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Endokarditt - Amboss Flashcards

1
Q

Hvilken etiologi har endokarditt?

A

Staphylococcus aureus

Viridans sterptococci

Staphylococcus epidermidis

Entereococci; spesielt enterococcus faecalis

Streptococcus gallolyticus subsp. gallolyticus (Sgg); Formerly known as Streptococcus bovis biotype I

Gram-negative HACEK-gruppen: Haemophilus species, Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella kingae

Fungal endokarditt; Candida, Aspergillus fumigatus

Coxiella burnetii og Bartonella arter

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2
Q

Hva karakteristikk har endokarditt forårsaket av S.aureus?

A
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3
Q

Hva karakteristikk har endokarditt forårsaket av viridans streptokokker?

A
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4
Q

Hvilken karakteristikk har endokarditt forårsaket av S.epidermidis?

A
S. epidermis is a skin commensal for which peripheral lines provide an easy port of entry.
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5
Q

Hvilke karakteristikk har endokarditter forårsaket av Enterokokker?

A
Resistant to penicillin G and cephalosporins (intrinsic cephalosporin resistance). E. faecalis is a common cause of UTIs, and it is also associated with catheter and pelvic infections.
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6
Q

Hvilke karakteristikk har endokarditter som skyldes S.gallolyticus?

A
Formerly known as Streptococcus bovis biotype I. The colonic tumor provides an entry point for bacteria.
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7
Q

Hvilke karakteristikk kjennetegner endokarditt forårsaket av HACEK?

A
Haemophilus species, Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella kingae.
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8
Q

Hvilke karakteristikk har endokarditter som forårsakes av fungi?

A
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9
Q

Hvilke karakteristikk har endokarditter som forårsakes av Coxiella burnetii og Bartonella arter?

A
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10
Q

Hvilken demografisk gruppe er i risikosonen for infeksiøs endokarditt (IE)?

A

Menn

Alder > 60 år

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11
Q

Hvilke hjertelidelser er en risikofaktor for IE?

A
Two-thirds of cases of CIED-associated endocarditis appear within a year of device implantation or manipulation, often within the first 3 months.
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12
Q

Hvilke ikke-kardielle risikofaktorer finnes for IE?

A
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13
Q

Hvordan er patogenesen til endokarditt?

A
Undamaged native valves are usually not susceptible to either thrombus formation or colonization by most types of bacteria (except for S. aureus).
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14
Q

Hvilke klaffer rammes oftest ved endokarditt?

A

“Don´t tri drugs for the sake of your tricuspid valves.”

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15
Q

Hvilke kliniske konsekvenser har patogenesen ved endokarditt?

A
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16
Q

Hvilke konstitusjonelle symptomer opplever pas. med endokarditt?

Konstitusjonelle = generelle

A
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17
Q

Hvilke kardielle manifestasjoner kan endokarditt føre til?

A

IE should always be considered as a cause of fever of unknown origin (FUO), especially in the presence of a new heart murmur.

Valvular stenosis due to IE occurs only rarely. May not be detectable on auscultation because of the low-pressure gradient across the valve. Diastolic murmurs that are loudest along the left sternal border typically suggest aortic regurgitation due to valvular disease, while murmurs that are loudest at the right sternal border suggest regurgitation due to aortic root dilation. More common in left-sided IE.

https://youtu.be/9bjWdJ-dfg0

https://youtu.be/waFHKp8uX6k

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18
Q

Hvilke årsaker er det som gir de ekstrakardielle manifestasjonen ved IE?

A

Up to one-third of patients with left-sided IE present with symptoms of stroke.

Vascular immunologic phenomena (e.g., Osler nodes, glomerulonephritis) are typically late manifestations of subacute bacterial endocarditis; they are less common in acute bacterial endocarditis given its rapid evolution.
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19
Q

Hvilke ekstrakardielle manifestasjoner ses ved IE?

