Clinical Pathological Correlation Flashcards
- 24 year old man presents with fever and exertional shortness of breath
- Previously well
- smoker, daily marijuana, occasional IVDU
- General malaise with subjective fevers and chills for 2-3 weeks • Lack of appetite, night sweats • One week of shortness of breath with exertion • Progressed to dyspnea with one flight of stairs • 2 pillow orthopnea, no paroxysmal nocturnal dyspnea • Mild cough with no sputum or hemoptysis • No recent travel, no sick contacts, no COVID exposure • No chest pain, occasional fast heartbeats with lightheadedness but no frank syncope
What is this clinical picture consistent with?
splinter hemorrhage, dyspnea, fever, murmur = endocarditis!!
Classical symptoms include: fevers chills nightsweats, anorexia/weight loss, congestive heart failure, NEW murmur
Risk factors for endocarditis
- pathological valve; rheumatic valve, degenerative valve, mtral valve prolapse, congenital heart disease
- patient factors: >30, IVDU, immunosuppression, poor dentition
- implanted devices ; prosthetic valve, pacemaker ICD, indwelling catheter.
5 characteristic physical exam findings of infective endocarditis (SOJOS)
- splinter hemorrhages
- osler nodes
- janeway lesions
- ocular findings
- splenomegaly
“2 options” for a new systolic murmur
- obstruction to systolic flow = STENOSIS of a semilunar valve (aortic or pulmonary)
- Turbulent flow in the wrong direction = regurgitation of an AV valve (mitral or tricuspid)
investigations for you suspecting infectious endocarditis
CXR and ECG fo sho
TEE ECHO
most common organism for infectious endocarditis
staph aureus
major criteria for infectious endocarditis
- typical microorganism for infective endo from 2 separate blood cultures
- evidence of endocardial involvement; oscillating intracardiac mass, on valve or supporting structures, or in the path or regurgitant jets.
- new valvular regurgitation/murmur
minor criteria for IE
- predisposing heart condition or IVDU
- fever
- vascular phenomena; emboli, septic pulmonary infarcts, mycotic aneurism, intracranial hemorhage, conjunctival hemorhage, janeway lesions
- immunologic phenomena; glomulonephrtisi, osler nodes, roth spots, rheumatoid factor
complications of IE
- sepsis
- thromboembolic events: stroke, mycotic aneurysm
- valvular destruction; heart failure
- abscess formation: heart block in aortic valve IE
management of IE
- consultation
- antibiotics
- surgery
which bacteris is the most common cause ofinfective endocarditis today?
a) Enterococcus faecalis b) Pseudomonas aeruginosa c) Staphylococcus auerus d) Escherichia coli
c. staphylococcus auerus
virulence factors of IE organisms include
- adhesion
- vegetation maturation
- tissue destruction
- chronicity
give examples of each virulence factor.
most of the IEagents are gram positive- staph A, streptococcus viridans, enterococcus etc. What are the gram negatives?
HACEK and non-HACEK
HACEK = H. influenzae, actinobacillus, cardiobacterum, eikenalla corroden, kingella.
non hacek = e. coli, klebsiella, pseudomonas.
examples of targeted gram positive agents
penicillin, amplicillin, cloxacillin, cefazolin, vancomyin
should you choose bactericidal or bacteriostatic antibiotics for IE
bactericidal– Beta lactams
Note: there’s a role of adjuvant antibiotic agents.
- aminoglycosides for enterococcus and streptococcus
- rigampin- prostehtic vavle.
route of administration for endocarditis
IV generally preferred
what is the duration of therapy when treating IE and what is the “start date of effective therapy” definition
4-6 week.
start date of effective therapy: date of first negative blood culture.
