Diseases of Pericardium / Endocarditis Flashcards
hx: 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 shows?
pt. has lyme disease –> pericarditis
EKG shows depressed PR interval
pericardial pain
pleuritic and postural (worse supine, relieved by sitting). It also tends to be substernal and may be associated with dyspnea, fever and rub.
stages of pericarditis as seen on EKG?
Stage 1 – widespread STE and PR depression with reciprocal changes in aVR (occurs during the first two weeks) - see fireman hat sign in ALL leads
Stage 2 – normalization of ST changes; generalized T wave flattening (1 to 3 weeks)
Stage 3– Flattened T waves become inverted (3 to several weeks)
Stage 4 – ECG returns to normal (several weeks onwards)
causes of pericarditis
- usually VIRAL (cocksacki or echo)
- TB (subacute w/ nighsweats)
- bacterial (toxic)
- uremia (shaggy/hemorrhagic, exudative)
- neoplastic (see tamponade)
- inflamm. rxn/dresslers (increased SR; days to several months after MI or surgery)
- radiation - usually first year
- drugs: clozapine
- myxedema (cholesterol crystals)
- autoimmune (SLE)
lab abnormalities seen in patient with myocarditis?
- many pts. with pericarditis also have myocarditis- will see elevated troponin levels, heart block, wall motion abnormalities, CHF
The ECG findings most commonly seen in myocarditis are diffuse T wave inversions; saddle-shaped ST-segment elevations may be present (these are also seen in pericarditis)
early/late disseminated lyme disease?
early: The classic triad of acute neurologic abnormalities: meningitis, cranial neuropathy*, and motor or sensory radiculoneuropathy, although each of these findings may occur alone.
Cardiac involvement with heart block and myopericarditis
Late lyme disease: see oligoarthritis
what causes pulsus paradoxus?
cardiac tamponade
- this is when systolic pressure drops with inspiration
Case: 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.
what is this called? whats seen on EKG?
Beck’s triad: JVD, muffled hearts sounds, low BP
EKG: see electrical alterans – pt. has pericardial tamponade, there has been some sort of secretion of fluid that’s surrounding the heart
think of when see Beck’s Triad?
“Dr. Beck, you PAY for the CT”
Becks triad, Pulsus paradoxus, electrical Alterans, slowed Y descent, Cardiac Tamponade
Beck’s triad: muffled heart sounds, decreased BP, ++ JVP
Pulsus paraxodus seen: inspiratory drop in systolic pressure
electrical alterans: see alternating sizes of QRS complexes due to swinging heart in fluid
slowed Y descent: atria has hard time emptying due to cardiac tamponade
Cardiac tamponade, when fluid accumulates in pericardium causing restriction of heart contraction
tx for cardiac tamponade?
pericardiocentesis - aspiration of the effusion around the heart
case: A 55 year old female with a remote history of chest trauma presents with fatigue, weakness, elevated JVP, edema, and hepatomegaly with ascites*. Kussmaul sign is present.
Kussmaul sign: when pt. takes breath the JVD increases - this is most often seen in contstrictive pericarditis
Kussmaul sign
seen in constrictive pericarditis = increasing of JVD when patient takes deep breath
(This sign can also be positive in severe COPD, pulmonary hypertension with RV failure, and more rarely in cardiac tamponade).
JVP wave in pt. with CP
constrictive pericarditis = heart in a steel cage - when the tricuspid opens its abrupt and sharp - results in sharp y descent giving an “M or W” configuration
JVP in CP vs. tamponade?
Tamponade – slow y descent
Constrictive pericarditis with
M or W configuration related
to early and abrupt diastolic
filling with rapid (sharp) X and Y descent.
Square root of CPK
- Square Root sign: seen on heart cath due to rapid ventricular filling followed by plateau phase during rest of diastole - related to rigid pericardium impairing mid/late diastolic filling resulting in decreased and equal diastolic filling pressures in all of the cardiac chambers
- Constrictive Pericarditis:
- Kussmaul Sign: increased JVD with deep breath
also think: pericardial knock and W/M waves
auscultation of CP?
Diastolic pericardial knock (auscultation - like an S3) and “septal bounce” (ECHO) due to rapid early filling in diastole. Also shows decreased mitral inflow.
