RheunimLogy
Rheumatol Int (1992) 12:61-63
Clinical and Experimental Investigations
9 Springer-Verlag 1992
Rheumatic manifestations of infective endocarditis P.J. Roberts-Thomson, M. Rischmueller, R.A. Kwiatek, M. Soden, M.J. Ahern, W.R. Hill, and R.A. Geddes Unit of Rheumatology, Department of Medicine, Flinders Medical Centre, Bedford Park, 5042, Australia Received July 22, 1991/Accepted October 16, 1991
Summary. Rheumatic manifestations are c o m m o n and varied in infective endocarditis. We performed a retrospective case analysis on 87 patients with 93 episodes of infective endocarditis admitted to Flinders Medical Centre over an 11 year period (1980-1990). Disabling musculoskeletal s y m p t o m s and signs were documented in 22 (25 %) of the patients. Thirteen patients developed severe or moderately severe low back pain during their illness, two with radiological evidence of a septic discitis or vertebral osteomyelitis. Two patients developed polyarthralgia/arthritis, four had septic arthritis (all with acute Staphylococcus aureus endocarditis), three developed severe loin pain, two acute gout, two had severe buttock pain and sacroiliac joint tenderness and two each developed disabling jaw/facial pain, neck/scapular pain and flank pain respectively. Five patients presented initially to the orthopaedic or rheumatological unit for management of their musculoskeletal symptoms. F o u r of seven patients with Streptococcus boris endocarditis demonstrated prominent low back pain supporting a previously noted association between this organism and back symptoms. Furthermore, in one patient who had three separate episodes of endocarditis involving three different organisms, florid back symptoms were only seen in the infective episode involving Streptococcus boris.
recognised [2, 3]. We reviewed our experience of the prevalence of musculoskeletal manifestations of infective endocarditis. We also attempted to identify any association between these rheumatic manifestations and the nature, duration or laboratory features of the infections.
Methods The case notes of patients with infective endocarditis admitted to Flinders Medical Centre, a tertiary referral centre, between 1980 and 1990 inclusive were reviewed. Patients were identified from the hospital's diagnostic discharge index, the Systemized Nomenclature of Medicine (SNOMED) autopsy diagnostic index and the endocarditis files of the Department of Microbiology. A diagnosis of infective endocarditis was acccepted providing acceptable clinical, microbiological, serological and echocardiographic criteria were met [1]. The patients were divided into two groups: those with subacute bacterial endocarditis and those with acute bacterial endocarditis. The latter diagnosis was made in patients whose presenting symptoms were of short duration (less than 2 weeks) and where an organism of high virulence was isolated from the blood. The case notes of all patients were reviewed to determine duration of symptoms before presentation, the identity of the infecting organisms, the presence or absence of extracardiac manifestations (musculoskeletal, renal, cerebral, cutaneous or splenic involvement), serological findings and the course of the illness and response to antibiotics.
Key words: Infective endocarditis - L o w back pain Discitis - Musculoskeletal manifestations
Introduction Arthralgias and myalgias are c o m m o n l y acknowledged clinical features of infective endocarditis and are mentioned in most standard textbooks or reviews of this infection [1]. Polyarthritis, although occurring infrequently, is also another well recognised rheumatic manifestation thought to occur as a result of deposition of circulating immune complexes [1 -3]. Axial symptoms, including neck or back pain, occur frequently but are less well
Results A total of 87 patients with endocarditis were identified over the 11 year period; 32 o f w h o m developed 34 episodes of acute bacterial endocarditis and 55 of w h o m developed 59 episodes of subacute bacterial endocarditis (Table 1). A further two patients with endocarditis were not included due to the lack of availability of medical records. In general, musculoskeletal symptoms were poorly documented in the case records. This p o o r documentation was particularly evident when non-specific symptoms of myalgia and arthralgia were present, even when these s y m p t o m s were mentioned in the referring letter. However, symptomatic or disabling musculoskele-
62 tal s y m p t o m s and signs were documented in 22 (25%) of the patients. The most c o m m o n musculoskeletal finding was low back pain, observed in 13 of the patients (Table 2). In at least nine of these patients the pain was severe, associated with local tenderness and spasm of the Table 1. Clinical and laboratory features of patients with infective endocarditis
No. of episodes Female Male Mean age (years) Mean duration of symptoms at presentation (days) Heroin addiction Prior cardiac lesion Infecting organism Staph. aureus Strep. pyogenes Strep, agalactiae Strep. viridans Strep. sanguis Strep. mitis Strep. boris Strep. faecalis Strep. salivaris Strep. mutans Others Culture negative Musculoskeletal symptoms" (n =22) Low back pain Loin pain Buttock pain Septic arthritis Polyarthritis/arthralgia Gout Other symptoms Mean C-reactive protein (mg/l) (n
