Chest pain and fever (Darrow)

Question 1

A 35 y/o female presents with sharp chest pain which was of sudden onset some 10 days ago. The pain has been less intense over the past week, but worse with inspiration. Two months ago she had a tick bite while hiking in New England. There is a biphasic high pitched squeaky sound at the left sternal border, louder with expiration and leaning forward. EKG is shown.

what does this patient have?
what type of cardiac problem?
1. What position causes the pain to be aggravated in this patient?
2. What is the most common cause of this type of EKG change?

Answer 1

Lyme disease with PERICARDITIS ***
EKG–> shows inverted t waves. PR segments are elevated

1. Pericardial pain is pleuritic and postural (worse supine and relieved by sitting). Substernal and associated with dyspnea, fever and rub

2. usually a viral cause (coxsacki) 
TB- night sweats, subacute
Bacterial - toxic
uremia- shaggy/hemorrhagic and exudative 
neoplastic - tamponade
inflammatory reaction/dresslers - 
radiation
drugs - clozapine
myxedema- cholesterol crystals
autoimmune - SLE

Question 2

Three weeks later the patient (with pericarditis) develops the following EKG and complains of exertional dyspnea and orthopnea. PE reveals basilar crackles and an occasional rubbing sound over the precordium. The patient has now developed a (an):

What lab abnormalities might be seen in this patient that may have portended the development of pulmonary edema?

Answer 2

myocarditis!

The EKG shows heart block. You cannot get heart block from just pericarditis there has to be involvement of the myocardium. So with chronic pericarditis you can develop myocarditis

Many cases of pericarditis include myocardial involvement (myocarditis) as well as pericardial and thus will be characterized by troponin elevations, heart block, wall motion abnormalities, and CHF.

Question 3

A 55 y/o male with diabetic renal failure has a BUN of 120 mg/dL and creatinine of 6.2 mg/dL. He presents with dyspnea, fatigue, neck vein distention, muffled heart sounds and BP of 90/70

1. What is the above triad and what has happened to
   this patient?

The patient is shown to have a greater than 10 mm drop in systolic blood pressure with inspiration.
2. What is the name for this phenomenon and what is the mechanism for this event during inspiration?

Answer 3

1. He has Beck’s triad
   pericardial tamponade - bag of water around his heart due to uremia
2. Pulsus paradoxus **

where there is decreased LV ejection during inspiration due to the high CVP leading to increased RV filling with septal motion toward the LV, thus limiting LV filling and LVEF. At the same time, inflow across the mitral valve will decrease by 25%.

when blood comes in during diastole with pericardial tamponade–> the septum moves to the left and so there is less room for left ventricular filling so the systolic pressure drops

Question 4

what is the early disseminated lyme disease

Answer 4

The classic triad of acute neurologic abnormalities is meningitis, cranial neuropathy*, and motor or sensory radiculoneuropathy, although each of these findings may occur alone.
Cardiac involvement with heart block and myopericarditis

Question 5

what is the late stage lyme disease

Answer 5

oligoarthritis

Question 6

what is beck’s triad?

Answer 6

neck vein distention, muffled heart sounds and BP of 90/70

Question 7

what are some causes of cardiac tamponade?

Answer 7

trauma
pericarditis
myocardial rupture
uremia
hypothyroidism

Question 8

what is the a wave in Jugular venous tracing

Answer 8

atrial contraction

Question 9

x wave?

Answer 9

atrial relaxation

Question 10

v wave

Answer 10

atrial filling

Question 11

y wave

Answer 11

atrial emptying

Question 12

in a patient with pericardial tamponade, what is seen in the jugular venous tracing ? what wave is abnormal?

Answer 12

the y wave does not depress fully back to baseline - decreased y descent

atrial emptying is not adequate b/c the “bag of water” is giving resistance

Pericardial Tamponade is characterized by intrapericardial pressures
of > 15 mmHg which restricts venous return and ventricular filling.
acv waves showing lack of y descent can be seen in the LA via
measuring wedge pressures.

a

Question 13

what is seen on echo of cardiac tamponade?

Answer 13

Cardiac ECHO in pericardial tamponade may reveal that during diastole the thinner walled RV collapses.

Question 14

“please Dr. Beck, you PAY for the CT !

Answer 14

Beck’s triad

• muffled heart sounds
• distended neck veins
• low BP

Pulsus paradoxus
electrical Alterans
slowed Y descent
Cardiac Tamponade

Question 15

what is the treatment

Answer 15

pericardiocentesis

Question 16

A 55 year old female with a remote history of chest trauma presents with fatigue, weakness, elevated JVP, edema, and hepatomegaly with ascites* (think back up in right ventricle) Kussmaul sign is present. Chest xray is shown. (calcium cage around heart)

*Marker for constrictive pericarditis, more so than cardiac tamponade

what is Kussmaul sign?