Other causes of constrictive pericarditis?
TB Post radiation Cardiac surgery Viruses trauma
How to tell restrictive cardiomyopathy from constrictive pericarditis?
Restrictive cardiomyopathies (amyloidosis, endomyocardial fibrosis, hemochromatosis, sarcoidosis, etc) = decreased ventricular filling or LV diastolic dysfunction.
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).
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.
tx for constrictive pericarditis?
Torsemide (bowel edema), thiazides, aldosterone antagonist (ascites).
pericardiectomy
homeless man, right hemiparesis, fever of 101, 6 blood cultures are negative, PE shows diastolic crescendo murmur at Erbs area, negative blood cultures.
- endocarditis ?
- EKG shows no vegetations
- due to bartonella hensalae or quintana (very difficult to colonize and grow)
Rules of 3’s - FUO
Fever of undetermined origin = fever for less than 6 mos, temperature of 38.3, 3 weeks of fever, negative work up on three different office evaluations
primary causes of FUO
Infection (TB, endocarditis, abscess)
- Cancer (lymphoma, leukemia)
- AI/CT disease (Still’s disease, SLE, cryoglobulinemia, PAN)
what causes fevers?
IL1 (endogenous pyrogen), IL6, TNFalpha: these all produce PGE2 via endothelial and glial receptor stimulation –> works on hypothalamus to produce fever
Duke’s criteria?
Need 2 major, on major and 3 minor, or 5 minor
Major criteria:
- Two positive blood cultures
- Echo evidence of endocardial involvement
- new regurg. murmur
Minor criteria:
1. predisposing condition (i.e. valve replacement)
- fever of 38 degrees or higher (100F)
- vascular emboli (vegetations that break off and implant in vessels)
- Janeway lesions (painless, flat, septic emboli)
- splinter hemorrhages (under finger nails)
- mycotic aneurysm (aneurysms can occur in arterial wall due to emboli, often aorta)
- conjunctival/cutaneous hemorrhage, PE, stroke, MI - Immunologic phenomena with agglutinating bodies:
- Osler nodes (painful and vasculitic)
- Roth Spots (retinal hemorrhages with pale centers)
- RF
- GN (hematuria/proteinuria)
tx for bartonella hensalae/quintana
Doxycycline 200 mg daily for 6 weeks
or
Gentamicin 3 mg for first two weeks
why does infective endocarditis develop? acute vs. subacute?
- Endocarditis is set up by regurigtant valves, bicuspid valves, rheumatic valves, calcific valves, MVP, PDA, coarctation, VSD
- Acute endocarditis manifests with virulent organisms: sudden, virulent, massive heart problems, hear valvular regurgitation, high fever, early embolization (this is often due to staph)
- Subacute endocarditis: more slowly developing, often due to strep viridans
Native valve endocarditis
- occurs from transient bacteremia as from brushing teeth and IV devices
- most commonly due to Staphylococcus
- May also be strep viridans, bovis or group D strep (enterococcus) or HACEK group
Drug use endocarditis
IV drug users most often get staphylococcus infection- esp. of the tricuspid valve
- second most common is enterococcus and streptococcus
Prosthetic valve endocarditis?
Early (w/in 2 mos.) = coagulase + and - staphylococcus (all staph is catalase positive, only staph aureus is coagulase positive), more rarely culture negatives and fungi
Late endocarditis: streptococcus or staph (coag + or -)
- culture negatives: zoonotics, fungi, sptretococcus on prior antibiotics
zoonotics
coxiella burnetti: “q fever”
- obtained from cattle, sheep, goats, cats
- causes Q fever, soaking sweats, h/a, no rash, endocarditis
brucella: obtained from goats, pigs, cows, dogs: acqd through direct contact w/ animal mean, infected milk (seen in vets, travelers, farmers)
- results in fever, chills, sweat, loss of appetite and undulant fever, endocarditis
bartonella henselae:
- “cat-scratch disease” - see enlarged lymph nodes, low grade fever, malaise, bacillary angiomatosis (nodules), endocarditis that is culture negative
- all are really hard to grow and will most likely show up culture negative
HACEK
slow growing organisms with prolonged incubation (takes 5 days for positive culture):
Haemophilus Acintobacillus cardiobacterium hominis eikenella corrodens (human bite!) kingella
how to ddx endocarditis via culture?
