23 - 155 - THE SKIN IN INFECTIVE ENDOCARDITIS, SEPSIS, SEPTIC SHOCK AND DIC

Question 1

most common cause of right-sided infective endocarditis

Answer 1

intravenous drug use

Question 2

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

Answer 2

Infective endocarditis (IE)

Question 3

most common clinical presentations of IE

Answer 3

include fever and a new cardiac murmur

Question 4

painless, irregular, nonblanchable, erythematous maculopapules that appear on the **palms and soles **and last days to weeks

Answer 4

Janeway lesions

Question 5

clinically definite case of infective endocarditis is defined as fulfilling how any criteria

Answer 5

2 major,
1 major plus 3 minor, or
5 minor criteria

Question 6

A clinically suspicious case of infective endocarditis is defined as fulfilling how many criteria

Answer 6

1 major and 1 minor,
or 3 minor criteria

Question 7

painful red papulonodules with a pale center on the fingertips lasting days to weeks

Answer 7

Osler nodes

• painful, perhaps because of involvement of the glomus bodies located in the fingertips

Question 8

Histology of janeway lesions

Answer 8

thrombi are found in small vessels in the absence of vasculitis.

Neutrophilic microabscesses can be seen in the dermis with occasional Grampositive organisms

Question 9

Histopath of osler nodes

Answer 9

neutrophilic microabscesses are present in the dermis, and arteriolar microemboli may contain Gram-positive cocci.

Question 10

Most commonly involved area in septic emboli

Answer 10

Toes

followed by fingers, and this condition presents as reticulated purpura or purple digit similar to that seen in cholesterol emboli syndrome

Question 11

Major Criteria in Modified Duke Criteria for Infective Endocarditis

Answer 11

Question 12

Minor Criteria in the Modified Duke Criteria for Infective Endocarditis

Answer 12

Question 13

causative organisms in 80% of IE cases

Answer 13

staphylococci, streptococci (coagulase negative and viridans group) or enterococci

Question 14

most common cause of IE in high-income countries

Answer 14

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).

Question 15

More than half of the cases of IE in injection drug users involve what side of the heart?

Answer 15

Right, involving the tricuspid valve

Question 16

Early prosthetic valve (1st 2 months following valve replacement) endocarditis is most commonly caused by

Answer 16

coagulase negative streptococci or by S. aureus

late prosthetic valve endocarditis can be caused by any of the infectious organism that can cause IE

Question 17

Vegetations larger than what mm are associated with a greater embolic risk

Answer 17

10 mm

Question 18

Poor prognostic indicators of IE

Answer 18

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.

Question 19

5-year mortality rate of IE

Answer 19

~ 40%

Question 20

major determinant of short-term prognosis of IE

Answer 20

Neurologic failure

Question 21

Most common cause of death in IE

Answer 21

Cerebral embolic disease and congestive heart failure

Question 22

Settings that require surgery in IE

Answer 22

Failure of parenteral antibiotic therapy,
perivulvar abscess,
valvular destruction/dysfunction with heart failure,
persistent fever, and
ischemic neurologic complications

Question 23

defined as life-threatening organ dysfunction that results from a dysregulated host response to infection

Answer 23

Sepsis

Question 24

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

Answer 24

MAP: 65 mm Hg or greater

Lactate: greater than 2 mmol/L

Question 25

Erythroderma in the septic patient suggests

Answer 25

staphylococcal or streptococcal toxic shock syndrome (TSS)

Question 26

finding of pustules on the skin of a septic patient, particularly in the neonate or immunocompromised individual, may be suggestive of

Answer 26

fungal infection, particularly with Candida species

Question 27

most common causes of cellulitis

Answer 27

S. aureus and group A Streptococcus

Question 28

differentiation of sepsis from infection is the presence of

Answer 28

organ dysfunction ## Footnote The organ systems commonly affected in sepsis include the renal, hepatic, central nervous, pulmonary, GI, and cardiovascular systems.

Question 29

acquired reactive syndrome of consumptive hypercoagulation, insufficient anticoagulation, hemorrhage, systemic vascular inflammation, and endothelial dysfunction

Answer 29

Disseminated intravascular coagulopathy

Question 30

Settings in Which Disseminated Intravascular Coagulation Can Occur

Answer 30

Question 31

The onset of DIC in the neonatal period is suggestive of

Answer 31

protein C or protein S deficiency.

Question 32

most characteristic cutaneous finding in DIC

Answer 32

diffuse noninflammatory retiform purpura from extensive microvascular occlusion, which is referred to as purpura fulminans ## Footnote * 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

Question 33

independent predictor for organ failure and mortality

Answer 33

DIC

Question 34

what bacterial species cause cause 80% of cases of infective endocarditis?

Answer 34

staphylococcal, streptococcal, and enterococcal bacteria

Question 35

most commonly a consequence of sepsis; results from systemic activation of the coagulation cascade.

Answer 35

Disseminated intravascular coagulation

Question 36

in the setting oral cavity procedures, this disease is the most-common cause of infective endocarditis in low-income countries

Answer 36

Rheumatic heart disease

Question 37

risk factors for infective endocarditis

Answer 37

history of IE, diabetes, cancer, congenital heart disease, dental procedures, HIV disease, IV drug abuse

Question 38

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

Answer 38

splinter hemorrhages, petechiae/purpura, Janeway lesions, Osler nodes ## Footnote * Cutaneous findings are caused either by **embolic events, thrombosis, or focal vasculitis,** and are more commonly found in left-sided IE

Question 39

These lesions were more frequently associated with **extracerebral** emboli

Answer 39

Janeway lesions ## Footnote 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

Question 40

1- to 2-mm red-brown or black longitudinal streaks under the nail plate

Answer 40

Splinter hemorrhages ## Footnote * 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

Question 41

Native valve endocarditis occurs most commonly in the setting of..

Answer 41

valvular disease or in people who use IV drugs. ## Footnote More than half of the cases of IE in injection drug users are right-sided, involving the tricuspid valve.

Question 42

histopath findings suggestive of IE

Answer 42

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 microembol**i on pathology are suggestive of IE.

Question 43

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.

Answer 43

48 hours

Question 44

Pustules resulting from disseminated gonococcemia are acrally located, typically tender and a characteristic what color?

Answer 44

gun-metal gray color ## Footnote 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.

Question 45

Classic ecthyma gangrenosum represents cutaneous seeding of bacteria, usually what organism?

Answer 45

Pseudomonas aeruginosa ## Footnote * 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.

Question 46

qSOFA (quick Sequential [sepsis-related] Organ Failure Assessment) score criteria

Answer 46

* respiratory rate greater than 22 breaths/min, * altered mental status, * systolic blood pressure less than 100 mm Hg) ## Footnote new bedside index to identify patients outside of critical care units to help determine if the patient is transitioning from infection to sepsis

Question 47

SOFA scores greater than what score are suggestive of a 10% mortality risk in the general hospitalized patient with suspected infections

Answer 47

2

Question 48

strong and independent predictor of adverse outcomes in septic patients

Answer 48

Decreasing thrombocytopenia (below 150 × 109/L) ## Footnote Hyperbilirubinemia (>1.2 mg/dL), renal insufficiency (creatinine >1.2 mg/dL) and urine output (<500 mL) are concerning for a worse prognosis

Question 49

This is a syndrome of multiorgan failure characterized by a petechiae or purpura, coagulopathy, cardiovascular collapse, and **bilateral adrenal hemorrhage**

Answer 49

Waterhouse-Friderichsen syndrome