Answer 16

deep breath–> external jugular increases in size!

Kussmaul sign is a marker for constrictive pericarditis

In constrictive pericarditis the jugular engorges with inspiration. This is referred to as the Kussmaul sign. (This sign can also be positive in severe COPD, pulmonary hypertension with RV failure, and more rarely in cardiac tamponade).

Question 17

what is characteristic of the JVP wave in a patient with CP

Answer 17

greatly magnified = M or W configuration for JVP pulse (or wedge pressure catheter) –> early and abrupt diastolic filling with rapid X and y descent

atrial emptying abrupt and sharp - sharp/quick y descent

this is different than cardiac tamponade which has a slow y descent

Question 18

what other signs besides M configuration on JVP, Jussmaul sign are see with constrictive pericarditis?

Answer 18

Diastolic pericardial knock (auscultation - like an S3) and “septal bounce” (ECHO) due to rapid early filling in diastole. Also shows decreased mitral inflow.
quick slamming of blood into the wall of the heart

“Square root” sign on heart cath (rapid ventricular filling followed by a plateau phase during the rest of diastole) related to the rigid pericardium impairing mid and late diastolic filling resulting in decreased and equal diastolic filling pressures in all the cardiac chambers

plateau in both R and L ventricles

Question 19

square root CPK =

Answer 19

square root sign in constrictive pericarditis with Kussmaul sign

Question 20

besides trauma, what 5 other causes are there for constrictive pericarditis

Answer 20

TB
post radiation
cardiac surgery
viruses
trauma

Question 21

What other cardiac entities would tend to simulate constrictive pericarditis

Answer 21

1) Restrictive cardiomyopathies*** amyloidosis
endomyocardial fibrosis
hemochromatosis
 sarcoidosis
  = decreased ventricular filling

2) LV diastolic dysfunction

Question 22

How does one differentiate CP

from restrictive heart disease?

Answer 22

One must do cardiac catherization to differentiate constrictive pericarditis (CP) from restrictive cardiomyopathy (RC). The LV end diastolic pressure is unequal (5 mmHg or higher) to the RV diastolic pressure in restrictive cardiomyopathy, whereas they are equal*** in constrictive pericarditis (square root sign). Also, pulmonary pressure is high in restrictive cardiomyopathy and low in constrictive pericarditis.

BNP - elevated in RC, but normal in CP.

Chest xray –
calcification in CP
LA enlargement in RC

EKG – BBB, hypertrophy, q waves, AV block in RC.

Question 23

what is the treatment for constrictive pericarditis ?

Answer 23

1. torsemide (bowel edema)
   thiazides
   aldosterone antagonist (ascites)
2. pericardiectomy - cut the calcific wall away from the heart.

Question 24

A 53 y/o homeless, alcoholic, male was admitted with a right hemiparesis. He had been seen in the ER two weeks ago and again one week ago after being picked up in the street by the police. He was found to have a fever of 38.3 degrees centigrade (101F) on both occasions. He was also found to be covered by body lice in each instance. A total of 6 blood cultures had been negative. Physical exam upon admission revealed a temperature of 39 degrees C, a diastolic descrendo murmur at Erbs area, and negative repeat blood cultures.
The patient receives an ECHO that shows no vegetations

1. what is the murmur?
2. Define the 3 weeks of fever and negative workup after 1 week of hospital evaluation.
3. What might you expect as the primary causes of an FUO?
   3-4 main
4. What actually causes the fever?

Answer 24

murmur–> aortic insufficiency

2. 
Rule of 3's
3 different days of office evaluation
Fever of undetermined origin?
Temp of 38.3 that has been present for 3 weeks with 3 different office evaluations or 1 week of inpatient evaluation 

3. Causes of FUO:
   infection- TB, endocarditis, occult abscess

Cancer - lymphoma, leukemia

Autoimmune/Connective tissue disease (SLE, cryoglobulinemia, PAN)

Drugs

4. IL1, IL6, TNF alpha - these produce prostaglandins (PGE2) via endothelial and glial receptor stimulation. Works in the hypothalamus to produce fever

Question 25

A 53 y/o homeless, alcoholic, male was admitted with a right hemiparesis. He had been seen in the ER two weeks ago and again one week ago after being picked up in the street by the police. He was found to have a fever of 38.3 degrees centigrade (101F) on both occasions. He was also found to be covered by body lice in each instance. A total of 6 blood cultures had been negative. Physical exam upon admission revealed a temperature of 39 degrees C, a diastolic descrendo murmur at Erbs area, and negative repeat blood cultures.
The patient receives an ECHO that shows no vegetations

does this patient meet Duk’es criteria for endocarditis?

