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Infective Endocarditis & R.F PDF
Infective Endocarditis & R.F PDF
Infective endocarditis
Case presentation:
47 year old female patient, she has chronic renal failure and presented
to the clinic with fever for the last three weeks, with chills and rigors,
she has poor appetite, weight loss, fatigue, upper abdominal pain, left
ankle pain and swelling, there is no cough, no sputum production, no
chest pain and no vomiting (means negative review of systems).
*Past medical history was positive for cholecystictomy.
*Drug history:
-Oscal: which is Ca (patients with chronic renal failure take Ca)
-Lanzoprazol: proton pump inhibitor.
-Neurobion: multi vitamins (B complex)
-Motilium: is an antiemetic.
*Blood pressure was 110/70, heart rate 100, temperature was 38 c, and
she was pale, no LN enlargement, normal S1 and S2, there was ejection
systolic murmur and end diastolic murmur at the lower sternal border
and at the apex.
*In the abdomen there is left upper quadrant tenderness, and in the
extremities there is left ankle swelling and no any skin lesions.
*On the chest x-ray there was slight cardiomegaly, and on the ECG
there is sinus tachycardia.
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*Lab results:
-Hb: 9.3
-WBC: 12.9
-CRP: 341
-PLT: 341
-Na: 129
-K: 4.0
-RBS: 135
Diagnosis:
The diagnosis depends on documentation of an organism (by bacteria),
ECHO finding, and the clinical findings.
There are criteria that it is important for the diagnosis of infective
endocarditis which is called DUKE criteria, which Composed of:
2 major, or 5 minor, or 1 major and 3 minors.
Major criteria ;
1) Echo; new vegetation, new valve regurg, abscess, new partial
dehiscence of prosthetic valve.
Partial dehiscence means: when there is an artificial valve and after a while the
valve leaks.
Minor criteria;
1) Predisposing heart condition or IV drug abuse.
2) Fever > 38.
3) Embolic phenomena.
4) Immunological phenomena.
5) Lesser echo or clinical data.
*Embolic phenomena;
1) Major arterial emboli.
2) Septic pulmonary or splenic emboli (like the case we shown)
3) Mycotic aneurism in the brain (cerebral)
4) Janeway lesions (small non tender macular lesions on the palms &
soles).
(The doctor said that it is always come in the exam to differentiate if it is tender or not)
*Immunological phenomena;
1) GN
2) Arthritis
3) Oslers nodes (painful nodular lesions on the pulp of the digits)
4) Roths spots (retinal hemorrhage)
5) Renal failure (RF)
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Acute bacterial endocarditis caused by Staphylococcus aureus with aortic valve ring abscess
extending into myocardium.
Treatment:
Strep viridians: penicillin,ceftriaxone,vancomicin + gentamicin
Enterococci: ampicillin + gentamicin
S.aureus: vancomicin + gentamicin
As we mentioned that the treatment for endocarditis is by giving
antibiotics, but the question is: do we need to do surgery for a patient
with infective endocarditis?
Other indications;
1) Recurrent endocarditis
2) Recurrent embolization
3) Abscess formation
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4) Fungal endocarditis
5) Prosthetic valve endocarditis
The doctor asks why endocarditis is difficult to treat?
One factor is that endocarditis usually caused by the worst and
strongest microorganisms.
The other factor that the cardiac valves are devoid from blood vessels
and the media to transfer the antibiotic to any place in the body is by
the blood, and the blood is not reaching there well, it is only reaches
the bases of the cusps, so it is difficult to treat it by antibiotics alone.
Rheumatic fever
Acute rheumatic fever is an inflammatory disease with devastating
sequeale, and it is linked to pharyngeal infection with group A beta
hemolytic streptococci.
It continues to be a problem worldwide:
Sporadic outbreaks in developed countries, in the past in developed
countries rheumatic heart disease was the main cause for valvular
heart disease, in the last 30 years the generative causes are the most
common causes of valvular heart disease in the west, and no more
rheumatic fever is considered as a leading cause of valvular heart
disease.
On the other hand there are still places in the developing countries
where rheumatic fever is still the leading cause of valvular heart
disease, luckily not in Jordan.
The pathogenesis:
Group A streptococci pharyngeal infection precedes clinical
manifestations of acute rheumatic fever by 2-6 weeks.
The antibodies made against group A streptococci cross react with
human tissue (heart valve and brain share common antigenic
sequences with GAS bacteria).
There is a theory of molecular mimicry:
There is an antigen in group A streptococci in its cell wall called M
antigen, it is thought that it cross react with the M antigen in the heart
and because of this mimicry the disease occurs.
