Chapter 155 - The Skin In Infective Endocarditis, Sepsis, Septic Shock, and DIC

Question 1

Most common cause of right sided infective endorcarditis

Answer 1

IV drug use

Question 2

80% of cases of infective endocarditis

Answer 2

Staphylococcal
Streptococcal
Enterococcal

Question 3

10th leading cause of death in US for all races and sexes at age 45 years and older

Answer 3

Sepsis

Question 4

Most common consequence of sepsis due to systemic activation of coagulation cascade

Answer 4

Disseminated intravascular coagulation

Question 5

Inflammation of endocardial lining of the heart (native or prosthetic, mural endocardium) and implanted material caused by infection from bacteria or fungus

Answer 5

Infective endorcarditis

Question 6

The MC clinical presentation of IE include

Answer 6

Fever

Cardiac murmur

Question 7

IE patients with skin manifestations had higher rates of cerebral emboli with increased mortality.
True or False

Answer 7

False, no increase mortality

Question 8

More frequently associated with extra cerebral emboli

Answer 8

Janeway Lesions

Question 9

1-2 mm red brown or black longitudinal streaks under nail plate result of small capillary vasculitis or from microemboli

Answer 9

Splinter hemorrhages

Question 10

Painless, irregular, nonblanching, erythematous maculopapules that appear on palms and soles and last days to weeks

Answer 10

Janeway lesions

Question 11

Painful red papulonodules with pale center on fingertips lasting days to weeks

Answer 11

Osler nodes

Question 12

Osler nodes are painful due to

Answer 12

Glomus body involvement

Question 13

Most concerning and severe complication of IE

Answer 13

Ischemic strokes

Question 14

The MC cause of IE in high income countries for both naive and prosthetic valves

Answer 14

Staphylococcus aureus

Question 15

Acc to modified Duke Criteria, a clinically definite case is

Answer 15

2 major
1 major + 3 minor
5 minor

Question 16

Acc to modified Duke Criteria, a clinically suspicious case is

Answer 16

1 major and 1 minor

3 minor

Question 17

Major criteria of modified duke criteria microbiologic

Answer 17

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

Question 18

Major criteria of modified duke criteria endocardial involvement

Answer 18

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

Question 19

Minor criteria of modified duke criteria (5)

Answer 19

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

Question 20

Prosthetic valve endocarditis is classified as early in first ___ months after valve replacement

Answer 20

2

Question 21

Early prosthetic valve endocarditis is caused by (2)

Answer 21

Coagulase negative streptococci

S. Aureus

Question 22

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

Answer 22

10

Question 23

Poor prognostic indicators (12)

Answer 23

L sided
Vegetation > 10mm
Prosthetic
Old agDM
Immunossuppressed
Heart failure
Renal failure
Septic shock
Brain hemorrhage
MRSA/polymicrobial infections

Question 24

Person with prosthetic valves have a ___% risk of developing Ie with 1 yr mortality rate of ___%

Answer 24

3-4%

50%

Question 25

MC COD

Answer 25

Cerebral embolic disease | Congestive heart failure

Question 26

Mx for IE

Answer 26

Strep and Staph: long term parenteral penicillin G for 4-6 weeks Enterococcal: Ampicillin/Penicillin + Gentamicin/streptomycin

Question 27

Surgery should be avoided for ___ weeks if IE is complicated by hemorrhagic strokes of if cerebral damage is severe

Answer 27

3

Question 28

AHA recommends antibiotic prophylaxis for patients at increased risk of IE. True or False

Answer 28

False, high risk of adverse outcome or procedure with contaminated wound or surgery on oral or nasal mucosa

Question 29

Life threatening organ dysfunction that results from dysregulated host response to infection

Answer 29

Sepsis

Question 30

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

Answer 30

65 | 2

Question 31

Erythroderma in septic patient suggests

Answer 31

TSS

Question 32

Patients with staphylococcal TSS are ___ likely to be erythrodermic and ___ likely to have positive blood culture than patients with streptococcal TSS

