Infections of the Heart Flashcards
what is endocarditis
aka infective endocarditis (IE)
infection of the endocardium - usually talking about the valve leaflets
what is the typical population that endocarditis is seen in
58 yo
M>W
no obvious racial/ethnic predilection
50-60% have some underlying cardiac condition
Who are at high risk of developing endocarditis
IVDU
hemodialysis
DM
HIV
immunosuppression
dental procedures
valvular heart disease
endovascular hardware
What is the most common location for endocarditis
Left sided > Right sided
EXCEPT in IVDU which is Right > Left
why is the left side of the heart more susceptible to endocarditis
there is more pressure (turbulent flow)
More O2 (bacterial growth)
Valvular disorders are more common
why are IVDU more susceptible to right sided endocarditis
direct venous inoculation
What microbes are most common with a native valve endocarditis
Staph aureus
strep viridans
enterococci
HACEK organisms
what are HACEK organisms
Haemophilus
Aggregatibacter
Cardiobacterium
Eikenella corrodens
Kingella
What microbes are most common with IVDU endocarditis
Staph aureus
enterococci
streptococci
gram negative aerobic bacilli
fungi
other ‘weird’ bugs
what microbes are most common in prosthetic valve endocarditis
Staph aureus
coagulase negative staph
streptococci
gram negative organisms
fungi
what is acute endocarditis
more virulent organisms (s. aureus)
normal or damaged valves
symptoms within days
high Fever (102-104)
rapidly progressive
more severe symptoms (look sick)
what is the number one cause of endocarditis
staph aureus
what is subacute endocarditis
less virulent organisms (steptococci, enterococci, other bacteria, fungi)
often predisposed valves
symptoms between days - weeks
milder fever (99-101)
slower progression
more mild symptoms (look stable)
less likely to develop complications
What is Osler’s nodes
painful raised red lesions on the hands and feet
what are janeway lesions
non-tender, flat, small red lesions on hands/feet
what are Splinter hemorrhages
capillary hemorrhages under the fingernail
what are classic manifestations of endocarditis
oslers nodes
janeway lesions
splinter hemorrhages
petechiae (palate or conjunctiva)
clubbing
roth spots (retinal hemorrhages with pale centers)
What are Roth spots
retinal hemorrhages with pale centers
how do you work up endocarditis
blood cultures (2-3 sets from 2 different locations)
Echocardiogram (TTE with follow up TEE if positive or high risk)
Duke Criteria (2major, 1 major + 3 minor, 5 minor)
Possible IE (1 major + 1 minor, 3 minor)
what is the treatment of endocarditis
EARLY infectious disease consult
empiric antibiotics (broad spectrum, based on organism)
Treatment length somewhere between 2-6 weeks
What are the treatment options for staph endocarditis
MSSA: nafcillin, oxacillin or cefazolin
MRSA: vancomycin or daptomycin
if PVE: Add Rifampin + Gentamycin
What are the treatment options for viridans strep endocarditis
PCN, Cefritaxone or vancomycin PLUS Gentamycin
What are the treatment options for enterococcus endocarditis
ampilcillin or PCN PLUS gentamycin or ceftriaxone
Vancomycin PLUS gentamycin
when is surgical intervention considered for endocarditis
large vegetations (>20mm)
septic pulmonary emboli
highly resistant organism
persistent bacteremia (source control)
severe tricuspid regurg - R heart failure resistant to treatment
what are complications of endocarditis
IVDU high risk for septic emboli - stroke, PE (mimic PNA), no benefit from anticoagulation or antiplatelet therapies
High risk of metastatic infections (PJI, spine infections, splenic abscess)
how are IVDU endocarditis treated differently
they often are unwilling to stay in the hospital for 4-6 weeks
cant d/c to home with central line
high risk of recurrence
higher mortality rate with HIV co-infection
Risk for HCV co-infection as well
Poorer long-term prognosis after surgery
how can endocarditis be prevented
indicated for select group of patients to have prophylaxis prior to dental work, invasive respiratory tract procedures, procedures involving skin or MSK infection
Amoxicillin 2g PO 1 hr prior to procedure
ampicillin or ceftriaxone 2g IV
if PCN allergy, cephalexin, clindamycin, azithromycin
What is the population that we see rheumatic heart disease in
higher in developing countries
endemic in some areas
peak incidence 5-15 yo
sequelae of strep pharyngitis
how long after pharyngitis do rheumatic heart disease symptoms occur
2-3 weeks s/p symptom development
what is the JONES criteria
Joints
O- heart
Nodules
Erythema marginatum
Sydenham chorea
2 Major OR 1 major and 1 minor
