Infective Endocarditis in Southern Morocco: The Ongoing Burden of Rheumatic Heart Disease

Abstract

Background:
Infective endocarditis (IE) remains a life-threatening infection of the endocardium and cardiac valves, with substantial morbidity and persistently high mortality. In regions where rheumatic heart disease (RHD) persists, it continues to be a major substrate for IE, including among patients with prosthetic valves implanted for rheumatic indications.

Aims:
To evaluate the frequency of major risk factors for IE, particularly RHD, and to describe the epidemiological and echocardiographic profile of IE in a tertiary-care hospital in Southern Morocco.

Methods:
We performed a retrospective descriptive study in the Cardiology Department of Souss Massa (Agadir, Morocco) university hospital, including patients managed between September 2022 and December 2025 with definite or possible IE according to the modified Duke criteria. Demographic characteristics, underlying cardiac conditions, clinical presentation, microbiological findings, echocardiographic features, management, and in-hospital outcomes were extracted from medical records.

Results:
34 patients were included (mean age 45 years), with male predominance (21 patients, 61.8%). A pre-existing cardiac condition was present in 28 patients (82.4%), and RHD was the most common underlying disease (14 patients, 41.2%). Prosthetic valve endocarditis was identified in 8 patients (23.5%); 7 of these (87.5%) had prosthetic valves implanted for rheumatic valvular disease. Left-sided IE predominated, mainly involving the mitral and aortic valves. Vegetations were detected in 31 patients (91.2%); significant valvular regurgitation was present in 32 patients (94.1%). Echocardiography showed perivalvular abscesses in 4 patients (11.8%) and valvular perforations in 2 patients (5.9%). Blood cultures were obtained in all patients; 29 patients (85.3%) were culture-positive, most commonly Staphylococcus aureus. All patients received intravenous antibiotics; penicillin plus gentamicin was the most frequent empirical regimen (25 patients, 73.5%). Surgery was indicated in 4 patients (11.8%). In-hospital mortality was 5.9% (2 patients).

Conclusion:
In Southern Morocco, IE predominantly affects relatively young patients and remains closely linked to RHD, including among those with prosthetic valves placed for rheumatic disease. The high proportion of RHD among IE cases highlights the ongoing burden of rheumatic valve disease and supports strengthening prevention and long-term management strategies in this setting.