heart valve replacement through surgery, when the damage is very severe or if for some reason the infection can’t be removed
  • The symptoms lead to heart failure (the heart is not pumping blood around the body
  • Continued fever even with treatment (antibiotics or antifungals)
  • Endocarditis caused by strong bacteria or fungi
  • 1 or more blood clots
  • Child has a prosthetic heart valve⁵

Surgeries can

• Repair the damage in the heart valve
• Replacement of the heart valve with an artificial heart valve
• Drain abscess (pus) in the heart and repair abnormal passageways developed in the heart^5,2

Can infective endocarditis be prevented?

There is no real process of prevention for infective endocarditis, but a few things can slightly reduce the risk. These include:

• Helping your child take care of their gums and teeth
• Have your child get regular checkups from the dentist
• Have good hygiene
• Take full antibiotic prescriptions to treat conditions such as strep throat

If your child has heart problems, consult with your doctor before any dental procedure, as some children will need antibiotics before dental or medical procedures.²

Managing infective endocarditis in children

Because of this severe infection, your child might need ongoing care, which can include:

• Repeated and regular checkups
• Repeated dental checkups
• Maintenance of good oral hygiene
• Repeated echocardiograms

Summary

Infective endocarditis is a very rare condition which can affect anyone but can be more prevalent in AMAB. This condition affects the heart’s membrane and can be caused by bacterial and fungal infections. In rare cases, children can be affected too. Damage to the heart, turbulent blood flow, and repetitive injection of drugs can all be risk factors for this disease, and symptoms can be very difficult to diagnose especially in younger children. If you suspect that your child has infective endocarditis, it is important to intervene immediately by seeking medical attention.