Infective Endocarditis

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INFECTIVE

ENDOCARDITIS
PATIENT’S DATA

Name : Chong Wai Peng


Gender : Female
Race : Chinese
Age : 36
Religion : Non- muslim
I/C Number : 721128-14-5252
Registration Number : AM 119355
Address: Cahaya
Referred From: Klinik Kesihatan Ampang
Date of Admission : 31 July 2009
Date of Clerking : 26 August 2009
Source of Information : Patient

PATIENT’S HISTORY
Chief Complaints

1) Yellow discolouration of skin and sclera for 4 months


2) Generalized body swelling for 3 months

History of Present Illness


Madam Chong Wai Peng was apparently well until she noticed by herself that her
skin and sclera turned yellow. . It was slow in onset, gradually increased in depth and
persists for last 4 months. It was associated with passing dark colour urine ( tea-coloured
urine) but no pale colour stool. There are also no pruritus, abdominal pain, bleeding
tendency, fever, any joint pain, recurrent leg ulcer or any heart valve replacement before.
Regarding the body swelling, it was involved bilateral leg swelling, gross
abdominal distention and bilateral upper limb swelling. It was started from legs and
extending upwards. It was also associated with shortness of breath on minimal exertion
and reduce effort tolerance. She claimed could walk less than 10 cm and climb less than 1
floor, meaning easily fatigue. No chest pain or palpitation. There are no orthopnea or
paroxysmal nocturnal dyspnoea.
She was not an intravenous drug user (IVDU). She had no history of blood
transfusion, tattoos, sexual promiscuity or recent injections. He had not been traveling or
eating out for ages, and did not have consumed any seafood for as long as he could recall.
No urinary tract symptom as well. No loss of appetite or loss of weight.

Systemic Review
She had no remarkable findings from other systems. He had no chest pain, cough,
bone pain or other complaints. She did not complain of dysuria, increased frequency,
haematuria, poor stream, terminal dribbling or other symptoms of urinary outflow
obstruction and infection.
Past Medical History
The patient has no known medical illness and she never admitted to the hospital before.
Past Surgical History
No past surgical history

Drug History
She had no known drug allergies or other known allergies., but there is history of
taking Chinese medication from sihsih two weeks ago.

Family History
There is family history of diabetes mellitus in the family ( her father) but there is
no malignancy in the family.

Social History
She is not working and married with 3 children. She stays in a double storey
house in Cahaya with husband’s family. She is not a smoker and occasionally alcohol
drinker.

Menstrual History
She had last menstrual period at 16 June 2009 with regular cycle, no clots and no
menorrhagia.

PHYSICAL EXAMINATION
Peripheral examination
On inspection, patient was relaxed, alert, conscious and not in pain. She was not
tachypnoiec. She was conscious and able to speak in full sentences. He is 15 on the
Glasgow Coma Scale (spontaneous eye opening, eye=4), obeying verbal command (best
motor response=6), with oriented verbal response (best verbal response=5); hence
without sign of hepatic encephalopathy. Her vital sign were :

Blood pressure : 151/95 mmHg


Pulse rate : 105 bpm
Respiratory rate : 20/ min
Temperature : afebrile
O2 saturation : 96%

Hands - clubbing
- Slighly pale
- no splinter hemorrahage
- No leuchonicia
- No osler’s nodes
- No janeway lesion
- No palmar erythema
- No dupuytren’s contracture
- No flapping tremor
- No muscle wasting
Pulses - PR: 84 bpm, regular rhythm, good volume
- no radio- radio delay
- no radio-femoral delay
- no collapsing pulse
Arms - ecchymoses
- No scratch mark
- No tattoo
- No IVDU sign
- No spider naevi
Face - slightly palllor
- tinge of jaundice
- dehydration status fairly good
- oral hygiene fairly good
Neck – JVP was raised, 4.5 cm
Legs – bilateral pitting edema

Cvs examination
Inspection- no scar
- no visible pulse
- no visible vein
- no visible mass
Palpation - apex beat was displaced at left anterior axillary line, fifth intercostals space
- no parasternal heave
- no thrill
Auscultation - s1s2 present
- ejection systolic murmur, grade 3/5, best heard
at aortic area, radiate to carotid artery and over the right clavicle, increased
in intensity during expiration

