23 - 155 - THE SKIN IN INFECTIVE ENDOCARDITIS, SEPSIS, SEPTIC SHOCK AND DIC Flashcards
most common cause of right-sided infective endocarditis
intravenous drug use
defined as inflammation of the endocardial lining of the heart (naïve or prosthetic heart valves, mural endocardium) and implanted material caused by infection from bacteria or fungus
Infective endocarditis (IE)
most common clinical presentations of IE
include fever and a new cardiac murmur
painless, irregular, nonblanchable, erythematous maculopapules that appear on the **palms and soles **and last days to weeks
Janeway lesions
clinically definite case of infective endocarditis is defined as fulfilling how any criteria
2 major,
1 major plus 3 minor, or
5 minor criteria
A clinically suspicious case of infective endocarditis is defined as fulfilling how many criteria
1 major and 1 minor,
or 3 minor criteria
painful red papulonodules with a pale center on the fingertips lasting days to weeks
Osler nodes
- painful, perhaps because of involvement of the glomus bodies located in the fingertips
Histology of janeway lesions
thrombi are found in small vessels in the absence of vasculitis.
Neutrophilic microabscesses can be seen in the dermis with occasional Grampositive organisms
Histopath of osler nodes
neutrophilic microabscesses are present in the dermis, and arteriolar microemboli may contain Gram-positive cocci.
Most commonly involved area in septic emboli
Toes
followed by fingers, and this condition presents as reticulated purpura or purple digit similar to that seen in cholesterol emboli syndrome
Major Criteria in Modified Duke Criteria for Infective Endocarditis
Minor Criteria in the Modified Duke Criteria for Infective Endocarditis
causative organisms in 80% of IE cases
staphylococci, streptococci (coagulase negative and viridans group) or enterococci
most common cause of IE in high-income countries
Staphylococcus aureus for both naïve and prosthetic valves
Rare causes may be from HACEK (Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, Kingella) organisms, as well as Bartonella, Brucella, and Coxiella species, and fungi (ie, Candida).
More than half of the cases of IE in injection drug users involve what side of the heart?
Right, involving the tricuspid valve
Early prosthetic valve (1st 2 months following valve replacement) endocarditis is most commonly caused by
coagulase negative streptococci or by S. aureus
late prosthetic valve endocarditis can be caused by any of the infectious organism that can cause IE
Vegetations larger than what mm are associated with a greater embolic risk
10 mm
Poor prognostic indicators of IE
left-sided IE,
vegetation size (>10 mm),
prosthetic valves,
older age,
diabetes,
immunosuppression,
heart failure,
renal failure,
septic shock,
brain hemorrhage,
and infections from methicillin-resistant S. aureus, fungi, or polymicrobial infections.
5-year mortality rate of IE
~ 40%
major determinant of short-term prognosis of IE
Neurologic failure
Most common cause of death in IE
Cerebral embolic disease and congestive heart failure
Settings that require surgery in IE
Failure of parenteral antibiotic therapy,
perivulvar abscess,
valvular destruction/dysfunction with heart failure,
persistent fever, and
ischemic neurologic complications
defined as life-threatening organ dysfunction that results from a dysregulated host response to infection
Sepsis
Septic shock is a subset of sepsis in which vasopressor therapy is required to maintain a mean arterial pressure of _________ and having a serum lactate level greater than __________ persisting after fluid resuscitation
MAP: 65 mm Hg or greater
Lactate: greater than 2 mmol/L
Erythroderma in the septic patient suggests
staphylococcal or streptococcal toxic shock syndrome (TSS)
finding of pustules on the skin of a septic patient, particularly in the neonate or immunocompromised individual, may be suggestive of
fungal infection, particularly with Candida species
most common causes of cellulitis
S. aureus and group A Streptococcus
differentiation of sepsis from infection is the presence of
organ dysfunction
The organ systems commonly affected in sepsis include the renal, hepatic, central nervous, pulmonary, GI, and cardiovascular systems.