- draw 3 cultures one hour apart in 3 different areas (major Duke’s criteria)
- if there are 2 positive or if there are 3 with one including coagulase negative staph.
culture negative in endocarditis?
- fungi
- special media: legionella, bartonella, abiotrophia
- no growth on artificial media: coxiella (Q fever), psittacosis
- slow growing with prolonged incubation: brucella, anerobes, HACEK
Hx: prosthetic aortic valve, low grade fever, new diastolic murmur at aortic area, negative blood cultures for 3 mos, cardiac echo shows no vegetations, abdominal aortic aneurysm found. has had a cat for 10 years. has positive RF, has osler nodes, janeway lesions, roth spots
coxiella burnetti –> endocarditis
abdominal aortic aneurysm is due to the mycotic aneurysm catching on the aorta and starting to grow
minor criteria: janeway lesions, aneurysm, roth spots, osler nodes, fever, RF…. has endocarditis
mycotic aneurysm
A mycotic aneurysm is an aneurysm arising from bacterial infection of the arterial wall. It can be a common complication of the hematogenous spread of bacterial infection
why do you see syncope in endocarditis?
see heart block due to endocarditis invading the myocardium and causing electrical problems
complications of endocarditis?
heart block seen on EKG, CHF, emboli/strokes, mycotic aneurysms, myocardial abscesses
(Remember infiltrative cardiac diseases can produce restrictive heart disease and lead to CHF and heart block as in scleroderma, hemochromotosis, amyloidosis, etc)
tx for streptococcus endocarditis?
penicillin for 4 weeks
tx for enterococcal endocarditis
penicillin + gentamicin for 4-6 weeks
- seen in nursing homes, with catheter placements and UTIs
tx fo staph endocarditis?
nafcillin for 6 weeks
if methicillin resistant then use vancomysin for 6 weeks
tx for native valve endocarditis?
Vancomycin for 4-6 weeks (covers staph, strep, enerococcus)
Switch when cultures return
tx for prosthetic valves?
same as native valve except 3 agents are used for staph (rifampin, vancomycin, gentamycin) for 3 weeks!!!
need to know that you use these three for staph.
rifampin is important b/c it kills staph that is adhered to foreign material, the other ones don’t
staph saprophyticus
coagulase - staph, seen in women often due to UTIs
describe the antibacterial effects of three meds used to tx staph?
- vancomycin: acts at cell wall
- gentamicin: works on ribosome 30s
- rifampin works on DNA dependent RNA polymerase
streptococcus bovis
type of Group D strep that causes GI neoplasms and is associated with colon cancer
streptococcus mutans
associated with poor dentation –> endocarditis
enteroccoci
Group D strep, found in bowel flora, associated with elderly with urinary problems
- 2nd/3rd most common cause of hospital acquired infection - UTIs and prosthetic valve endocarditis
HACEK
this group has prolonged incubation
what bacteria are associated with late prosthetic valve (> 2 mos)?
Strep, or staph
IV drug users bacteria?
staph aureus or epidermis
alcoholics and street people bacteria?
Bartonella henselae
what population must use endocarditis prophylaxis? what to use and when?
- previous IE
- prosthetic valves or material
- cyanotic congenital heart disease (TF, Eisenmenger syndrome, unless repaired ofver 6 mos ago)
use for perforating procedures of:
teeth, lungs, skin
give amoxicillin 2 grams 1 hour before dental procedure
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 with an occasional diastolic extra sound at the mitral valve area upon standing. There is a lesion resembling an Osler node on her right great toe. This patient most likely has (a) (an):
if pt. has atrial myxoma it can present as endocarditis, but if its not infected and is tumor emboli it will look like endocarditis (cultures will be negative) – pt. has fever and w/l, elevated sed rate (can get in atrial myxoma), pulmonary edema
syncope seperates it out – pt. with atrial myxoma gets syncope when standing up due to obstruction – get diastolic rumble sounding like mitral stenosis (usually in left atrium into ventricle), have an extra diastolic sound when standing up, tumor plops down in there
Looks like a systemic illness with emboli-usually left atrium. Diastolic tumor plop and rumble, upright CHF.
