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Adult Clinical Medicine > Infectious Cardiology > Flashcards

Infectious Cardiology Flashcards

1
Q

___ is infection of normal OR abnormal valves with a virulent organism (e.g., Staphylococcus Aureus)

A

Acute Bacterial Endocarditis (ABE)

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2
Q

What is endocarditis

A

Infection of the endothelial lining of the heart (including, but not limited to the valves)

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3
Q

____ is indolent infection of abnormal valves with a less virulent organism (e.g., Streptococcus Viridans)

A

Subacute Bacterial Endocarditis (SBE)

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4
Q

What are the high risk groups for endocarditis

A
  1. Abnormal cardiac structure (anatomy or FB)
  2. Abnormal risk of bacteremia
  3. Age > 60 years (Probably related to increased risk of healthcare-associated infections)
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5
Q

What abnormal cardiac structures put you at risk for endocarditis

A
  1. Congenital Heart Disease (10-20% of cases)
  2. Bicuspid Aortic Valve,
  3. Ventricular Septal Defect,
  4. Pulmonic Stenosis,
  5. patent ductus arteriosus
  6. Abnormal cardiac valves
  7. Prosthetic valve (type doesn’t matter)
  8. Mitral Valve Regurgitation
  9. Aortic Stenosis/Regurgitation
  10. Indwelling pacemaker lead
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6
Q

People who are at risk for bacteremia and therefore endocarditis includes

A
  1. IV drug use (IVDU)
  2. Indwelling central venous catheter
  3. Chronic hemodialysis
  4. Poor Dentition/Dental Caries
  5. Colon CA/Inflammatory Bowel Disease: ↑ risk of Streptococcus Gallolyticus (formely S.Bovis) bacteremia***
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7
Q

IVDU are more often to develop what type of endocarditis

A

Classic description of RIGHT-sided endocarditis (Tricuspid or Pulmonic Valve) occuring more often in IVDU as compared to non-IVD users

*BUT L-sided is still more common than R-sided endocarditis in IVDU (57% L and 40% R)

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8
Q

What pathogens commonly cause endocarditis

A
  1. 80% Gram Positive Cocci (GPC)**
    - 32% S. Aureus
    - 18% S. Viridans
  2. 10% culture-negative
  3. 4% Gram Negative Rods (GNR): 2% HACEK, 2% non-HACEK
  4. 2% fungus

*Prosthetic valve has 20-30% Staph/Strep

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9
Q

HACEK causes of endocarditis

A
  • Fastidious gram-negative rod bacteria
  • Cause <0.005% of endocarditis cases

Specific HACEK bacteria:

  1. Haemophilus species
  2. Aggregatibacter (formerly Actinobacillus actinomycete comitants)
  3. Cardiobacterium hominis
  4. Eikenella species
  5. Kingella kingae
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10
Q

what organisms commonly cause endocarditis in IVDU

A
  1. 60% Staphylococcus Aureus (S. Aureus)
  2. 20% Streptococcus Viridans (S.Viridans)
  3. 10% Gram-negative (esp. salmonella, serratia)
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11
Q

What organisms commonly cause endocarditis in prosthetic valves

A
  1. 30-35% S. Epidermidis (usually non-pathologic skin flora)

2. 5-10% Fungus and Diphtheroids

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12
Q

Clinical presentation of acute bacterial endocarditis (S. aureus)

A
  1. Abrupt onset: high fever, chills, night sweats
  2. Prominent leukocytosis
  3. Rapid, severe valve destruction
  4. Apical Heart murmur (not always in R-sided)
  5. Often complicated by heart failure (reflecting the side of valves involved)
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13
Q

Clinical presentation of subacute bacterial endocarditis (S. Viridans)

A
  1. Indolent onset: fever, night sweats, weight loss
  2. Apical Heart murmur (not always in R-sided)
  3. Minor endocardial damage
  4. Leukocytosis often minimal or not present
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14
Q

