IE

Question 1

What is IE?

Answer 1

Infection of the endothelial layer of the heart wall causing inflammation

Question 2

Why does IE also affect valves?

Answer 2

Valves are often in contact with the endothelium so infection spreads

Question 3

Risk factors for IE?

Answer 3

IV drug abusers
Males 
Heart surgery - valvular/prosthetics
Dental work - poor dental hygiene 
Congenital heart issues affecting valves
Rheumatic heart disease affecting valves

Question 4

What gender has the worst prognosis?

Answer 4

Females

Question 5

Why are IV drug abusers more at risk?

Answer 5

Breach of skin allows normal skin bacteria to enter bloodstream

Question 6

Why are people with poor dental hygiene who go for dental work more at risk?

Answer 6

Dentist could cause a breach in mouth and bacteria such as strep which grows in mouth can enter bloodstream

Question 7

What is the pathophysiology?

Answer 7

Bacteria infects endocardium and valves

Bacteria begin to multiply and cause “fibrin plated” vegetation on valves

Valves become calcified and decreases blood flow causing heart failure and fatigue

Valves also become thrombosed

Question 8

How is vegetation detected?

Answer 8

Echocardiograms

Question 9

What is a major problem with vegetation?

Answer 9

It can break off and cause emboli’s

Question 10

What can occur if the emboli is in the right side of the heart?

Answer 10

Pulmonary embolism

Question 11

What can occur if the emboli is in the left side of the heart?

Answer 11

Can enter the systemic circulation and maybe cause a stroke or infarct elsewhere

Question 12

What is a common complication of IE?

Answer 12

Heart failure - if valves are destroyed

Question 13

What happens to the blood flow out of the heart once valves have vegetation?

Answer 13

Becomes turbulent

Question 14

What are the main symptoms?

Answer 14

Fever, chills - infection
Weight loss
Headache
MSK pain

Question 15

Do previously damaged valves increase risk of IE?

Answer 15

Yes - makes it easier for bacteria to attach as there will be a thrombus formed on the sit of injury

Question 16

What are some signs of IE that suggest immune complex deposition?

Answer 16

Splinter haemorrhages

Roth spots - retinal bleeds, white centre on retina

Oslers nodes - deep red painful spots on finger tips

Janeway lesions - Flat red spots on hands and soles of feet - escape of blood from ruptured vessel

Vasculitic rash - widespread small red/purple dots that don’t go away with compression

Nephritis

Question 17

What are some other signs that suggest IE?

Answer 17

A new murmur

Question 18

In what type of patient will signs be absent?

Answer 18

Elderly
Immuno-compromised
IE with less virulent/atypical bacteria
After a patient has had antibiotics

Question 19

What is a major complication of IE?

Answer 19

Heart failure

Question 20

What are the major signs of the duke criteria?

Answer 20

2 positive blood cultures for common organisms that cause IE

Echocardiogram shows positive vegetation

New murmur

Question 21

What are the minor signs of the duke criteria?

Answer 21

Predisposing valvular condition or is an IVDA

Fever - over 38

Blood cultures that don’t meet the major criteria - shows an atypical organism

Immunologic phenomena

Vascular phenomena

Question 22

What shows immunological phenomena?

Answer 22

Oslers nodes
Roth spots
Nephritis

Question 23

What shows a vascular phenomena?

Answer 23

Arterial emboli
Janeway lesions
Intracerebral bleed
Conjunctival bleed

Question 24

How is IE diagnosed using the Duke criteria?

Answer 24

2 major
5 minor
1 major and 3 minor

Either all major, all minor or 1 major 3 minors

Question 25

What investigative tests can be done?

Answer 25

FBC
C-reactive protein and ESR test
Urea and Electrolytes
Blood culture

Urinalysis
ECG
CxR
Echo

Question 26

What is the 1st line investigation and why?

Answer 26

Echos - to spot vegetation

Question 27

Why is CRP and ESR tests done?

Answer 27

To test for inflammation

Question 28

Why is a FBC done?

Answer 28

Check for raised neutrophil count for infection

Question 29

How are blood cultures done?

Answer 29

Done BEFORE any antibiotics are given

3 sets at different sites of body

Done 6 hours in-between sets

Question 30

How are blood cultures done if patient is in sepsis/shock and time is a major constraint?

Answer 30

2 sets with an hour in-between

Question 31

What are the common organisms that cause infection?

Answer 31

Strep
Staph
Enterococci

Question 32

What type of streps cause infection?

Answer 32

Oral strep

Question 33

What types of staph cause infection?

Answer 33

Staph aureus
Staph epidermis
Coagulase negative staph

Question 34

Name a type of enterococci that causes infection?

Answer 34

E. faecalis

Question 35

What are some atypical infective causes?

Answer 35

Intracellular bacteria:
Coxiella Burnetii
Bartonella

Fastidious organisms:
HACEK group
Brucella
Fungi

Question 36

What is a specific test for intracellular bacteria such as coxiella burnetii

Answer 36

Serological testing

PCR

Question 37

How are echos undertaken?

Answer 37

A trans-thoracic echo is done (TTE) and if low clinical suspicion and test is normal leave it at that

If high clinical suspicion or TTE shows some IE do a trans-oesophageal (TOE) to see IE better

Question 38

What is tested for in a CxR?

Answer 38

Heart failure

Pulmonary abscess

Question 39

What does a urine test look for?

Answer 39

Blood - nephritis

Question 40

Treatment?

Answer 40

Look at marty’s Ox handbook cards