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Infective endocarditis Flashcards

1
Q

What is infective endocarditis?

A

Infective endocarditis is an endovascular infection of cardiovascular structures, including cardiac valves, atrial and ventricular endocardium, large intrathoracic vessels and intracardiac foreign bodies, e.g. prosthetic valves, pacemaker leads and surgical conduits.

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2
Q

How does damaged endocardium predispose someone to IE?

A

Damaged endocardium promotes platelet and fibrin deposition which allows organisms to adhere and grow, leading to an infected vegetation. Valvular lesions may create non-laminar flow, and jet lesions from septal defects or a patent ductus arteriosus result in abnormal vascular endothelium.

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3
Q

Which valves are most commonly affected in IE?

A

Aortic and Mitral valves in non drug users

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4
Q

Which valves are most commonly affected in IVDUs?

A

Right sided heart lesions (tricuspid and pulmonary)

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5
Q

What are cardiac risk factors for IE?

A
  • Mitral valve prolapse
  • Congenital Heart Disease
  • Aortic stenosis
  • Aortic regurgitation
  • Mitral regurgitation
  • Rheumatic Heart Disease
  • Prosthetic heart valve
  • Cardiac Surgery
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6
Q

What are non-infective risk factors for IE?

A
  • IVDU
  • Indwelling medical devices
  • Diabetes mellitus
  • AIDS
  • Chronic skin infection, burns
  • GU infection
  • GI lesions
  • Organ transplant
  • Homelessness
  • Pneumonia
  • Poor dental hygeine/dental work
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7
Q

If someone presented with a new murmur and a fever, what might you suspect?

A

IE until proven otherwise

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8
Q

What organisms can cause IE?

A
  • Strep. viridans
  • Enterococci
  • Staph aureus/epidermidis
  • HACEK organisms
  • Coxiella burnetti
  • Chlamydia
  • Candida
  • Aspergillus
  • Histoplasma
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9
Q

What are symptoms of infective endocarditis?

A
  • Malaise
  • Pyrexia (90%)
  • Rigors
  • Night sweats
  • Weight loss
  • Headache
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10
Q

What signs might be seen in someone with infective endocarditis?

A
  • Septic signs
  • New/changing pre-existing cardiac murmur
  • Skin lesions
  • Roth’s spots
  • Spenomegaly/splenic infarct
  • Embolic phenomena
  • Glomerulonephritis/AKI
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11
Q

What are septic signs seen in IE?

A
  • Fever
  • Rigors
  • Night sweats
  • Splenomegaly
  • Clubbing
  • Malaise/Weight loss
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12
Q

What is the following?

A

Clubbing of the fingers and toes

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13
Q

What can valvular vegetations do to the valve?

A
  • Valve destruction
  • Valve regurgitation
  • Valve obstruction
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14
Q

What is the following?

A

Osler’s nodes - Tender, red-purple, slightly raised, cutaneous nodules often with a pale surface. Most frequently found over the tips of the fingers and toes, but can be present on the thenar eminences and are often painful.

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15
Q

What is the cause of the following?

A

Osler’s nodes - result from the deposition of immune complexes. The resulting inflammatory response leads to swelling, redness, and pain that characterize these lesions.

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16
Q

What is the following?

A

Janeway Lesions - Non-tender, haemorrhagic macules or papules often found on the palms or soles – especially on thenar or hypothenar eminences

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17
Q

What causes the following?

A

Janeway Lesions - thought to be caused by septic micro-emboli deposited in peripheral sites, which causes microabscesses of the dermis with marked necrosis and inflammatory infiltrate not involving the epidermis

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18
Q

What are signs of long standing infection in infective endocarditis?

A
  • Anaemia
  • Clubbing
  • Splenomegaly
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19
Q

What are the following?

A

Splinter haemorrhages - Small, red-brown lines of blood seen beneath the nails. They run in line with the nail and look like splinters caught underneath the nail.

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20
Q

What causes the following?

A

Splinter haemorrhages - In bacterial endocarditis, this sign is thought to be caused by emboli creating clots in capillaries under the nail, resulting in haemorrhage.