Describe the findings of right sided valve involvement of endocarditis

A

Tricuspid much more common than pulmonic*

  1. Cardiovascular: possible CHF, heart block/cardiac arrest (most feared)
  2. Hematologic: (elevated ESR, leukocytosis, anemia, positive RF/ANA)
  3. Pulmonary: (Abscesses in Right-sided)
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15
Q

Describe the findings of left sided valve involvement of endocarditis

A
  1. mitral and aortic valves
  2. Cardiovascular: CHF, heart block, mycotic aneurysms*
  3. Hematologic: (elevated ESR, leukocytosis, anemia, positive RF/ANA)
  4. Derm: manifestations of emboli
  5. GI: Splenic infarct, Mesenteric infarct
  6. Neuro: Roth spots, Mycotic aneurysm, stroke, encephalitis/abscess/meningitis
  7. Msk: Septic arthrits, osteomyelitis
  8. Renal: Infectious glomerulonephritis, infarcts
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16
Q

Symptoms and hx suggestive of endocarditis

A
  1. Fever (onset, frequency)?
  2. Night Sweats?
  3. Arthralgias?
  4. Malaise/Weakness?
  5. Weight Loss?
  6. Shortness of Breath (CHF sx)?
  7. Abdominal pain (splenic infarct/mesenteric infarct)
  8. Rashes/skin changes
  9. Arthralgias/bone pain (septic joint/osteomyelitis)
  • History of predisposing structural cardiac abnormality
  • History of bacteremia risk
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17
Q

PE findings suggestive of endocarditis

A
  1. Constitutional -Fever
  2. Cardiovascular -Murmur, CHF signs
  3. GI - Splenomegaly, Abdominal Tenderness to palpation (TTP)
  4. Neuro - neurologic signs, Roth spots on funduscopic exam
  5. Msk. - bony TTP
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18
Q

Describe the derm findings of endocarditis

A
  1. Petechiae- esp. on soft palate
  2. Janeway Lesions- purple-red painless lesions on palms/soles
  3. Osler’s Nodes
  4. Splinter Hemorrhages
  5. Roth Spots- retinal hemorrhage, pale center
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19
Q

describe the petechiae that is seen with endocarditis

A
  1. Painless* red intradermal hemorrhage
  2. Usually < 2mm
  3. May be seen most commonly on upper/soft palate** or extremities in endocarditis
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20
Q

Describe the janeway lesions that are seen with endocarditis

A
  1. Non-tender erythematous or hemorrhagic macular or nodular lesions on palms/soles*
  2. May ulcerate
  3. Causative organisms may be cultured if ulcerated
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21
Q

describe the Osler’s nodes that are seen with endocarditis

A
  1. Painful*, immune complex-related inflammatory nodules on finger pads
  2. Occur in 25% of SBE, rare in ABE
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22
Q

describe the splinter hemorrhages that are seen with endocarditis

A
  1. Linear, red hemorrhages in nails
  2. If present in proximal 1/3 of nail bed, stronger likelihood they’re non-traumatic
  3. More common in SBE
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23
Q

describe the Roth spots that are seen with endocarditis

A

retinal hemorrhage with pale center (cotton-wool spot) due to ischemia

*not specific to endocarditis

24
Q

Workup/labs for endocarditis

A
  1. Blood cultures x 3 sets (minimum) prior to giving antibiotics.
  2. CBC – leukocytosis (ABE), normocytic anemia
  3. ESR – elevated, often over 100
  4. Creatinine – assure renal fx’n preserved
  5. Urinalysis- microscopic hematuria*, glomerulonephritis (proteinuria, RBC casts)
  6. EKG – evaluate for conduction defects on admission and regularly, thereafter
25
Q

Blood cultures ___ sets (minimum) prior to giving antibiotics in endocarditis

A

x 3

26
Q

If endocarditis suspected based on history/physical/blood cultures get:

A
  1. Trans-thoracic Echocardiogram - 34% positive for vegetation on valve
  2. Trans-esophageal echocardiogram- 81.4% positive for vegetation on valve**
27
Q

