Chapter 155 - The Skin In Infective Endocarditis, Sepsis, Septic Shock, and DIC Flashcards
Most common cause of right sided infective endorcarditis
IV drug use
80% of cases of infective endocarditis
Staphylococcal
Streptococcal
Enterococcal
10th leading cause of death in US for all races and sexes at age 45 years and older
Sepsis
Most common consequence of sepsis due to systemic activation of coagulation cascade
Disseminated intravascular coagulation
Inflammation of endocardial lining of the heart (native or prosthetic, mural endocardium) and implanted material caused by infection from bacteria or fungus
Infective endorcarditis
The MC clinical presentation of IE include
Fever
Cardiac murmur
IE patients with skin manifestations had higher rates of cerebral emboli with increased mortality.
True or False
False, no increase mortality
More frequently associated with extra cerebral emboli
Janeway Lesions
1-2 mm red brown or black longitudinal streaks under nail plate result of small capillary vasculitis or from microemboli
Splinter hemorrhages
Painless, irregular, nonblanching, erythematous maculopapules that appear on palms and soles and last days to weeks
Janeway lesions
Painful red papulonodules with pale center on fingertips lasting days to weeks
Osler nodes
Osler nodes are painful due to
Glomus body involvement
Most concerning and severe complication of IE
Ischemic strokes
The MC cause of IE in high income countries for both naive and prosthetic valves
Staphylococcus aureus
Acc to modified Duke Criteria, a clinically definite case is
2 major
1 major + 3 minor
5 minor
Acc to modified Duke Criteria, a clinically suspicious case is
1 major and 1 minor
3 minor
Major criteria of modified duke criteria microbiologic
2 separate blood cultures positive for typical microorganism
OR
Persistently positive blood culture for typical microorganism
OR
Single positive blood culture for Coxiella burnetii or PHASE1 IgG Ab titer to C. Burnetii ratio greater than 1:500
Major criteria of modified duke criteria endocardial involvement
New valvular regurgitation
OR
Positive echocardiogram showing oscillating echogenic intracardiac mass at the site of endocardial injury, a periannular abscess, or new dehiscence of prosthetic valve
Minor criteria of modified duke criteria (5)
Predisposition to infective endocarditis
Fever
Vascular phenomena (osler nodes, roth spots)
Immune factors (+ RF or glomerulonephritis)
Serologic evidence of active infection not meeting major microbiologic criteria
Prosthetic valve endocarditis is classified as early in first ___ months after valve replacement
2
Early prosthetic valve endocarditis is caused by (2)
Coagulase negative streptococci
S. Aureus
Vegetations larger than ___ mm are associated with a greater embolic risk
10
Poor prognostic indicators (12)
L sided Vegetation > 10mm Prosthetic Old agDM Immunossuppressed Heart failure Renal failure Septic shock Brain hemorrhage MRSA/polymicrobial infections
Person with prosthetic valves have a ___% risk of developing Ie with 1 yr mortality rate of ___%
3-4%
50%
MC COD
Cerebral embolic disease
Congestive heart failure
Mx for IE
Strep and Staph:
long term parenteral penicillin G for 4-6 weeks
Enterococcal:
Ampicillin/Penicillin + Gentamicin/streptomycin
Surgery should be avoided for ___ weeks if IE is complicated by hemorrhagic strokes of if cerebral damage is severe
3
AHA recommends antibiotic prophylaxis for patients at increased risk of IE.
True or False
False, high risk of adverse outcome or procedure with contaminated wound or surgery on oral or nasal mucosa
Life threatening organ dysfunction that results from dysregulated host response to infection
Sepsis
Vasopressor therapy is required to maintain MAP of ___ mmHg or greater and serum lactate level greater than ___mmol/L persisting after fluid resuscitation in septic shock
65
2
Erythroderma in septic patient suggests
TSS
Patients with staphylococcal TSS are ___ likely to be erythrodermic and ___ likely to have positive blood culture than patients with streptococcal TSS
More
Less
Finding of pustules in the skin if septic neonate is suggestive of ____ infection
Candidal
Purpura in septic patients is suggestive of
- Oncology patient undergoing BM transplantation
- If immunocompromised, opportunistic fungal infection
(Aspergillus, Fusarium, Candida)
In immunosuppressed patients, ___ can cause cellulitis in setting of AIDS
Cryptococcus neoformans
Patients with liver compromise can develop hemorrhagic bullous cellulitis from ____
Vibrio vulnificus
Mortality rate exceeds ___% in those with V. Vulnificus sepsis
40
qSOFA means
Quick sequential organ failure assessment
qSOFA criteria
- Partial pressure arterial oxygen/ fraction of inspired oxygen
- Mean arterial pressure
- Platelet count
- Serum bilirubin (> 1.2 mg/dl)
- Glasgow coma scale score
- Urine output (<500 ml)
- Creatinine (> 1.2 mg/dl)
SOFA scores greater than ___ are suggestive of a 10% mortality risk
2
Hypotension in septic shock is most likely produced by (2)
COX 2
NO
Strong and independent predictor of adverse outcomes in sepsis
Decreasing thrombocytopenia (below 150 x 109/L)
Sepsis precedes sepric shock in ___% of patients
50
Acc to Surviving Sepsis Campaign, improving blood volume, cellular hypoxia, and tissue and organ perfusion within the first ___ hours
6
Defined as acquired reactive syndrome of consumptive hyper coagulation, insufficient anticoagulation, hemorrhage, systemic vascular inflammation, and endothelial dysfunction
Disseminated intravascular coagulation
Most characteristic cutaneous finding in DIC
Diffuse noninflammatory retiform purpura
Complications of DIC (3)
Amputation
Multiorgan failure
Death
In DIC, coagulation is tissue factor dependent.
True or False
False, dependent
Individuals with high levels of ___ are at hugher risk of mortality than DIC
PAI-1
Plasminogen activator inhibitor type I
Independent predictor for organ failure and mortality
DIc
Vaccination for (3) has been shown to decrease sepsis
H. Influenzae
S. Pneumoniae
N. Meningitidis
Vasopressors should maintain MAP at ___ and serum lactate level at ___
65 mmHg
2mmol/L
QSoFA scores greater than 2 are indicative of ___% mortality
10
Necrotic soft tissue infections have higher mortality when associated with (4)
Hospital acquired
Older than 75 years old
Severe peripheral vascular disease coexistent sepsis/septic shock
Erythematous papule that expands and eventually become a necrotic bulla
Ecthyma gangrenosum
Treatment for staphylococcal or streptococcal IE
4-6 weeks parenteral antibiotics of penicillin derivative
Treatment for Enterococcal IE
Ampicillin or Penicillin with Gentamicin or Streptomycin
Decreases risk of death of Ie
Surgical intervention within 48 hours
Vegetations larger than 10mm
DIC in neonatal period is suggestive of
Protein C /Protein S deficiency