Answer 25

1. Two major out of three criteria of:
   A. Two positive blood cultures
   B. Echo evidence of endocardial involvement (i.e. vegetations on the valve or free wall of ventricle, etc.)
   C. New regurgitant murmur (aortic or pulmonic insufficiency, or mitral or tricuspid regurg)
2. One major and 3 minor or 5 minor, with minor being:
   A. Predisposing condition (valve replacement)B. Fever of 38 degrees (1004F) or higherC. Vascular emboli: Janeway lesion (flat, painless, and septic microemboli), splinter hemorrhages (fingers), mycotic aneurysm (caught on atheroslcerotic plaque), conjunctival or cutaneous hemorrhage, PE, stroke, MI, etc.

vegetations are breaking off and emoblizing***

D. Immunologic phenomena with agglutinating antibodies: Osler node (painful and vasculitic), Roth spots, RF, GN (hematuria and proteinuria), etc.

antigen/antibody complex–> binds complement–> gets caught in capillaries

Question 26

what are the major dukes criteria

Answer 26

Two major out of three criteria of:
A. Two positive blood cultures
B. Echo evidence of endocardial involvement
C. New regurgitant murmur

Question 27

what are the minor Duke criteria

Answer 27

One major and 3 minor or 5 minor, with minor being:
A. Predisposing condition
B. Fever of 38 degrees (1004F) or higher
C. Vascular emboli: Janeway lesion (flat, painless, and septic microemboli), splinter hemorrhages, mycotic aneurysm, conjunctival or cutaneous hemorrhage, PE, stroke, MI, etc.

 D. Immunologic phenomena with agglutinating antibodies: Osler node (painful and vasculitic), Roth spots (eye), RF, GN (hematuria and proteinuria), etc.

Question 28

osler node

Answer 28

immunologic process

painful and vasculitic

Question 29

janeway lesions

Answer 29

flat, painless and septic microemboli

Question 30

A 53 y/o homeless, alcoholic, male was admitted with a right hemiparesis. He had been seen in the ER two weeks ago and again one week ago after being picked up in the street by the police. He was found to have a fever of 38.3 degrees centigrade (101F) on both occasions. He was also found to be covered by body lice in each instance. A total of 6 blood cultures had been negative. Physical exam upon admission revealed a temperature of 39 degrees C, a diastolic descrendo murmur at Erbs area, and negative repeat blood cultures.
The patient receives an ECHO that shows no vegetations

what organism is most likely involved with this patient and what would be the treatment?

Answer 30

Bartonella hensalae or quintana

Treatment: Doxycycline 200 mg daily x 6 weeks with gentamicin 3mg/kg/day for the first two weeks

Bacillary angiomatosis caused by Bartonella quintana in
an human immunodeficiency virus positive patient

Question 31

why does endocarditis develop?

Answer 31

set up by regurgitant valves, bicuspid valves, rheumatic valves, calcific valves, MVP, PDA, Coarctation, VSD

Question 32

different b/w acute and subacute endocarditis

Answer 32

Acute–> develops suddenly, very virulent organism (staph aureus), high fever, early embolization

subacute–> most commonly caused by strep viridans, previously abnormal valve, fatigue, low grade fever

Question 33

differentiate native valve from prosthetic valve endocarditis

Answer 33

native valve–>
from transient bactermia as from brushing teeth to IV devices. Now most commonly due to Staphylococcus***. May also be Strept viridans or bovis, group D streptococcus (enterococcus- someone with chronic urinary tract infections) or HACEK group.

Prosthetic valve–>
Early (within 2 mo) = coagulase + and – staphylococcus, or more rarely culture negatives and fungi.

Late–> = streptococcus or or staph (coag – and +)

Question 34

what if you have a patient that has endocarditis but there isn’t anything growing?

Answer 34

zoonotics* (coxiella, brucella, bartonella), fungi, or Streptococcus on prior antibiotics.

its a strep infection but the patient has been on antibiotics

Question 35

IV drug users have what organism as the cause of endocarditis?

Answer 35

most commonly Staph aureus –> usually seen on the tricuspid valve

Question 36

how do you make the diagnosis of endocarditis?

Answer 36

Draw 3 cultures one hour apart

– major criteria = 2 positives (three if skin contamination, ie. coag neg staph)

Question 37

what organisms are culture negative in endocarditis ?

Answer 37

Culture negative:
1. fungi

2. special media - Legionella, Bartonella, and Abiotrophia(nutritionally deficient strept)
3. No growth on artificial media - Tropheryma whipelli, Q fever or psittacosis pathogens,
4. slow growing with prolonged incubation - Brucella, anareobes, HACEK* (positive by 5 days)

HACEK =Aggregatibacter (Haemophilus) aphrophilus, Aggregatibacter (Acintobacillus)
actinomcetemcomitans, Cardiobacterium hominis, Eikenella corrodens***, Kingella

Question 38

A patient, who works for a computer company and has a history of a prosthetic aortic valve, has had a low grade fever, a new diastolic murmur at the aortic area and negative blood cultures for the past three months. Cardiac ECHO has shown no vegetations, but an abdominal aortic aneurysm (potential mycotic aneurysm***) was accidentally found. He has had a cat for 10 years. He is positive for RF (rheumatoid factor). What minor criteria for endocarditis are shown?