A

Perifere embolier og immunologiske fenomener

Embolier til intraabdominale organer

Nevrologiske manifestasjoner

Pulmonale manifestasjoner

Artritt

“FROM JANE: Features of IE include Fever, Roth spots, Osler nodes, Murmur, Janeway lesions, Anemia, Nail bed hemorrhage and Emboli

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20
Q

Hva er tegn på perifere embolier og immunologiske fenomener ved IE?

A
Reports vary; previously it was thought that peripheral signs of embolic and immunologic phenomena were present in up to 50% of patients. Caused by septic microemboli from infected cardiac valves. Characterized histologically by microthrombi that form at the site of retinal capillary damage.
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21
Q

Hva viser bildet?

A
Splinter hemorrhages in endocarditic; The vertical hemorrhages (arrowheads) underneath this patient's fingernails are most commonly caused by trauma but can also occur as a result of immune complex deposition or microthrombosis in subacute, infective endocarditis, SLE, or rheumatoid arthritis.
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22
Q

Hva viser bildet?

A
Janeway lesions: Multiple erythematous macules are visible on the thenar eminence and the base of the thumb. These Janeway lesions are typically caused by septic microembolisms secondary to infective endocarditis.
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23
Q

Hva viser bildet?

A
Osler nodes: There are multiple raised nodular lesions on the palm and palmar aspects of the first and second digits. The lesions appear dark brown, indicating subcutaneous hemorrhages. This is the typical appearance of Osler nodes.
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24
Q

Hva viser bildet?

A
Roth spots; Fundus photography of a left eye: There are multiple red, white-centered lesions, which reflect small retinal hemorrhages with central accumulation of leukocytes or fibrin thrombocyte emboli (examples indicated by arrowheads). Although these findings were formerly considered to be associated almost exclusively with infective endocarditis, they may actually occur in a variety of conditions, including hypertensive, diabetic, and HIV-related retinopathy; leukemia; and intracranial hemorrhage. Circle: optic disc; M= macula.
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25
Q

Hvilke embolier til intraabdominale organer kan IE føre til?

A
LUQ; Left upper quadrant.
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26
Q

Hvilke nevrologiske manifestasjoner kan endokarditt føre til?

A
Among patients with left-sided IE, 20–35% present with symptoms and signs of an ischemic stroke and ∼ 50% have evidence of an ischemic stroke on imaging.
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27
Q

Hvilke pulmonale manifestasjoner kan IE føre til?

A
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28
Q

Ved hvilken type forekommer artritt ved IE?

A

Forekommer hovedsakelig ved subakutt IE

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29
Q

Fyll inn figuren?

A
Clinical features of infective endocarditis.
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30
Q

Hvordan kan man klassifisere IE?

A
Although this is not a definitive classification system, it can help in the approach to management and selection of empiric antibiotic regimens.
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31
Q

Hvordan kan man klassifisere IE basert på hvilken hjerteklaff som er affisert?

A
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32
Q

Ved akutt bakteriell endokarditt, hvordan er hhv.:
- Kliniske trekk
- Hovedpatogener
- Affektere klaffer

A
Vegetations are conglomerates of bacteria, platelets, fibrin, and inflammatory cells.
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33
Q

Ved subakutt bakterielle endokarditt, hva er hhv.:
- Kliniske trekk
- Hovedpatogener
- Affektere hjerteklaffer

A
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34
Q

Ved endokarditt hos pas. med prostetisk hjerteklaff, hva er hhv.:
- Kliniske trekk
- Hovedpatogener
- Affektere hjerteklaffer

35
Q

Hvordan klassifiserer man IE basert på lokalisasjon?

A

Høyresidig IE

Can apply to both native valve endocarditis and prosthetic valve endocarditis

Venstresidig IE

Can apply to both native valve endocarditis and prosthetic valve endocarditis.

