ABC | Volume 112, Nº2, February 2019

Viewpoint Sobreiro et al Early diagnosis and treatment in endocarditis Arq Bras Cardiol. 2019; 112(2):201-203 Figure 1 – IE diagnosis flowchart. *Possible cases according to Duke’s criteria are all those that do not fit as definite or rejected cases. INFECTIVE ENDOCARDITIS PRE-EXISTING CARDIOPATHY CLINICAL SUSPICION FEVER+MURMUR SIGNS OF SYSTEMIC EMBOLIZATION + + + – – – – – BLOOD CULTURE TRANSTHORACIC ECHOCARDIOGRAM IE DIAGNOSIS DEFINITE DUKE TRANSESOPHAGEAL ECHOCARDIOGRAM SEROLOGIES POLYMERASE CHAIN REACTION RIBOSOMAL RNA SPECIAL CULTURES PET SCAN/CT MAGNETIC RESONANCE MULTISLICE TOMOGRAPHY REJECTED DUKE * CONSIDER ALTERNATIVE DIAGNOSIS Other imaging methods have also shown to be promising in the early diagnosis of patients with suspected IE that is difficult to be confirmed, such as multislice computed tomography (MSCT), magnetic resonance imaging (MRI) and positron‑emission computed tomography (PET/CT). 1 PET/CT has been shown to be particularly important in cases of patients with valve prostheses or cardiac devices with more than three months of implantation (Figure 1), in addition to the relevant potential in detecting extracardiac infectious foci, malignancy, and other types of inflammation. 7,9 When assessing prosthetic valve dysfunction, a recent study 6 suggested that MSCT may be equivalent or superior to the echocardiography to identify prosthesis-related vegetation, abscesses, pseudoaneurysms and dehiscence. However, there have been few studies comparing the two techniques and, therefore, the echocardiogram persists as the first-choice method in the investigation. 6 Thus, it is worth emphasizing that even the most modern imaging techniques are not always conclusive or unquestionably clarify the presence of endocarditis, particularly in these difficult-to-diagnose subgroups, such as the elderly and patients with implantable devices/catheters. In conclusion, the trinomial high clinical suspicion, microbiological and imaging methods remain essential for the early diagnosis in IE. The inclusion of new imaging and microbiological identification methods, associated to a multidisciplinary team consisting of cardiologists, infectologists, imaging specialists, microbiologists and other specialties, for specific cases, such as neurologists are crucial in this scenario. 6 We emphasize that the change in the course of IE prognosis depends on the rapid establishment of targeted therapy, which in turn is only possible when an early diagnosis is attained. 3 High-risk subgroups, such as the elderly and patients with implanted prosthetic material deserve special attention, as a delayed diagnosis has led to increased mortality. Thus, future guidelines should consider the inclusion of these new techniques in the diagnosis of IE. 2 Author contributions Conception and design of the research: Sampaio RO; acquisition of data: Sobreiro DI, Brazil CVA; analysis and interpretation of the data: Sobreiro DI, Brazil CVA; writing of the manuscript: Sobreiro DI, Sampaio RO, Lopes ASSA, Branco CEB; critical revision of the manuscript for intellectual contente: Sampaio RO, Tarasoutchi F, Strabelli TMV. Potential Conflict of Interest No potential conflict of interest relevant to this article was reported. 202