Respiratory examination
- Bibasal crepitation
- Air entry equal bilaterally

Abdominal examination
- Abdomen was grossly distended
- There are striae
- Soft, non tender
- Splenomegaly, troub’s space dullness
- Kidneys not ballotable
- Fluid thrill positive

Nervous system
No neurological deficit signs were detected. Cranial nerves were intact. Normal
muscle tone, normal muscle power and normal reflexes were noted. Sensations were
intact.
Examination of other systems is unremarkable

CASE SUMMARY
In summary, 36 year old Chinese lady, with no known medical illness comes in
with the history of yellow discolouration of skin and sclera for 4 months associated with
passing dark colour urine and generalized body swelling for 3 months associated with
shorthness of breath on minimal exertion and reduces effort tolerance. In addition history
of taking Chinese medication 2 weeks prior to admission.
On examination, patient was slightly pallor, tinge of jaundice, there is clubbing
and bruises. JVP was raised and pitting edema noted. Heart was enlarged with evidence
of displaced apex beat and present of heart murmur. Abdomen was distended with full of
water as evidence of positive fluid thrill, spleen was enlarged. In addition bibasal
crepitation.

PROVISIONAL DIAGNOSIS
Heart Disease ( Infective Endocarditis or Rheumatic Heart Disease )
DIFFERENTIAL DIAGNOSIS
1) Hemolytic anemia secondary to autoimmune disease
2) Chronic Liver Disease

INVESTIGATION
Some investigation was done with the purpose :
1) to confirm the diagnosis
2) to identify the organism involved for management purpose
3) monitor patient’s response to therapy

A) Blood Investigation
Full blood count

WBC 4.5 x 109 /L Normal (4-11x 109/L)


Hb 6.5 g/dL Low (12-16 g/dL)
Plt 121x 109/L Thrombocytopenia (150-400x 109/L)
Hct 23.3% Low (35-47%)
MCV 101 fl Macrocytic (76-98 fl)
MCH 28.5 pg/cell Normocytic (27-32 pg/cell)

Renal Profile/ Electrolytes

Urea 2.3 mmol/L Slightly low (2.5-6.5 mmol/L)


Sodium 142 mmol/L Normal (135-145 mmol/L)
Potassium 3.4 mmol/L Slightly low (3.5-5 mmol/L)
Chloride 104 mmol/L Normal (95-105 mmol/L)
Creatinine 75 μmol/L Normal (60-130 μmol/L)

Liver function Test


Total protein 74 g/L Normal (65-80 g/L)
Albumin 38 g/L Normal (35-55 g/L
Total bilirubin 62 μmol/L Very high (5-17 μmol/L)
Indirect bilirubin 46 μmol/L Very high (3.4-12 μmol/L)
Direct bilirubin 16 μmol/L Very high (1.7-5 μmol/L)
ALP 59 IU/L Normal (30-130 IU/L)
ALT 11 IU/L Normal (5-40 IU/L)

Urea Full Examination and Microscopic Examination

Glu -ve Normal


Pro 2+ Proteinuria
RBC 2+ Hematuria
Nitrite -ve Normal
Leu 2+ Infection

Cardiac Profile

CK 35 IU/L Normal (0-170 IU/L)


LDH 919 IU/L Very high (70-250 IU/L)

Fasting Lipid Profile

TC 2.2 mmol/L Normal ( <6 mmol/L)


TG 0.8 mmol/L Normal ( 0.5-1.9 mmol/L)
HDL 1.0 mmol/L Normal
LDL 0.83 mmol/L Normal

Other Test

ESR 82 0-6 mm in 1 hour


TIBC 65.7
UIBC 54.5
T4 24.34 pmol/L Normal (10.3-34.8 pmol/L)
TSH 2.38 mU/L Normal (0.5-5 mU/L)
B) Blood culture – no result yet

