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Infective endocarditis in children--incidence, pattern, diagnosis and management in a developing country
1Department of Paediatric Cardiology, Punjab Institute of Cardiology, Lahore, Pakistan. drmasood@wol.net.pk
Insights
Infective endocarditis affects children in developing nations, with rheumatic heart disease being a common cause. Echocardiography is more sensitive than blood cultures for diagnosis, and mortality remains high.
Area of Science:
- Pediatric Cardiology
- Infectious Diseases
- Cardiovascular Medicine
Background:
- Infective endocarditis (IE) presents diagnostic challenges in developing countries due to late referrals, low blood culture yields, and high rheumatic heart disease (RHD) incidence.
- IE diagnosis in pediatric populations requires careful consideration of specific epidemiological factors and diagnostic limitations.
Purpose of the Study:
- To evaluate the clinical presentation and diagnostic criteria for infective endocarditis in a pediatric tertiary referral center.
- To determine the outcomes and identify prognostic factors for infective endocarditis in this setting.
Main Methods:
- A retrospective analysis of pediatric patients diagnosed with infective endocarditis between April 1997 and March 2000.
- Diagnosis was based on modified Duke's criteria, including expanded minor criteria like acute phase reactants and splenomegaly.
- Patients were categorized as definite, possible, or rejected IE cases.
Main Results:
- The incidence of IE was 32 per 1000 hospital admissions (3.2%).
- Rheumatic heart disease (53%) and congenital heart disease (45%) were the predominant underlying cardiac lesions.
- Blood cultures yielded positive results in 47% of cases, while echocardiography detected vegetations in 71%.
- Overall mortality was 13%, with a 30% mortality rate in patients with aortic valve involvement.
Conclusions:
- Infective endocarditis has a significant incidence in pediatric cardiology centers in developing regions, with RHD as a major underlying condition.
- Echocardiography proves more sensitive than blood cultures for IE diagnosis in this population.
- High mortality rates persist, particularly with aortic valve involvement, underscoring the need for improved diagnostic and therapeutic strategies.
Background:
In developing countries, patients with infective endocarditis are referred late, there is low yield of blood cultures and incidence of rheumatic heart disease is still high.
Objective:
Evaluate clinical pattern, assess diagnostic criteria in our settings and determine outcome.
Setting:
A tertiary referral center for paediatric and adult cardiology.
Patients And Methods:
All children with infective endocarditis admitted to a single center from April 1997 to March 2000 were analysed. The diagnosis was based on Duke's criteria, which proposed two major and six minor criteria. Minor criteria were expanded to include raised acute phase reactants and presence of newly diagnosed or increasing splenomegally. The patients were stratified as definite, possible and rejected cases.
Results:
Of 1402 hospital admissions, 45 patients fulfilled the diagnostic criteria for infective endocarditis giving an incidence of 32 per 1000 hospital admissions. The mean age was 7.9 +/- 4 years (4 months to 16 years) with only two patients under 1 year of age. Rheumatic heart disease was the underlying lesion in 24 patients (53%) while congenital heart lesions occurred in 20 patients (45%). Previous antibiotic treatment was given in 26 patients (58%) definitely. Blood cultures were positive in 21 patients (47%); Streptococcus Viridans being the most common organism, while vegetations on echocardiography were present in 32 patients (71%). Surgery was undertaken in four patients and five patients left against medical advise. Of 10 patients with aortic valve involvement, there were three deaths (30%) and overall mortality was 13% (six patients).
Conclusions:
The incidence of infective endocarditis is 32 per 1000 (3.2%) hospital admissions in a tertiary paediatric cardiology referral center. Rheumatic heart disease is still the most common underlying heart lesion. Blood cultures are positive in less than 50% of cases and echocardiography in expert hands is a more sensitive tool in our set up. Mortality is still high and aortic valve involvement in particular, carried poor prognosis.