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The host immune response may play a role in determining who develop
ARF following infection.
*The virulent strains are the rheumatologic serotypes.
*And the most important antigenic proteins in the external layer of the
cell wall are the M,T,R proteins.
Clinical features:
Following upper airway infection with GAS, there is a silent period of 26 weeks, and sudden onset of fever, malaise (feeling of ill being), pallor,
and fatigue.
It is characterized by:
1) Arthritis 2) Carditis 3) Sydenhams chorea 4) Erythema
marginatum 5) subcutaneous nodule
They are called major manifestations of jones criteria either because of
frequency or specifity.
* The doctor here insists on the importance of the criteria of infective
endocarditis and rheumatoid fever and differentiating between them.
Other features:
1) Arthralgias
3) Serositis
2) Epistaxis
*Involvement of the lung, kidneys, and CNS.
Arthritis:
The most common feature present in 80% of patients.
*It is painful, migratory, short duration, excellent response to
salicylates.
*usually more than 5 joints are affected and large joints preferred;
Knees, ankles, wrists, elbows, shoulders.
*Small joints and cervical spine are less commonly involved.
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HADI'S PART
Carditis:
NOTE: if the pt has pericardial effusion on the echo and you can't hear the heart
sounds this indicates that the amount of the effusion is significant.
This chest X-ray for a pt with RF and you can see Cardiomegaly ( the cardio-thoracic
ratio more than 50%).
Sydenhams Chorea:
Extrapyramidal disorder characterized by fast, clonic, involuntary
movements (especially face and limbs) and the pt looks like dancing.
Muscular hypotonus
Emotional liability: crying then smilingetc.
The First sign starts with difficulty in walking, talking, writing
Usually Sydenham's Chorea is a late manifestation occure months after
the infection.
rarely the only manifestation of ARF.
Occurs in 30% of patients with ARF and can return back after the pt recovered
from the ARF.
1/2 of these (30%) also have carditis (more common with sydenham's chorea) or
arthritis.
Usually benign and resolves in 2 - 3 months and can last for more than 2 years.
Subcutaneous Nodules:
Usually 0.5 - 2 cm long, Firm, non-tender, isolated or in clusters.
Most common: along extensor surfaces of joint (Knees, elbows, wrists); just
move your hand over the skin and you will feel the nodules. Also you find it on
bony prominences, tendons, dorsi of feet, occiput or cervical spine.
Last a few days only and Occur in 9 - 20% of cases.
Often associated with carditis (always if you found subcutaneous nodules then
the pt 100% has carditis).
Erythema Marginatum:
Present in 7% of patients
Cutaneous lesion: Reddish pink border, Pale center, Round or irregular shape.
Erythema marginatum : notice the pink border and the pale in the center.
-Epistaxis
-Pneumonitis
DIAGNOSIS
In the diagnosis we follow jone's criteria which is:-
dr
here
slides so I will
some notes.
Laboratory Studies
- None capable of diagnosing ARF: clinical
diagnosis
- Can help eliminate other diseases
- Aids in diagnosis
- Monitor inflammatory process
- Evaluate extent of cardiac involvement
- CBC: not very helpful we can see leukocytosis
- increase CRP, increase ESR: non-specific indicators of inflammation
- Tests for anti-streptococcal antibody
- CXR for cardiomegaly
- EKG: prolonged PR interval in 1/3 patients
not specific to ARF
not associated with later cardiac sequelae
TREATMENT
The treatment of ARF depends mainly on the Eradication of the group A strep,
and the best treatment is a sigle dose of IM benzathine penicillin G acts for
month. We give the dose for pts >27 kg 1,200,000 units and for pts <27 kg
600,000 units.
Other alternatives
-
For arthritis:
-
primary prophylaxis:
we mean by primary prophylaxis is to give the treatment before having the
disease, but the secondary prophylaxis is to prevent the complications and the
recurrence of the disease.
We use antibiotics (penicillin) as we said, and in Jordan we apply roles to
-
Overcrowding
Secondary prophylaxis
Benzathine PCN given to prevent recurrences of ARF and to prevent any chronic valve
disease, studies shows that pts with ARF when they treated they get what we call it
chronic smoldering (it means that there is a disease but progress very slowly).
Pts with valvular disease (mitral regurge or stenosis or aortic regurge) we give them
lifelong penicillin treatment.
Conclusions:
-
THE END
Best regard to all group A9 every one of them except sheikh el group Saleh Abu
Lebdeh( from Omar )
. /0 1/