36
Q

Ved høyresidig endokarditt, hva er hhv.:
- Klassiske kliniske trekk
- Hovedpatogener
- Affektere hjerteklaffer

A
In patients with a patent foramen ovale and/or septal defects, right-sided endocarditis may cause systemic embolism.
37
Q

Ved venstresidig endokarditt, hva er hhv.:
- Klassiske kliniske kjennetrekk
- Hovedpatogener
- Affektere hjerteklaffer

38
Q

Hvordan tilnærmerer man seg diagnostikken ved mistanke om IE?

A
At least three separate sets of blood cultures are recommended prior to initiating antibiotics. Transthoracic echocardiography (TTE) is the initial imaging modality of choice as it is less invasive. The need for transesophageal echocardiography (TEE) is assessed based on patient risk factors and TTE findings.
39
Q

Hva regnes som hovedkriterier i “Modified Duke criteria”?

A
The first and last sample should be obtained at least 1 hour apart.
40
Q

Hvilke kriterier regnes som bikriterier i “Modified Duke kriterier”?

A
It is not entirely clear which conditions are considered a clear predisposition and therefore a minor criterion. Common examples include prior episodes of IE and the presence of valvular defects. Arterial emboli, septic infarctions, intracranial or conjunctival hemorrhages, mycotic aneurysm, Janeway lesions. Glomerulonephritis, Osler nodes, Roth spots, positive rheumatoid factor.
41
Q

Hvilke patologiske funn bruker man i “Modified Duke criteria”?

A
From the examination of a vegetation (including emboli) or an intracardiac abscess.
42
Q

Ved bruk av Dukes kriterier, når regnes det som en:
- Definitiv IE
- Mulig IE
- Ikke IE

A
When antimicrobial therapy has been given for ≤ 4 days.
43
Q

Hvilke varianter har de modifiserte Dukes kriterier en lavere sensitivitet?

A

The Duke criteria have decreased sensitivity for some conditions, among them prosthetic valve endocarditis, right-sided endocarditis, and infection of a cardiac device.

Adequate assessment of patients with IE can be challenging and requires experience and an individualized approach.

44
Q

Hvilke rutineblodprøver bør tas ved mistanke om endokarditt?

A
Inflammatory markers may be within normal range. Up to 50% of patients with endocarditis may have hematuria secondary to renal infarct and/or glomerulonephritis.
45
Q

Hvordan skal man tolke blodkulturer ved IE?

A
Fungal cultures are not routinely recommended initially (Candida is the most common fungal pathogen and grows in standard cultures). The reported percentage of blood culture-negative endocarditis differs widely in the literature (2–40%). A single dose of antibiotics usually does not result in negative cultures. Even with effective treatment, it may take several days for bacteremia to resolve.
46
Q

Hvilken type ekkokardiografi er indisert hos alle pas. med IE?

A
In clinical practice, TEE is often routinely performed if IE is suspected. However, the 2015 AHA guidelines state that if clinical suspicion for IE is low (e.g., in otherwise healthy patients with fever of unknown origin) TTE alone may be sufficient.
47
Q

Når er det indikasjon for å utføre en transøsofagal ekkokardiografi (TØE = TEE)?

A
E.g., prosthetic heart valve, congenital heart disease, history of endocarditis, new murmur, heart failure, peripheral signs of endocarditis. Repeat after 3–5 days if TEE is negative but suspicion remains high.
48
Q

Hva regner man er funn på TTE/TEE som er en indikasjon på IE?

A
A thickened nonhomogeneous area around the valve with a hypoechoic or hyperechoic appearance. Visible as new valvular regurgitation with or without the presence of a vegetation/abscess and rocking motion of the prosthesis. Valvular tissue showing a saccular bulging. Reduced right or left ventricular function.
49
Q

Hva viser bildet?

A
Bacterial endocarditis of the mitral valve; Echocardiography (transesophageal; mid esophageal two-chamber view): An irregularly shaped vegetation (red overlay) is seen on the mitral valve (green overlay). LA: left atrium; LV: left ventricle.
50
Q

Hva viser bildet?