Answer 32

More | Less

Question 33

Finding of pustules in the skin if septic neonate is suggestive of ____ infection

Answer 33

Candidal

Question 34

Purpura in septic patients is suggestive of

Answer 34

1. Oncology patient undergoing BM transplantation 2. If immunocompromised, opportunistic fungal infection (Aspergillus, Fusarium, Candida)

Question 35

In immunosuppressed patients, ___ can cause cellulitis in setting of AIDS

Answer 35

Cryptococcus neoformans

Question 36

Patients with liver compromise can develop hemorrhagic bullous cellulitis from ____

Answer 36

Vibrio vulnificus

Question 37

Mortality rate exceeds ___% in those with V. Vulnificus sepsis

Answer 37

40

Question 38

qSOFA means

Answer 38

Quick sequential organ failure assessment

Question 39

qSOFA criteria

Answer 39

1. Partial pressure arterial oxygen/ fraction of inspired oxygen 2. Mean arterial pressure 3. Platelet count 4. Serum bilirubin (> 1.2 mg/dl) 5. Glasgow coma scale score 6. Urine output (<500 ml) 7. Creatinine (> 1.2 mg/dl)

Question 40

SOFA scores greater than ___ are suggestive of a 10% mortality risk

Answer 40

2

Question 41

Hypotension in septic shock is most likely produced by (2)

Answer 41

COX 2 | NO

Question 42

Strong and independent predictor of adverse outcomes in sepsis

Answer 42

Decreasing thrombocytopenia (below 150 x 109/L)

Question 43

Sepsis precedes sepric shock in ___% of patients

Answer 43

50

Question 44

Acc to Surviving Sepsis Campaign, improving blood volume, cellular hypoxia, and tissue and organ perfusion within the first ___ hours

Answer 44

6

Question 45

Defined as acquired reactive syndrome of consumptive hyper coagulation, insufficient anticoagulation, hemorrhage, systemic vascular inflammation, and endothelial dysfunction

Answer 45

Disseminated intravascular coagulation

Question 46

Most characteristic cutaneous finding in DIC

Answer 46

Diffuse noninflammatory retiform purpura

Question 47

Complications of DIC (3)

Answer 47

Amputation Multiorgan failure Death

Question 48

In DIC, coagulation is tissue factor dependent. | True or False

Answer 48

False, dependent

Question 49

Individuals with high levels of ___ are at hugher risk of mortality than DIC

Answer 49

PAI-1 | Plasminogen activator inhibitor type I

Question 50

Independent predictor for organ failure and mortality

Answer 50

DIc

Question 51

Vaccination for (3) has been shown to decrease sepsis

Answer 51

H. Influenzae S. Pneumoniae N. Meningitidis

Question 52

Vasopressors should maintain MAP at ___ and serum lactate level at ___

Answer 52

65 mmHg | 2mmol/L

Question 53

QSoFA scores greater than 2 are indicative of ___% mortality

Answer 53

10

Question 54

Necrotic soft tissue infections have higher mortality when associated with (4)

Answer 54

Hospital acquired Older than 75 years old Severe peripheral vascular disease coexistent sepsis/septic shock

Question 55

Erythematous papule that expands and eventually become a necrotic bulla

Answer 55

Ecthyma gangrenosum

Question 56

Treatment for staphylococcal or streptococcal IE

Answer 56

4-6 weeks parenteral antibiotics of penicillin derivative

Question 57

Treatment for Enterococcal IE

Answer 57

Ampicillin or Penicillin with Gentamicin or Streptomycin

Question 58

Decreases risk of death of Ie

Answer 58

Surgical intervention within 48 hours | Vegetations larger than 10mm

Question 59

DIC in neonatal period is suggestive of

Answer 59

Protein C /Protein S deficiency