Gram + Infections Flashcards
Acute Rheumatic Fever
Describe the Pathophysiology
Endocarditis with
Acute Rheumatic Fever
When does it occur?
2-3 weeks after initial infection.
Acute Rheumatic Fever
What are the variable presentations of Acute Rheumatic Fever
Carditis (50-70%)
Arthritis 35-66%
Chorea 10-30%
Subcutaneous nodule 0-10%
Erythema marginatum <6%
Acute Rheumatic Fever
Which Valves are affected?
Mitral valve 75-80%
Aortic valve 30% (usually with other valves)
Tricuspid & Pulmonary valves < 5%
Acute Rheumatic Fever
What criteria is used for diagnosis?
JONES
Acute Rheumatic Fever
how do we treat?
treat group A strep
Educate about oral health
Salicylates, bed rest for carditis.
continuous antibiotic prophylaxis for years (Pen G IM every 3-4 weeks).
Acute Rheumatic Fever
what are long term implications?
valvular stenosis and/or regurgitation.
chronic rheumatic disease.
Acute Rheumatic Fever
Infective Endocarditis and how Dx
Fever, evidence of systemic emboli (caused by vegitation in valves), + blood cultures,
Infectious Endocarditis
pathogens
Staph (mucoid-producing strains of S aureus).
Strep viridans.
Enterococcus.
Fungal.
Infectious endocarditis
IV drug use
More common in males.
S aureas >60% of cases.
Typically R sided valves, esp tricuspid.
Higher recurrence rate.
IE predisposition
Valvular heart disease
Congenital heart disease
Prosthetic valve
History of IE
Pacemaker
Hypertrophic cardiomyopathy
prosthetic valve
How to Dx IE
Blood cultures
Echocardiography (identifies specific valves)
CXR may show cardiac abnormality
Chest CT may show emboli
Caution with cardiac catheterization
Infective endocarditis
Duke Criteria for Dx
2+ major criteria, 1 major + 3 minor, or 5 minor
Infective Endocarditis
Major Criteria
Positive blood cultures
Typical microbe in 2 cultures
Persistently + cultures
Single + culture for Coxiella burnetii
Evidence of endocardial involvement
Definite vegetation
Myocardial abscess
New partial dehiscence of prosthetic valve
New or worsening regurgitation murmur
IE
Minor Criteria
Predisposition: Heart condition/IV drug abuse.
Fever > 100.4.
Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhage, Janeway lesions.
Immunologic phenomena: glomerulonephritis, Osler’s nodes, Roth spots, rheumatoid factor
Microbiologic evidence (+ blood cult not meeting major criteria).
Echo findings that do not meet major criteria
Acute IE
<6 week incubation – can be very rapid course
Toxic presentation (high fevers, CP, SOB, very tired)
Rapid progression fatal if untreated
S. aureus most common
Subacute IE
greater than 6 week incubation – can be several months
Less dramatic presentation (low grade fever, night sweats, weight loss)
Gradual progression
Less virulent organisms: S. viridians, enterococcus
IE
Treatment for valve destruction
Surgery
IE
Early surgical indicators
Acute heart failure due to valve destruction
Unresponsive to antibiotics
Septal abscess
Sinus of Valsalva involved
Recurrent IE with same organism
Embolism despite treatment
Large mobile vegetation
IE
Late surgery indication
after antibiotic course is completed
IE
Post surgery meds
antibiotics, antifungals for 6 weeks, and anticoagulants for life
IE
Prognosis if untreated, with treatment, how many will need surgery, what about with fungal infection
untreated almost always fatal.
~70% survive w treatment
60% will have surgery
mortality rate higher with fungal infection
IE
Valve complications
Valve damage/destruction –> Heart failure
IE
Peripheral embolization Complications
Myocardium MI
Lungs > Septic PE (R side)
Brain/spinal cord > Stroke/paralysis
Eyes > Blindness
Extremities > Limb ischemia
Spleen/kidney > Infarct