Non tender erythematous
lesions on soles and palms

Tender nodules on finger tips

The patient develops a syncopal episode and the EKG shows heart block…..
what has happened?
what are other complications of bacterial endocarditis”?

Answer 38

Roth spots, osler nodes, Janeway lesions

3 minor criteria!

what has happened?

Complications?
heart block (ECG)
 CHF
emboli (strokes)
mycotic aneurysms
myocardial abscess
lung abscess -due septic pulmonary emboli from the tricuspid valve

Question 39

A patient, who works for a computer company and has a history of a prosthetic aortic valve, has had a low grade fever, a new diastolic murmur at the aortic area and negative blood cultures for the past three months. Cardiac ECHO has shown no vegetations, but an abdominal aortic aneurysm (potential mycotic aneurysm***) was accidentally found. He has had a cat for 10 years. He is positive for RF (rheumatoid factor).

Most likely organism in this patient is:

A. Tropheryma whippelii  
B. Staph epidermidis  
C. Coxiella burnetii  
D. HACEK group  
E. Streptococcus viridans

Answer 39

Coxiella burnetii

Question 40

how do you treat strep endocarditis

Answer 40

Penicillin for 4 weeks

Question 41

enterococcal endocarditis treatment?

Answer 41

nursing home patients who have catheter in or have been treated many times for UTI get this

Penicillin plus gentamicin for 4-6 weeks

Question 42

how do you treat staph endocarditis

Answer 42

nafcillin for 6 weeks

if methicillin resistance use Vancomycin

Question 43

treatment for native valve

Answer 43

most likely it is strep so use Vancomycin for 3-6 weeks

Question 44

treatment for prosthetic valve

Answer 44

more likely to be staph - so use 3 antibiotics

rifampin (kills staph that is adhered to foreign material), vancomycin, gentamicin

for 6 weeks

Question 45

where does vancomycin work?

Answer 45

cell wall

Question 46

Gentamicin

Answer 46

30 S ribosome

Question 47

Rifampin

Answer 47

works on DNA/RNA dependent polymerase

Question 48

streptococcus bovis

Answer 48

came from GI tract/neoplasm

Question 49

Strep mutans

Answer 49

from brushing teeth–> poor dentition

Question 50

enterococci

Answer 50

elderly with urinary problem

Question 51

HACEK

Answer 51

prolonged incubation

Question 52

late prosthetic valve endocarditis (>2 mo)

Answer 52

more likely streptococcus

Question 53

IV drug user

Answer 53

staph aureus (or epidermis)

Question 54

alcoholics and street people

Answer 54

bartonella

Question 55

no growth endocarditis

Answer 55

tropheryma, Q fever

Question 56

When should endocarditis prophylaxis be used?

what is the antibiotic given?

Answer 56

Only in high risk cardiac populations, ie:
1. Previous IE (endocarditis)
2. Prosthetic valves or material
3. Cyanotic** congenital heart disease (ie. Tetralogy of Fallot,
Eisenmenger syndrome, etc.) (not so if repaired > 6 mo ago)

Only for perforating procedures of:

1. Teeth
2. Lungs
3. Skin 

Antibiotic:
Dental – amoxicillin 2 grams 1 hour before the procedure

Question 57

A 35 y/o female presents with fever, weight loss, leukocytosis, elevated sed rate, elevated RF, and episodic pulmonary edema and syncope, especially with standing. The patient had a recent stroke. A physical exam shows a diastolic rumble (sounds like mitral stenosis) with an occasional diastolic extra sound at the mitral valve area upon standing (tumor is “plopping” down) There is a lesion resembling an Osler node on her right great toe. This patient most likely has (a) (an):

A. atrial septal defect.
B. mitral stenosis.
C. aortic insufficiency.
D. triscupid endocarditis.
E. atrial myxoma.

Answer 57

atrial myoxma can present like endocarditis- tumor emobli!

it is not infective - cultures are negative

why syncope with standing?
myxoma occludes mitral or tricuspid valve b/c of obstructive cardiomyopathy

Question 58

atrial myxoma

Answer 58

Atrial myxoma – seen in Carney complex of pigmented skin lesions and endocrine neoplasia. Looks like a systemic illness with emboli-usually left atrium. Diastolic tumor plop and rumble, upright CHF. Cause is related to a cAMP activated protein kinase A with activated cell proliferation (PRKAR1A gene); a multiple neoplasia syndrome.