What are the major criteria for endocarditis

A
  1. Sustained bacteremia (3/4 sets 1 hr apart OR 2 sets 12 hours apart) by potentially causative organism
  2. Endocardial involvement
    -Vegetation (oscillating intracardiac mass), valve abscess/perf’n, prosthetic dehiscence
    OR
    -New Valvular regurgitation
28
Q

What are the minor criteria for endocarditis

A
  1. Predisposing medical condition (abnl valve or bacteremia-prone)
  2. Fever (>38°C)
  3. Vascular phenomena (septic emboli, mycotic aneurysm, janeway)
  4. Immune phenomena (glomerulonephritis, Osler’s nodes, Roth spots, RF+)
  5. Blood cx + (not major) or serologic evidence of infx’n
29
Q

Diagnosis by Modified Duke Criteria for Infectious Endocarditis (definite pathologic, definite clinical, possible)

A

Definite pathologic: Micro-organism demonstrated in vegetation or cardiac abscess OR pathology of vegetation shows active endocarditis

Definite clinical: 2 major, OR 1 major/3 minor, OR 5 minor criteria

Possible: 1 major/1 minor OR 3 minor

30
Q

what is the empiric therapy for native valve ABE and native valve SBE

A

ABE: Nafcillin + Gentamicin OR Vancomycin + Gent

SBE: consider waiting for cx results before empiric rx if pt stable—Ampicillin/Gentamicin

31
Q

what is the empiric therapy for prosthetic valve endocarditis?

A

vanco + Gent + Rifampin

32
Q

Describe the culture guided Abx use for endocarditis

A
  1. MSSA: Oxacillin or Nafcillin
  2. MRSA: Vancomycin, often with Rifampin to help eradicate
  3. S.Viridans/Bovis- Penicillin G
  4. Enterococcus- Ampicillin/Gentamicin
  5. HACEK organisms: Ceftriaxone
33
Q

How long do you use Abx for with endocarditis

A

Duration of therapy: 6 weeks of IV antibiotics is standard to allow full eradication of bacteria.

34
Q

Surgical indications for endocarditis

A
  1. Incompetent Valve causing CHF despite maximal medical therapy
  2. Heart Block worsening (due to conduction system involvement)
  3. Cardiac Abscess
  4. Recurrent emboli on medical therapy
  5. Fungal infection
35
Q

When is anticoagulation therapy indicated for endocarditis

A
  1. Anticoagulation generally accepted despite ↑ risk in certain conditions:
    - Prosthetic heart valveAcute coronary syndrome
  2. Anticoagulation with heparin/coumadin is contra-indicated due to potential for hemorrhage from emboli
36
Q

What people need cardiac pts abx prophylaxis prior to dental procedures?

A
  1. Congenital Cyanotic Heart Disease
    - Unrepaired or repaired with residual defects
  2. Prosthetic valve
  3. Prior endocarditis hx
  4. “Valvulopathy” of heart transplant

*No longer prophylax MR/AS/AI

37
Q

What abx do you use for endocarditis prophylaxis

A

Give amoxicillin (clindamycin if pcn-allergic) prior to dental procedures for at-risk pts

38
Q

What are the infectious causes of pericarditis (31%)

A
  1. Viral (21%)
    - Coxsackie B, echovirus, HIV, EBV, other
  2. Non-TB Bacterial (6%)
    - S.Aureus, S. Pneumoniae, Neisseria, F. Tularensis
  3. TB (4%)
  4. Fungal (<1%)
    - Histoplasma, Candida, Aspergillus
39
Q

What are the non-infectious causes of pericarditis (68%)

A
  1. Neoplastic (35%)
  2. Immune-mediated (23%)
    - Delayed postcardiac injury (“Dressler’s syndrome”)
    - Collagen vascular Disease (SLE/RA)
    - Rheumatic Fever
  3. Uremic (6%)
  4. Idiopathic (4%)
  5. Drug-induced
  6. Traumatic
  7. Immediate post-MI (larger infarcts)
  8. Pericardial Effusion without carditis (CHF/cirrhosis)
40
Q

