Infective endocarditis

Question 1

Etiology

Answer 1

• Microbial infection of a heart valve
• bacterium, rickettsia (Coxiella burnetti - Q fever endocarditis), chlamydia or fungus
• Streptococcal - viridans, enterococci
• Staphyl aureus
• Gram-negative bacilli, Haemophilus influencer
• Gram –ve Klebsiella, E-Coli, Viruses.

Question 2

Pathogenesis

Answer 2

• presence of organisms in the bloodstream and abnormal cardiac endothelium facilitating their adherence
  and growth.
• may occur due to patient- (poor dental hygiene, intravenous drug use) or be associated with procedures
  (dental treatment, intravascular cannulae, cardiac surgery, or permanent pacemakers).
• Damaged endocardium promotes platelet and fibrin deposition allows organisms to adhere and grow
• Aortic and mitral valves are most commonly involved

Question 3

Clinical picture - hard

Answer 3

Occur as an acute, fulminating, chronic or subacute illness with low-grade fever.
High clinical suspicion:
a. Regurgitant-murmur
b. embolic event
c. sepsis
d. haematuria, glomerulonephritis and suspected renal infarction
e. fever‘ plus:
- prosthetic material inside the heart
- other high predisposition for infective endocarditis, e.g. i.v. drug abuse
- newly developed ventricular arrhythmias or conduction disturbances
- first manifestation of congestive cardiac failure
- blood cultures (with typical organism)
- cutaneous (Osler, Janeway) or ophthalmic (Roth) manifestations
- peripheral abscesses (renal, splenic, spine)
- recent diagnostic / therapeutic interventions result in bacteraemia.
Low clinical suspicion. Fever only

Question 4

Clinical picture senior - acute, subacute

Answer 4

1. Acute:
   - increased perspiration, weakness, anorexia, sleeplessness, ↑ temperature > 39 degrees, lose weight.
   muscle dystrophy, hypovolemia with tachycardia, anemia, damage of valve, wide spread abscess,
   thromboembolism
2. Subacute :
   - Onset : Cold, weakness, malaise, headache, sweat, subfebrile 1-2months.
   - After 2-3weeks, like in acute: ↑ temperature then drop to subfebrile level, lose weight, colour skin change
   - clubbed fingers, splenomegaly, liver cirrhosis, disease of blood.
   - inspiratory dyspnoe, palpitation, enlarged heart shape, sstolic & diastolic murmur.
   - Vascular patho : Embolism & toxical vasculitis, myocarditis (enlarged heart by edema), pericarditis (pain)
   exarcebate heart failure, embolism to coronary vessels.
   - Petechial; spots HR in sclera & conjuctiva.
   - Systemic immune vasculitis : Causes glomerularnephritis & HT. Hematuria.
   - vasculitis on skin : Osler‘s Nodules in palm, soles. painful, red colour, protruded.
   - Systemic vasculitis in liver with toxic effect & hepatitis - hepatomegaly.
   - thrombosis of pulmonary artery with necrosis, infarction of lung. pneumonitis.
   - Toxicity with depression of bone marrow: hyporegenerative anemia, lymphopenia, plasmocytosis.

Question 5

Syndrome

Answer 5

1. syndrome of inflammatory changes and septicaemia
   - fever, chill, hemorrhagic rash, leucocytosis shift to left, accelerated ESR, high fibrinogen and α2-globulin contents, positive bl cultures
2. intoxication syndrome
   - weakness, hyperhidrosis, headache, myalgia and arthralgia, poor appetite, pallor with icteric blue
3. syndrome of thromboembolic complication
   - focal nephritis, MI, Infarction of spleen and intestine, Cerebral thrombo embolism
   - Embolism of retina and vessels of lower extremities
4. syndrome of valvular lesions
   - involvement of aortic and mitral valves
5. syndrome of immune disorders
   - immune complexes in circulating blood
6. syndrome of immune lesions of organs and systems
   - diffuse glomerulonephritis, myocarditis, hepatitis, vasculitis

Question 6

investigation - blood analysis, biochemical , urinalysis, instrumental, microbiology, ecg, chest x-ray

Answer 6

1. Blood :
   - Aneosinophilia symptomatic for whole period of disease.
   - Plasmacytosis appear in blood.
   - Inflammatory markers. C-reactive protein (CRP) and ESR are increased.
2. Biochemical :
   - Dysproteinaemia : alpha2-globulinaemia.
   - transient azotemia
   - serum Ig are increase, total complement and C3 complement are decreased
   - Liver biochemistry. Serum alkaline phosphatase may be increased.
3. Urine :
   - Proteinuria, hematuria, leucocyturia, cylinduria: Toxic kidney/glomerulonephritis.
   - Presence bacteria in blood : Not sterile.
4. Instrumental :
   - US : Show bacteria situated in valve. shows vegetations & cond of chambers (size,etc).
   - US of spleen (enlarged), kidney.
   - valvular dysfunction, aortic root abscesses
5. Microbiology
   - serological test
6. PCR in culture-negative infective endocarditis
7. ECG - atrioventricular block
8. Chest X-ray
   - heart failure or, in right-sided endocarditis, multiple pulmonary emboli and/oral abscesses.

Question 7

treatment

Answer 7

1. Antibacterial/Antiinfective Remedy :
   - Penicillin. If mix flora, combination therapy with A‘glycoside (Gentamycin/Tobramycin).
   - Monolactam AB : Tionam. last gen Penicillin : beta lactam, Amoxycoclaf. plus
   Vancomycin/Cephalosporins of 3rd – 4th gen & Lincomycin.
   - Enterococci : Vancomycin + Cephalosporins.
   - Ampicillin; Pepericillin; Vancomycin; Tobramycin.
   - Gram –ve : Cephalosporins (3rd & 4th gen), A‘glycoside last gen, Monolactam AB.
2. Remedy for immunity : Cephalosporins with A‘glycosides or Quinolones.
   - Fungi : Diflucan, Ketokenazole, Fungisone.
   - Antivirus : Cicloferon, Foskarnet.
   - AB Fluoroquinolone before minor surgery.
   - staphylococcal – vancomycin; gentamycin
   - streptococcal – penicillin, gentamycin
   - enterococcal – ampicillin / amoxicillin; gentamycin