A
Aortic valve vegetation; Echocardiography (transesophageal; mid esophageal long axis view): A vegetation (red arrow) is seen as an echogenic structure on the right coronary cusp (green overlay) of the aortic valve. A: aorta; LA: left atrium; LV: left ventricle; RV: right ventricle.
51
Q

Hva viser bildet?

A
Perivalvular abscess of aortic valve; A 60-year-old woman with increasing shortness of breath, fever, and chest discomfort following aortic valve replacement The mid esophageal aortic valve short axis view demonstrates perivalvular thickening and irregularity (arrowhead) and a mobile hyperechoic mass arising from the aortic valve (arrow). These findings are consistent with infective endocarditis associated with a perivalvular abscess of a prosthetic aortic valve.
52
Q

Hvilke andre us. er akt. ved diagnostisering av IE?

A

Serologi

Vevsprøver

EKG

Bildediagnostikk

Us. av tannstatus

Kolonoskopi

53
Q

Hvorfor bør man ta serologi ved IE?

54
Q

Hvorfor bør man ta vevsprøver ved IE?

A
The type of infiltrating cells, degree of destruction, and presence of fibrin deposition will depend on the pathogen. Highly virulent organisms typically lead to extensive neutrophilic infiltration, areas of tissue destruction, and large colonies of microorganisms. Less virulent organisms are associated with findings of focal colonies, neutrophils, and evidence of healing (fibrin deposition and mononuclear inflammatory cells). Culture of the cardiac valve vegetation is part of the pathological criteria in the modified Duke criteria. Routine culture of valves that are removed for reasons other than endocarditis is not recommended. Can also be done using blood samples but using resected heart valve tissue is more common.
55
Q

Hvorfor tar man EKG ved IE?

A

Obtain an ECG in all patients with suspected IE to assess for new conduction abnormalities (e.g., AV block, bundle branch block) that suggest the development of a perivalvular or myocardial abscess. Consider urgent cardiac imaging (e.g., TEE, cardiac MRI) if these abnormalities are present.

ECG is usually repeated daily. Timing should be determined based on findings and clinical course of the patient.
56
Q

Hvorfor er det indikasjoner for bildediagnostikk ved IE?

57
Q

Hva viser bildet?

A
Septic pulmonary emboli; X-ray chest (supine) of a 24-year-old patient with history of intravenous drug use and septic emboli: Numerous pulmonary nodules are present in both lungs (examples indicated by green overlay). Some nodules have lucent centers indicating cavitation (examples indicated by red overlay). Air-space opacities, which were better appreciated on a subsequent CT scan (not shown), obscure the margins of some nodules. The cardiac silhouette appears prominent as a result of rotation of the patient to the left. The differential diagnosis of causes of multiple cavitary lung nodules includes bacterial, tuberculous, fungal, and parasitic infections as well as several noninfectious causes (e.g., rheumatic diseases and malignancies). Arrowheads: thoracic spine spinous processes; dashed lines: medial clavicles; yellow overlay: right central line.
58
Q

Hvilke patologiske funn forekommer ved akutt endokarditt?

59
Q

Hvilke patologiske funn forekommer ved kronisk endokarditt?

60
Q

Hva viser bildet?

A
Infective endocarditis; Photograph of a dissected heart specimen opened to show the endocardial aspect of left atrium and ventricle: The mitral valve is thickened (indicated by arrow) and shows numerous yellow vegetations on the atrial (superior) aspect of the valve (examples indicated by arrowheads). This gross appearance is typical of infective endocarditis of the mitral valve.
61
Q

Hva viser bildet?

A
Valve thrombosis in recurrent endocarditis of the mitral valve: Macroscopic specimen showing the left atrium and the left ventricle. Thrombotic material is visible in the left atrium in the mitral valve region.
62
Q

Hva viser pilen til?