Describe the presentation of pericarditis

A
  1. Positional Pleuritic Chest Pain
    - Better leaning forward, worse supine
    - May radiate to trapezius muscles of upper back
  2. Fever
  3. Pericardial Friction Rub
  4. If Pericardial effusion is present:
    - Distant heart sounds
    - Fainter rub
    - Dullness over left posterior lung field (Ewart’s sign)
41
Q

What are the ECG changes with pericarditis

A
  1. Diffuse ST elevation,
  2. precordial PR depr’n (V1-V6)
    * Important to differentiate from Acute MI

*percardial effusion shows depressed voltage throughtout

42
Q

How do you dx pericarditis

A

2 or more of the following 4 findings

  1. Chest pain
  2. Pericardial friction rub
  3. Appropriate ECG changes
  4. Pericardial Effusion

*Presence of pericardial effusion is NOT required for dx

43
Q

What labs do you get for pericarditis

A
  1. Thyroid testing (TSH),
  2. Renal function (Creatinine),
  3. ANA,
  4. rheumatoid factor
44
Q

What is the workup of pericarditis

A
  1. EKG
  2. Labs (TSH, Cr, ANA, RF)
  3. Consider TB/fungal evaluation in appropriate pt (immunosuppressed, TB exposures)
  4. Consider evaluation for recent MI (e.g., wall motion abnormalities by ECHO, troponin less helpful because often ↑ in pericarditis)
45
Q

Treatment of pericarditis

A
  1. Avoid anticoagulation, may cause hemorrhage and cardiac tamponade
    * Caveat: if immediate post-MI period continue aspirin/heparin unless pericardial effusion > 1 cm or tamponade sx develop
  2. Non-steroidal anti-inflammatory medications (NSAIDs)
  3. Colchicine or Steroids (if NSAIDs ineffective)
46
Q

Complications of pericarditis

A
  1. Cardiac tamponade (Occurs in up to 10-15% of acute pericarditis, medical emergency)
  2. constrictive pericarditis
47
Q

with cardiac tamponade, Pericardial pressure reaches 20-24 mm Hg and causes ___ which exceeds venous return capacity

A

elevated right atrial pressure

48
Q

Presentation of cardiac tamponade

A
  1. Low Blood Pressure
  2. Elevated Jugular Venous Pressure
  3. Pulsus Paradoxus present
49
Q

How do you treat cardiac tamponade

A

drain pericardial space (pericardiocentesis)

50
Q

Chronic pericardial inflammation causes fibrosis and scar

A

constrictive pericarditis

51
Q

Most common causes of constrictive pericarditis

A
  1. TB (world-wide)
  2. Idiopathic, thought due to prior acute pericarditis (USA)
  3. Post mediastinal XRT (Hodgkin’s, Breast CA)
  4. Prior cardiac surgery
52
Q

Symptoms of constrictive pericarditis

A
  1. Right heart failure (edema, hepatic vascular congestion)

2. Left heart failure develops later (dyspnea, cough, orthopnea/PND)

53
Q

PE finding of constrictive pericarditis

A
  1. Normal BP
  2. Elevated JVP
  3. Kussmaul’s Sign (inspiratory ↑JVP as diaphragm displaces blood from engorged splanchnic veins)
  4. Pericardial Knock (early diastole, sudden ↓ filling as constrictive pericarditis ↓ venous return )
54
Q

What is the workup of constrictive pericarditis

A
  1. CXR – may show eggshell calcifications (esp. on lateral view)
  2. EKG – No specific findings
  3. Echo – May show calcified and thickened pericardium, preserved LV Fx’n
  4. Right and Left Heart Catheterization
55
Q

Right and Left Heart Catheterization with constrictive pericarditis shows

A
  1. Show near-equalization of diastolic pressure in all four chambers (within 5 mm Hg)
  2. “square-root” pressure dip/plateau in RV and LV diastole
56
Q

What is the treatment of constrictive pericarditis

A
  1. Complete pericardial resection
  2. Outcome is poor if patients have shortness of breath at rest (NYHA Class IV), and surgery not recommended in these patients.

Adult Clinical Medicine (26 decks)

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