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21
Q

What skin lesions are found in Infective endocarditis?

A
  • Osler’s nodes
  • Janeway lesions
  • Splinter haemorrhages
  • Petechiae (most common)
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22
Q

What is the following?

A

Roth spots - oval retinal haemorrhages with a pale centre located near the optic disc

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23
Q

What causes the following?

A

Roth spots - insult causes rupturing of the retinal capillaries, followed by extrusion of whole blood, leading to platelet activation, the coagulation cascade and a platelet fibrin thrombus. The fibrin appears as the white lesion within the haemorrhage.

It is suggested that in subacute bacterial endocarditis, thrombocytopenia secondary to a low-grade disseminated intravascular coagulopathy can prompt capillary bleeding in the retinal vasculature.

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24
Q

Why can AV block occur in IE?

A

Aortic root vegetations can prolong PR interval, and if serious can cause complete AV block

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25
Q

What are cardiac signs of IE?

A
  • CCF
  • Palpitations
  • Tachycardia
  • New murmur
  • Pericarditis
  • AV block
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26
Q

What systems are affected by immune complex deposition in infective endocarditis?

A
  • Skin
  • Eyes
  • Renal
  • Cerebral
  • Musculoskeletal
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27
Q

What cerebral signs might you see in someone with IE?

A
  • Toxic encephalopaty
  • Cerebral Abscess
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28
Q

What are musculoskeletal manifestations of IE?

A
  • Arthralgia
  • Arthritis
29
Q

What mnemonic can be used to remember signs/symtpoms of IE?

A
  • Fever
  • Roth spots
  • Oslers nodes
  • Murmur
  • Janeway lesions
  • Anaemia
  • Nail bed haemorrhages
  • Embolic events
30
Q

What diagnostic criteria are used for diagnosing IE?

A

Dukes criteria

31
Q

What are the major criteria for Dukes criteria for IE?

A

Blood culture +ve

  • Typical micro-organisms in 2 seperate cultures or
  • Persistently +ve blood cultures drawn 12 hours apart

Endocardial involvement

  • Positive echocardiogram - vegetation, abscess or valve dehiscence or New valvular regurgitation
32
Q

What are the minor diagnostic critera of the Dukes criteria?

A
  • Fever > 38oC
  • Immunological phenomena
  • Vascular phenomena
  • Echo positive for IE but not meeting major criteria
  • Predisposing condition/drug use
  • Microbiological evidence
33
Q

What vascular phenomena are part of the minor diagnostic criteria for the Dukes criteria for infective endocarditis?

A
  • Arterial emboli
  • Septic pulmonary infarcts
  • Mycotic aneurysms
  • Intracranial and conjunctival haemorrhages
  • Janeway lesions
34
Q

What immunological phenomena are part of the minor diagnostic criteria for the Dukes criteria for infective endocarditis?

A
  • Glomerulonephritis
  • Osler’s nodes
  • Roth spots
35
Q

What microbiological evidence needs to be present as part of the minor diagnostic criteria of the modified dukes criteria for infective endocarditis?

A

Positive blood cultures but not meeting major criteria

36
Q

What combination of criteria would give you a definitive diagnosis of IE?

A
  • 2 major criteria
  • 1 major and 3 minor criteria
  • 5 minor criteria
37
Q

What combination of dukes criteria may indicate a possibility that someone has infective endocarditis?

A
  • 1 major
  • 3 minor
38
Q

What investigations may you do in someone with suspected IE?

A
  • Blood cultures
  • Bloods - FBC, U+E’s, LFT’s, ESR/CRP
  • Urinalysis
  • ECG
  • CXR
  • Echo
39
Q

If taking blood cultures for IE, how many would you take and where would you take them from?

A

At least 3 sets from 3 different sites at least 1 hour apart

40
Q

What might you see for FBC in someone with IE?

A
  • Normochromic, normocytic anaemia
  • Neutrophil leucocytosis
  • Thrombocytopenia
41
Q

What might you see in U+E’s in someone with IE?