what is the diagnostic criteria for acute rheumatic fever
JONES criteria
What are the Major JONES criteria
erythema marginatum
carditis
skin nodules
sydenham chorea
migratory polyarthritis
what are the Minor JONES criteria
fever
arthralgia
raised ESR
Raised CRP
prolonged PR-interval
Hx rheumatic fever or rheumatic heart disease
What is erythema marginatum
rapidly enlarging ring or crescent shaped macules with central clearing
what are subcutaneous nodules
small, firm, non-tender nodules that adherent to underlying structures
what is sydenham chorea
random, continuous, involuntary movements
what occurs with rheumatic heart disease
valvular damage secondary to rheumatic fever: valvular damage - stenosis, regurgitation or both
manifests as new or changing murmur
50-70% involve mitral valve
30% involves the aortic valve
what is the treatment for rheumatic heart disease
early appropriate treatment of streph pharyngitis
treatment of acute rheumatic fever: NSAIDs, PCN, +/- prednisone for symptomatic treatment
prevention of recurrent episodes of rheumatic fever
(PCN prophylaxis IM every 4 weeks)
What is myocarditis
inflammation of the myocardium
who usually presents with myocarditis
primarily young, healthy patients
kids
pregnant females
immunosuppressed
what are the types of myocarditis
infectious (viral is m/c, bacteria, fungi, spirochetes etc) and non-infectious myocarditis (autoimmune, meds, venoms, hypothermia, radiation injury)
What is the presentation of myocarditis
flu-like illness that persists for 7-14 days (fever, malaise, myalgias, n/v/d)
dyspnea, chest pain, arrhythmias, tachycardia, hypotension
kids compensate until they cant - hypoxia, respiratory distress, cyanosis, cardiac arrest
may see S3, S4, Rales, Tachycardia
How do you work up myocarditis
most lab findings will be non-specific
abnormal EKG, elevated troponins, elevated WBC, ESR, CRP
+ viral antibody titers
abnormal echo
Nuclear imaging (MRI) or cardiac muscle biopsy
what is the gold standard diagnostic study for myocarditis
Cardiac muscle biopsy
How do you treat acute myocarditis
IV,O2, monitor
treatment of arrhythmias
treatment of HF
how do you treat sub-acute to chronic
avoid cardiotoxic agents
avoid NSAIDs
serial echos to monitor
if mild, spontaneous recovery over several months
if severe, referral to advanaced care
What is pericarditis
inflammation of the pericardium
epidemiology poorly defined
infectious vs non-infectious
what is desslers syndrome
post MI pericarditis
what is the classic presentation of pericarditis
sharp, stabbing retrosternal chest pain
fever
pain that is pleuritic and postural (worse with inspiration, better sitting up and leaning forward)
pain may radiate to shoulder
Kussmaul’s sign
hours to days
what is Kussmaul’s sign
elevated JVP with inspiration (should decrease)
How is pericarditis worked up
no specific lab testing - elevated ESR, CRPand troponins
classiv EKG findings
echo to rule out pericardial effusion/tamponade
what is the treatment of pericarditis
treat underlying cause
activity restriction until asymptomatic or CRP normalizes
what is the prognosis of pericarditis
most patients recover completely
those who do not improve should get further work-up
complications include pericardial effusions or tamponade
What is pericardial effusion
build up of fluid in the pericardial space
between pericardium and heart
What is pericardial tamponade
when pressure gets high enough (>15 mmHg)
what is the leading cause of pericardial effusion and tamponade
viral
secondary to viral pericarditis
what is the presentation of pericardial effusion and tamponade
acute effusions
chronic effusions
first, non-specific symptoms
-dyspnea, cought, edema, fatigue, +/- pain, +/- symptoms consistent with pericarditis
what is the presentation of later stages pericardial effusion and tamponade
venous congestions - tachycardia, increased CO, hypotension and reduced CO
what is found on PE for a patient with Pericardial effusion and tamponae
pericardial friction rub
other PE findings in tamponade
Becks Triad
pulsus paradoxus
trachycardia, tachypena
cool, clammy extremties,cyanosis
What is Becks Triad
hypotension
JVD
muffled heart sounds
how do you work up pericardial effusion and tamponade
depends on urgency of situation
if theres time, Chest XR, EKG
Endocardiogram is the best test for diagnosis
pericardiocentesis (diagnostic AND therapeutic
what is the treatment or pericardial effusion/tamponade
if small without tamponade- observation and treatment of underlying cause
if tamponade present - urgent pericardiocentesis
if present, recurrent, or very large, consider pericardial window