Rheumatol Int (1992) 12:61-63
Clinical and Experimental Investigations
9 Springer-Verlag 1992
Rheumatic manifestations of infective endocarditis P.J. Roberts-Thomson, M. Rischmueller, R.A. Kwiatek, M. Soden, M.J. Ahern, W.R. Hill, and R.A. Geddes Unit of Rheumatology, Department of Medicine, Flinders Medical Centre, Bedford Park, 5042, Australia Received July 22, 1991/Accepted October 16, 1991
Summary. Rheumatic manifestations are c o m m o n and varied in infective endocarditis. We performed a retrospective case analysis on 87 patients with 93 episodes of infective endocarditis admitted to Flinders Medical Centre over an 11 year period (1980-1990). Disabling musculoskeletal s y m p t o m s and signs were documented in 22 (25 %) of the patients. Thirteen patients developed severe or moderately severe low back pain during their illness, two with radiological evidence of a septic discitis or vertebral osteomyelitis. Two patients developed polyarthralgia/arthritis, four had septic arthritis (all with acute Staphylococcus aureus endocarditis), three developed severe loin pain, two acute gout, two had severe buttock pain and sacroiliac joint tenderness and two each developed disabling jaw/facial pain, neck/scapular pain and flank pain respectively. Five patients presented initially to the orthopaedic or rheumatological unit for management of their musculoskeletal symptoms. F o u r of seven patients with Streptococcus boris endocarditis demonstrated prominent low back pain supporting a previously noted association between this organism and back symptoms. Furthermore, in one patient who had three separate episodes of endocarditis involving three different organisms, florid back symptoms were only seen in the infective episode involving Streptococcus boris.
recognised [2, 3]. We reviewed our experience of the prevalence of musculoskeletal manifestations of infective endocarditis. We also attempted to identify any association between these rheumatic manifestations and the nature, duration or laboratory features of the infections.
Methods The case notes of patients with infective endocarditis admitted to Flinders Medical Centre, a tertiary referral centre, between 1980 and 1990 inclusive were reviewed. Patients were identified from the hospital's diagnostic discharge index, the Systemized Nomenclature of Medicine (SNOMED) autopsy diagnostic index and the endocarditis files of the Department of Microbiology. A diagnosis of infective endocarditis was acccepted providing acceptable clinical, microbiological, serological and echocardiographic criteria were met [1]. The patients were divided into two groups: those with subacute bacterial endocarditis and those with acute bacterial endocarditis. The latter diagnosis was made in patients whose presenting symptoms were of short duration (less than 2 weeks) and where an organism of high virulence was isolated from the blood. The case notes of all patients were reviewed to determine duration of symptoms before presentation, the identity of the infecting organisms, the presence or absence of extracardiac manifestations (musculoskeletal, renal, cerebral, cutaneous or splenic involvement), serological findings and the course of the illness and response to antibiotics.
Key words: Infective endocarditis - L o w back pain Discitis - Musculoskeletal manifestations
Introduction Arthralgias and myalgias are c o m m o n l y acknowledged clinical features of infective endocarditis and are mentioned in most standard textbooks or reviews of this infection [1]. Polyarthritis, although occurring infrequently, is also another well recognised rheumatic manifestation thought to occur as a result of deposition of circulating immune complexes [1 -3]. Axial symptoms, including neck or back pain, occur frequently but are less well
Results A total of 87 patients with endocarditis were identified over the 11 year period; 32 o f w h o m developed 34 episodes of acute bacterial endocarditis and 55 of w h o m developed 59 episodes of subacute bacterial endocarditis (Table 1). A further two patients with endocarditis were not included due to the lack of availability of medical records. In general, musculoskeletal symptoms were poorly documented in the case records. This p o o r documentation was particularly evident when non-specific symptoms of myalgia and arthralgia were present, even when these s y m p t o m s were mentioned in the referring letter. However, symptomatic or disabling musculoskele-
62 tal s y m p t o m s and signs were documented in 22 (25%) of the patients. The most c o m m o n musculoskeletal finding was low back pain, observed in 13 of the patients (Table 2). In at least nine of these patients the pain was severe, associated with local tenderness and spasm of the Table 1. Clinical and laboratory features of patients with infective endocarditis
No. of episodes Female Male Mean age (years) Mean duration of symptoms at presentation (days) Heroin addiction Prior cardiac lesion Infecting organism Staph. aureus Strep. pyogenes Strep, agalactiae Strep. viridans Strep. sanguis Strep. mitis Strep. boris Strep. faecalis Strep. salivaris Strep. mutans Others Culture negative Musculoskeletal symptoms" (n =22) Low back pain Loin pain Buttock pain Septic arthritis Polyarthritis/arthralgia Gout Other symptoms Mean C-reactive protein (mg/l) (n