63
Q

Hva viser pilen til?

64
Q

Hva viser pilen til?

65
Q

Hva viser pilen til?

66
Q

Hva viser pilen til?

67
Q

Hva viser pilen til?

68
Q

Hva er “Noninfective endocarditis (nonbacterial thrombotic endocarditis)?

69
Q

Hvilken etiologi har ikke-infeksiøs endokarditt?

70
Q

Hvilken klinikk forekommer ved ikke-infeksiøs endokarditt?

71
Q

Hvordan diagnostiserer man ikke-infeksiøs endokarditt?

72
Q

Hvordan behandler man ikke-infeksiøs endokarditt?

73
Q

Hvilke diff.diagnoser har man til IE?

74
Q

Hvordan er den initielle behandlingen av IE?

A
Early involvement of a formal multidisciplinary endocarditis team (e.g., infectious disease, cardiology, and thoracic surgery) has been shown to significantly improve outcomes. Some patients may require a higher level of care (e.g., observational unit for patients with new-onset AV block). Empiric antibiotic therapy is indicated in most patients, especially if there is evidence of clinical instability or complications. For clinically stable patients without evidence of complications, antibiotic therapy may be delayed (in consultation with infectious disease) until blood culture results are available.

https://www.helsedirektoratet.no/retningslinjer/antibiotika-i-sykehus/endokarditt#kontraindikasjon-standard-0-182d2f2b-0a50-469c-8b01-cf032d5a5806-0

75
Q

Hvilken type tilleggsbehandling kan man gi pas. med IE?

A
Recommendations are based on limited evidence. Expert consultation is advised. While this is a topic of ongoing debate, many experts hold anticoagulation for ≥ 2 weeks due to the risk of bleeding, even in patients with mechanical valves. Treating opioid use disorder may improve antibiotic adherence. To treat dental sources of bacteremia (e.g., periodontal disease) and prevent recurrent IE, especially in patients requiring valve surgery.
76
Q

Hvordan skal man behandle pas. som er akutt syke der årsaken skyldes IE?

77
Q

Hva bør alle pas. med mistenkt IE gjennomgå?

78
Q

Hvilke kardielle komplikasjoner kan oppstå pga. IE?

A
Typically occurs as a result of valvulopathy. May be related to primary infection or immune response. Due to the spread of infection into the myocardium; more common in left-sided endocarditis.
79
Q

Hvilke emboliske komplikasjoner kan oppstå pga. av IE?

80
Q

Hvilke metastatiske infeksjoner er en komplikasjon til IE?

81
Q

Hvilke type skade er ofte multifaktoriell, og kan være en komplikasjon til IE?

A

Akutt nyreskade

E.g., due to renal infarct, congestive heart failure, immune complex deposition, antibiotic toxicity

82
Q

Til hvilken pasientgruppe er endokardittprofylakse indisert?

A
This recommendation is consistent with the 2021 American Heart Association (AHA) scientific statement on the prevention of IE due to Viridans streptococci. Guidance in other regions may differ.

https://www.helsedirektoratet.no/retningslinjer/antibiotika-i-sykehus/endokarditt#endokarditt-profylakse-ved-inngrep

83
Q

Hvilke pas trenger endokardittprofylakse kardielle?

Kirurgiske inngrep

A
The presence of CIEDs, septal defect closure devices, coronary artery stents, or vena cava filters is not an indication for IE prophylaxis. This includes annuloplasty, rings, clips, and ventricular assist devices. Prophylaxis is recommended by the AHA/ACC guidelines but not by the European Society of Cardiology.
84
Q

Hvilke inngrep trenger IE profylakse i enkelte tilfeller?

A
I.e., those involving perforation of the oral mucosa or manipulation of gingival tissue and/or the periapical region of the teeth.

Infeksjonsmedisin (14 decks)

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