Clinical Presentation of Pediatric Infective Endocarditis

Infective endocarditis in children can be categorized into two main types: acute and subacute. The acute form typically presents with a sudden onset of symptoms, including high fever, chills, and signs of systemic toxicity. This type of infection can progress rapidly, often masking typical heart-related symptoms at the beginning. Within a short period, heart murmurs may develop, and the condition can quickly lead to acute congestive heart failure, which can be fatal if not promptly treated.

Changing Trends Due to Antibiotic Use

Thanks to the widespread use of antibiotics, acute infective endocarditis has become relatively rare in clinical settings. Most cases diagnosed today are of the subacute type, which tends to develop more gradually and subtly. This slower progression can make diagnosis more challenging, especially in pediatric patients who may not clearly communicate their symptoms.

Recognizing Subacute Infective Endocarditis

Children with subacute infective endocarditis often experience non-specific symptoms such as general malaise, fatigue, low-grade fever, and unexplained weight loss. One of the more distinctive features of this condition is the potential for embolic manifestations, as infected material can break off and travel through the bloodstream to various organs.

Skin Manifestations

When emboli reach the skin, they may appear as small, scattered petechiae or as Osler's nodes—small, raised, red nodules typically found on the pads of the fingers or toes. These physical findings can be crucial clues in diagnosing endocarditis when considered alongside other clinical indicators.

Internal Organ Involvement

When emboli affect internal organs, symptoms can vary significantly. Splenomegaly (enlarged spleen) is a common finding, sometimes accompanied by abdominal pain or hematuria (blood in the urine). In some cases, children may present primarily with an enlarged spleen while showing minimal other systemic symptoms, highlighting the importance of maintaining a high index of suspicion for endocarditis during diagnosis.

Pulmonary and Neurological Complications

Pulmonary embolism can cause chest pain, coughing, hemoptysis (coughing up blood), and abnormal lung sounds. Cerebral embolism, on the other hand, may result in neurological symptoms such as dizziness, headache, hemiparesis (paralysis on one side of the body), aphasia (difficulty speaking), seizures, or even coma—symptoms that can mimic those of encephalitis.

Diagnostic Considerations in Pediatric Patients

It's important to note that children may present with isolated symptoms that don't immediately suggest heart disease. For example, a child might complain only of headache and vomiting without any other obvious clinical signs. In such cases, careful cardiac auscultation is essential to detect any abnormal heart murmurs.

Comprehensive evaluation should include a thorough medical history to identify potential risk factors such as persistent low-grade fever, chest discomfort, or inappropriate antibiotic use. By gathering all available clinical information and carefully analyzing the patient's presentation, healthcare providers can improve diagnostic accuracy and reduce the likelihood of misdiagnosis or missed diagnosis.