C) Radiology
1- abdominal x-ray- It was showed dilated sigmoid colon
2- chest x-ray-It was showed cardiomegaly and blunting of cardiophrenic
angle
D) Ecg
No abnormal changes detected

E) Echocardigram
1- Chamber size
LV- dilated +6 cm
LA - dilated +4.5 cm
RA - dilated +4 cm
RV – slightly dilated +3.3 cm
2- LV contraction-Anterior septal + anterior + septal hypokinesia
3- LV function-Satisfactory
4- Ejection fraction
45% (Teichcoz)
405 ( Mod Simpson)
5- Valve morphology
AOV- mild AR
- mild to moderate AS
MV - mild MR
TV – moderate to severe TR
6- ASD/VSD/PDA- no
7- Clot/thrombus - no
8- Vegetation- no
9- Pericardial Effusion
Minimal PE + 0.6cm
RA free wall collapsed
PE RA free wall + 1.2 cm
10- Others

4) Full Blood Count


RBC- mild anisopoikilocytosis
- elliptocytes, tear drop
WBC- no blast
- hypersegmented neutrophils
Plt- platelet clumps seen anisocytosis
Impression-
1) anemia secondary to nutritional deficiency suggest folate, B12, Iron
Studies
2) Pseudothrombocytopenia

DISCUSSION

Infective endocarditis is an infection of the endocardial surface of heart. The


disease can occur as an acute, fulminating infection, but more commonly runs as an
insidious course and is known as subacute bacterial endocarditis (SBE). Endocarditis is
usually consequence of two factors: the presence of organisms in the bloodstream and
abnormal cardiac endothelium facilitating their adherence and growth.
Patient can present with an acute illness and the classic features of a new
changing heart murmur and a fever. However, they may present with a subacute insidious
illness. A high index of suspicion for the possibility of endocarditis is therefore required,
otherwise the diagnosis can be delayed with potentially catastrophic consequences.
Clinical signs tend to arise from the following pathological processes: systemic features
of infection, embolization, and immune complex deposition.
Based on the history, physical examination and investigation, this patient have
sign of infective endocarditis like malaise, clubbing, cardiac murmur, skin lesion like
petechiae, splenomegaly, hematuria and proteinuria. The full blood count also shows
macrocytic normorcytic anemia and thrombocytopenia. Usually it is normochromic
normocytic anemia. There is electrolytes imbalance, hematuria and proteinuria as
evidence of kidney involvement. There is glomerulonephritis caused by immune
complex deposition. Inflammatory marker like ESR also increased.
Chest x-ray shows cardiomegaly and pleural effusion. In addition sign of bilateral
ankle edema, dypsnea on minimal exertion, displacement of apex beat and presence of
cardiac murmur give clue about the involvement of cardiac. Then the echocardiogram
show significant changes.
There are criteria for the diagnosis of infective endocarditis. They have been
subsequently been refined and are now commonly known as Duke Criteria. As the result
of blood culture is not ready yet, the patient still needs treatment and had been
hospitalized. All the sign highly suggestive to the diagnosis of infective endocarditis.

PRINCIPLE OF THERAPY

Therapy of endocarditis is difficult because organisms reside within a protected


site within the vegetation. High concentration of intravenous antibiotic are required for
prolonged periods to achieve successful treatment. Where possible, synergistic
combinations of antibiotics are used, in order to maximize the microbiocidal effect.
Empirical antibiotic treatment is started only after cultures are taken. The regimen
is then adjusted according to culture results. The treatment should continue for 4-6
weeks. For clinical endocarditis while the culture result awaited and no suspicion of
staphylococci, starts the regimen with penicillin 1.2 g 4- hourly and gentamicin 80 mg
12- hourly. If there is suspected staphylococcal endocarditis (IVDU, recent intravascular
devices or cardiac surgery or acute infection), starts the regimen with vancomycin 1 g 12-
hourly and gentamycin 80 mg 12- hourly.

REFERENCES

1- Kumar & Clarks Clinical Medicine Sixth Edition, Parveen Kumar, Micheal Clark
2- In A Page Medicine, Scott Kahan, Bimal Ashar

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