acquired reactive syndrome of consumptive hypercoagulation, insufficient anticoagulation, hemorrhage, systemic vascular inflammation, and endothelial dysfunction
Disseminated intravascular coagulopathy
Settings in Which Disseminated Intravascular Coagulation Can Occur
The onset of DIC in the neonatal period is suggestive of
protein C or protein S deficiency.
most characteristic cutaneous finding in DIC
diffuse noninflammatory retiform purpura from extensive microvascular occlusion, which is referred to as purpura fulminans
- Skin lesions may develop bullae, active hemorrhage, and necrosis
- Patients with purpura fulminans may present with ischemic digits or extremities that if left untreated can progress to gangrene
independent predictor for organ failure and mortality
DIC
what bacterial species cause cause 80% of cases of infective endocarditis?
staphylococcal, streptococcal, and enterococcal bacteria
most commonly a consequence of sepsis; results from systemic activation of the coagulation cascade.
Disseminated intravascular coagulation
in the setting oral cavity procedures, this disease is the most-common cause of infective endocarditis in low-income countries
Rheumatic heart disease
risk factors for infective endocarditis
history of IE, diabetes, cancer, congenital heart disease, dental procedures, HIV disease, IV drug abuse
These cutaneous signs of IE are nonspecific but may help the dermatologist in assisting the primary medical team in diagnosing IE during the inpatient consultation
splinter hemorrhages, petechiae/purpura, Janeway lesions, Osler nodes
- Cutaneous findings are caused either by embolic events, thrombosis, or focal vasculitis, and are more commonly found in left-sided IE
These lesions were more frequently associated with extracerebral emboli
Janeway lesions
IE patients with skin manifestations had higher rates of cerebral emboli without increased mortality, whereas Janeway lesions were more frequently associated with extracerebral emboli, and if purpura was present, larger valvular vegetations occurred
1- to 2-mm red-brown or black longitudinal streaks under the nail plate
Splinter hemorrhages
- They are seen in approximately 15% of patients with IE and are considered to be of greater diagnostic value if proximally located.
- result of small capillary vasculitis, or from microemboli
Native valve endocarditis occurs most commonly in the setting of..
valvular disease or in people who use IV drugs.
More than half of the cases of IE in injection drug users are right-sided, involving the tricuspid valve.
histopath findings suggestive of IE
Clinical pathologic correlation of systemic symptoms and skin lesions with findings of extravasated red blood cells, fibrinoid degeneration of vasculature, karyorrhexis, and Gram-positive/negative organisms in microemboli on pathology are suggestive of IE.
Recent data suggest surgical intervention within how many hours of diagnosing IE and when vegetations are larger than 10 mm decreases the risk of death in IE.
48 hours
Pustules resulting from disseminated gonococcemia are acrally located, typically tender and a characteristic what color?
gun-metal gray color
Pustules resulting from disseminated gonococcemia are acrally located, typically tender and a characteristic gun-metal gray color, hemorrhagic or black, and are most commonly seen in the otherwise healthy adolescent or young adult.
Classic ecthyma gangrenosum represents cutaneous seeding of bacteria, usually what organism?
Pseudomonas aeruginosa
- Ecthyma gangrenosum begins as an erythematous papule that expands and eventually becomes a necrotic bulla.
- Lesions are most commonly seen between the umbilicus and the knees.
qSOFA (quick Sequential [sepsis-related] Organ Failure Assessment) score criteria
- respiratory rate greater than 22 breaths/min,
- altered mental status,
- systolic blood pressure less than 100 mm Hg)
new bedside index to identify patients outside of critical care units to help determine if the patient is transitioning from infection to sepsis
SOFA scores greater than what score are suggestive of a 10% mortality risk in the general hospitalized patient with suspected infections
2
strong and independent predictor of adverse outcomes in septic patients
Decreasing thrombocytopenia (below 150 × 109/L)
Hyperbilirubinemia (>1.2 mg/dL), renal insufficiency (creatinine >1.2 mg/dL) and urine output (<500 mL) are concerning for a worse prognosis
This is a syndrome of multiorgan failure characterized by a petechiae or purpura, coagulopathy, cardiovascular collapse, and bilateral adrenal hemorrhage
Waterhouse-Friderichsen syndrome
