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Chapter 155: The Skin in Infective Endocarditis, Sepsis, Septic Shock, and Disseminated Intravascular Coagulation

Joseph C. English III; Misha Rosenbach

AT-A-GLANCE

AT-A-GLANCE

  • Infective endocarditis: staphylococcal, streptococcal, and enterococcal bacteria cause 80% of cases; intravenous drug use is the most common cause of right-sided infective endocarditis.

  • Sepsis: Gram-positive and Gram-negative bacteria, fungi, and viruses may cause sepsis; 10th leading cause of death in the United States for all races and sexes at age 45 years and older.

  • Disseminated intravascular coagulation: most commonly a consequence of sepsis; results from systemic activation of the coagulation cascade.

  • Cutaneous manifestations of these entities include: splinter hemorrhages, Janeway lesions, Osler nodules, erythroderma, cellulitis, purpura, hemorrhage, purpura fulminans, and skin necrosis.

INFECTIVE ENDOCARDITIS

DEFINITION AND HISTORICAL PERSPECTIVE

Infective endocarditis (IE) is defined as inflammation of the endocardial lining of the heart (naïve or prosthetic heart valves, mural endocardium) and implanted material caused by infection from bacteria or fungus.1,2 The historical definitions of IE as acute, subacute, and chronic IE have been discarded for a more appropriate description based on infectious agent and the infected endocardial structure.3,4

EPIDEMIOLOGY

The incidence of IE is 3 to 10 cases per 100,000 people.4,5 The male-to-female ratio is 2:1 and the incidence peaks at 194 cases per million in men 75 to 79 years of age.5 Pediatric cases are rare. Rheumatic heart disease in the setting oral cavity procedures is the most-common cause in low-income countries; however, IE is now more commonly seen in health care–associated cases in the setting of valvular heart disease, prosthetic valves, implantable pacemakers and defibrillators, hemodialysis, IV lines, and invasive procedures in higher-income countries.5 In addition, risk factors include a history of IE, diabetes, cancer, congenital heart disease, dental procedures, HIV disease, IV drug abuse.1,4-6

CLINICAL FEATURES

The most common clinical presentations of IE include fever and a new cardiac murmur; consequently, IE should be considered in the differential diagnosis of all fevers, embolic events of unknown origin, and patients with persistently positive blood cultures.5 The modified Duke criteria (Table 155-1),7 help make the diagnosis of IE. Newer reviews of the Duke criteria for diagnosing IE note its continual importance in identifying IE.2

Table 155-1Modified Duke Criteria for Infective Endocarditis
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Table 155-1 Modified Duke Criteria for Infective Endocarditis

A clinically definite case is defined as fulfilling 2 major, 1 major plus 3 minor, or 5 minor criteria.

  • A clinically suspicious case is defined as fulfilling 1 major and 1 minor, or 3 minor criteria

Major Criteria

  1. Microbiologic

    1. Two separate blood cultures positive for typical microorganism

      or

    2. Persistently positive blood culture for typical microorganism

      or

    3. Single positive blood culture for Coxiella burnetii or a Phase I immunoglobulin G antibody titer to C. burnetii ratio greater than 1:800

  2. Evidence of ...

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