A

May be deranged

42
Q

What might you see on LFTs in someone with IE?

A

May be deranged, esp. ALP and gamma-GT

43
Q

What might you see on ESR/CRP in someone with IE?

A

Acute phase reaction

44
Q

What might you see on urinalysis in someone with IE?

A

Microscopic haematuria +/- proteinuria

45
Q

What might you see on ECG in someone with IE?

A
  • Changes associated with underlying cause
  • AV block - aortic root abscess
  • Acute MI
46
Q

What might you see on CXR in someone with IE?

A
  • Pulmonary oedema
  • Multiple infected/infarcted areas from septic emboli
47
Q

What type of Echo would you perform as 1st line investigation if there was clinical suspicion of IE?

A

Transthoracic echo

48
Q

What are the HACEK organisms?

A
  • Haemophilus
  • Actinobacillus
  • Cardiobacterium
  • Eikenella
  • Kingella
49
Q

If a TTE was positive, what would be your next line of investigation?

A

Transoesophageal Echo

50
Q

If a TTE was negative, what would be your next line of investigation?

A

Determine if high risk of IE

  • Yes - TOE
  • No - No further investigation
51
Q

When should you consider repeating a TOE?

A

If clinical condition changes, or if TOE is negative but there is still clinical suspicion of IE

52
Q

Where might you find peripheral abscesses in IE?

A
  • Renal
  • Spleen
  • Spine
53
Q

When would you start antibiotics in IE?

A

After cultures taken, but before results are found

54
Q

How empirical antibiotics would you treat someone with a indolent native valve infective endocarditis?

A

IV Gentamicin and Amoxicillin

55
Q

What dose of gentamicin would you give someone with indolent native valve infective endocarditis?

A

1mg/kg per hr

56
Q

What dose of amoxicillin would you give someone with indolent native valve infective endocarditis?

A

2g every 4 hours

57
Q

If someone was penicillin allergic, what empirical antibiotics would you use to treat indolent native valve IE?

A

IV Vancomycin and Gentamicin

58
Q

If someone had septic native valve infective endocarditis, what antibiotics would you use?

A

IV Vancomycin and Gentamicin

59
Q

What empirical antibiotics would you use in someone with a prosthetic valve with infective endocarditis?

A

IV Vancomycin + Gentamicin + Rifampicin

60
Q

What dose of rifampicin wyould you give someone as an empirical antibiotic for prosthetic valve endocarditis?

A

300-600mg orally/IV, 12 hrly

61
Q

How would you monitor someone with IE while they are having treatment?

A
  • Clinical features
  • Echo
  • ECG
  • Micro - blood cultures, vanc/gent levels
  • Bloods - U+E’s, LFTs, CRP
62
Q

How quicly should patients respond to antibiotic treatment?

A

48 hrs - if not responding in this time - need to consider other causes

63
Q

How often should you perform ECHO when treating someone for IE?

64
Q

How often should you perform ECG when monitoring someone being treated for IE?

65
Q

When would you consider surgical intervention in IE?

A
  • Heart failure
  • Valvular obstruction
  • Fungal endocarditis
  • Persistent infection
  • Myocardial abscess formation
  • Repeated Embolism
  • Unstable Prosthetic valve infection
66
Q

What high risk groups should be offered prophylactic treatment of IE?

A
  • Acquired VHD
  • Valve replacement
  • Congenital heart defect
  • Hypertrophic cardiomyopathy
  • Previous IE
67
Q

What are the most common causes of splinter haemorrhages?

A
  1. Microtrauma - !!!!most common!!!; e.g. gardening
  2. Infective endocarditis
  3. Vasculitis - Scleroderma, SLE
68
Q

What are the 5 main signs most commonly seen in infective endocarditis?

A
  • 2 in the hands - clubbing and splinter haemorrhages
  • 1 in the heart - changing murmurs
  • 2 in the abdomen - splenomegaly and microscopic haematuria

Plus rarities - Janeway’s lesions, oslers nodes etc

Cardiology (29 decks)

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