Endocarditis

Question 1

Strongest risk factor for infective endocarditis

Answer 1

Previous episode of endocarditis

Question 2

Risk factors for IE

Answer 2

Rheumatic valve disease 
Prosthetic valves 
Congenital heart defects 
IVDU 
Recent piercings

Question 3

Valve most commonly affected by IE

Answer 3

Mitral valve

Question 4

Most common organisms that cause IE

Answer 4

Staph aureus(now most common, esp in IVDUs)

Strep viridans(historically most common)

Coagulase negative staph such as staph epidermis

Question 5

What are IEs from strep viridans linked to

Answer 5

Poor dental hygiene or following a dental procedure

Question 6

What are IEs from staph epidermis linked to

Answer 6

Staphylococcus epidermidis
commonly colonize indwelling lines and are the most cause of endocarditis in patients following prosthetic valve surgery, usually the result of perioperative contamination.

Question 7

Non-infective causes of IE

Answer 7

systemic lupus erythematosus (Libman-Sacks)

malignancy: marantic endocarditis

Question 8

Culture negative causes of IE

Answer 8

prior antibiotic therapy
Coxiella burnetii
Bartonella
Brucella
HACEK

Question 9

What is HACEK

Answer 9

Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella

Question 10

Pathophys of IE

Answer 10

Endocardial injury → adherence of platelet and fibrin plug → circulating micro-organisms leads to secondary infection of plug → activation of coagulation cascade → adherence of more fibrin and platelets → growth of plug/vegetation

Question 11

Symptoms of IE

Answer 11

Fever(90%)  
Chills 
Anorexia 
Weight loss 
Malaise 
Arthralgia 
Night sweats 
Abdominal pain

Question 12

Signs of IE

Answer 12

Heart murmurs(usually only present in left-sided) 
Cutaneous manifestations 
Janeway lesions 
Osler nodes 
Roth spots

Question 13

Cutaneous manifestations of IE

Answer 13

Petechiae on extremities or mucous membranes (30%)
Splinter haemorrhages (reddish-brown linear lesion on the nail bed)

Question 14

What are janeway lesions

Answer 14

non-tender macules on palms and soles, more associated with acute onset

Question 15

What are Osler nodes

Answer 15

tender nodules on fingers and toes

Question 16

What are Roth spots

Answer 16

haemorrhagic retinal lesions with a pale centre

Question 17

Poor prognostic factors for IE

Answer 17

Staphylococcus aureus infection
Prosthetic valve (especially ‘early’, acquired during surgery)
Culture negative endocarditis
Low complement levels

Question 18

Indications for surgery in IE

Answer 18

severe valvular incompetence
aortic abscess
infections resistant to antibiotics/fungal infections
cardiac failure
recurrent emboli after antibiotic therapy

Question 19

What can indicate an aortic abscess in IE

Answer 19

often indicated by a lengthening PR interval

Question 20

Suggested antibiotic therapy in native valve IE

Answer 20

Amoxicillin

Question 21

Suggested antibiotic in IE caused by staph

Answer 21

Flucloxacillin

Question 22

Suggested antibiotic in IE caused by fully-sensitive strep

Answer 22

Benzylpencillin

Question 23

Criteria used to diagnose IE

Answer 23

Modified Duke criteria

Question 24

Major criteria for IE diagnosis

Answer 24

Positive blood cultures

Evidence of endocardial involvement(Echo, new valvular regurg)

Question 25

Blood culture recommendation for IE

Answer 25

At least 3 samples from different sites over 30-60 mins is recommended.

Adequate blood culture samples must be taken before starting any antibiotics, regardless of the clinical decision to start empirical antibiotics or to delay treatment.

Question 26

First line imaging ix for IE

Answer 26

Transthoracic echo usually

Transoesophageal echo has a higher sensitivity and is preferred if available

Question 27

Cardiac complications of IE

Answer 27

Valvular insufficiency, if left untreated, leading to congestive heart failure is the most common

Pericarditis

Perivalvular abscess

Question 28

Complications of IE from metastatic infection

Answer 28

Embolisation (which can lead to infarction and subsequent damage to various peripheral tissues)
Metastatic abscess formation
Mycotic aneurysms

Question 29

Type of complications - right-sided vs left sided IE

Answer 29

Systemic emboli affecting the brain, kidneys, spleen, and other soft tissues commonly occurs in left sided IE whereas pulmonary emboli most commonly occur in right sided IE.

Question 30

Pulmonary complications of IE

Answer 30

Septic pulmonary emboli (75% of cases with right sided IE) can manifest as pulmonary infarction or can lead to to a pulmonary infection, abscesses, pleural effusion, and empyema.

Question 31

neurological complications of IE

Answer 31

Neurological complications (40%) (including embolic stroke, intracerebral haemorrhage, cerebral abscess, meningitis, encephalopathy, seizures)

Question 32

Renal complications of IE

Answer 32

The most common renal complications include renal infarction, abscess (which are both secondary to septic embolisation) can present with isolating clinical features eg. costovertebral angle tenderness or with acute renal failure.

Question 33

MSK complications of IE

Answer 33

Vertebral osteomyelitis
Septic arthritis
Psoas abscess

Question 34

Causes of myocarditis

Answer 34

Viral - coxsackie B, HIV
Bacterial - diphtheria 
Lyme disease 
Toxoplasmosis 
Autoimmune

Question 35

Which drug is associated with myocarditis

Answer 35

Doxorubicin

Question 36

Presentation of myocarditis

Answer 36

usually young patient with an acute history
chest pain
dyspnoea
arrhythmias

Question 37

ECG changes in myocarditis

Answer 37

tachycardia
arrhythmias
ST/T wave changes including ST-segment elevation and T wave inversio

Question 38

Mx of myocarditis

Answer 38

treatment of underlying cause e.g. antibiotics if bacterial cause

supportive treatment e.g. of heart failure or arrhythmias

Question 39

Complications of myocarditis

Answer 39

heart failure
arrhythmia, possibly leading to sudden death
dilated cardiomyopathy: usually a late complication