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HHAD: Human Disease > Infective endocarditis and rheumatic fever > Flashcards

Infective endocarditis and rheumatic fever Flashcards

1
Q

What is rheumatic fever? What parts of the body does it affect? (4)

A

It is a multisystem disease which occurs after a group A streptococcal infection. It affects the heart, skin, joints and CNS

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2
Q

What bacteria cause rheumatic fever?

A

Group A, beta heamolytic streptococci

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3
Q

How long is the latent period for rheumatic fever?

A

2-6 weeks

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4
Q

What are the risk factors for rheumatic fever? (4)

A

Patients from low socio-economic groups
Overcrowded conditions
HLA DR4 positive

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5
Q

When does rheumatic fever occur?

A

Occurs after repeated oropharyngeal streptococcal infections causing an exaggerated B lymphocyte response

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6
Q

In rheumatic fever, what cross-reacts with connective tissue?

A

Streptococcal antigens

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7
Q

Rheumatic fever causes Vasculitis - what is this? What does it affect in rheumatic fever?

A

Vasculitis means inflammation of the blood vessels. It affects the connective tissue in rheumatic fever

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8
Q

What microscopic structures would be visible when looking at a patient with rheumatic fever

A

Aschoff’s body - this is an aggregate of large cells with polymorphs and basophils around a vascular fibrinoid core

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9
Q

Rheumatic fever causes pancarditis - what is this?

What part of the body is most severely involved in this?

A

Pancarditis is inflammation of the heart.

The endocardium is the most severely involved

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10
Q

Chronic rheumatic fever may develop in what percentage of patients with acute rheumatic fever?

A

50%

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11
Q

What is the percentage of mortality in patients with rheumatic fever and carditis?

A

1%

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12
Q

What criteria is used when trying to diagnose rheumatic fever?

A

Duckett-Jones Criteria

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13
Q

What criteria combination indicates a high probability of rheumatic fever?

A

2 major criteria and one minor criteria

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14
Q

Name some examples of major criteria for rheumatic fever?

A

Carditis, polyarthritis, erythema marginatum ( rare skin rash that spreads on the trunk and limbs), subcutaneous nodule, chorea (movement disorder that causes involuntary, irregular, unpredictable muscle movements)

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15
Q

Name some examples of minor criteria for rheumatic fever?

A 
Fever
Arthralgia (joint stiffness)
Previous rheumatic fever
Raised acute phase proteins ECR (erythrocyte sedimentation rate), CRP (C-reactive protein), Ferritin
Prolonged P=R interval on ECG
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16
Q

What is polyarthritis?

A

It is when 5 or more joints are affected with arthritis

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17
Q

In what percentage of patients with rheumatic fever suffer with polyarthritis?

A

80-90%

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18
Q

What may be the first clinical manifestation of rheumatic fever after the streptococcal sore throat?

A

Polyarthritis

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19
Q

How long does polyarthritis last for?

A

4-6 weeks

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20
Q

What joints are mainly affected by polyarthritis?

A

Knee, ankle, elbow, hip and shoulder

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21
Q

How long may the pain last for in a particular joint when suffering with polyarthritis?

A

A week

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22
Q

What is carditis?

A

Carditis is the inflammation of the heart

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23
Q

In what percentage does carditis occur in rheumatic fever patients?

A

40-50%

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24
Q

How soon after polyarthritis does carditis occur in rheumatic fever patients?

A

2 weeks

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25
Q

How long does carditis last for in RF patients?

A

3-6 months

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26
Q

What are the clinical features of carditis in RF patients?

A

They may vary - they may not have any symptoms (be asymptomatic) or they may present with congestive heart failure

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27
Q

If a RF pt has a symptomatic carditis, how may this be recognised??

A

After other clinical signs have presented
or
Cardiomegaly on a chest x-ray

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28
Q

What is pericarditis?

A

Inflammation of the pericardium

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29
Q

How does pericarditis present?

A

Presents with fluid in the pericardial space and may give rise to an intermittent pericardial rub

30
Q

What is myocarditis?

A

It is the inflammation of the heart muscle (myocardium) - all of the myocardium may be involved

31
Q

How may patients with myocarditis present?

A

Left ventricular failure which may lead to right ventricular failure and subsequent congestive cardiac failure

32
Q

What is endocarditis?

A

It is a rare and potentially fatal infection of the inner lining of the heart

33
Q

Which part of the heart is most commonly affected by endocarditis?

A

Mitral valve.

It may occur alone or in association with the aortic valve failure.

34
Q

What is it called when mitral and aortic valve endocarditis disease occur together?

A

Fulminant

This is associated with a high mortality rate

35
Q

What is valvulitis?

A

It is the inflammation of the heart valves - this is a common complication of acute rheumatic fever

36
Q

What does valvulitis result in?

A

Results in nodules on the mitral and aortic valves resulting in murmurs

37
Q

What clinical manifestation indicates late stages of RF?

A

Chorea

38
Q

How long after other features of RF may chorea occur?

A

4-6 months

39
Q

In what percentage of RF patients does chorea occur?

A

10%

40
Q

What name is given to involuntary movements of face and limbs, that disappears during sleep?

A

Syndenham’s chorea

41
Q

What is another name for Sydenham’s chorea?

A

St Vitus’ dance

42
Q

What type of nodules are rare in RF patients?

A

Subcutaneous nodules

43
Q

What do subcutaneous nodules look like?

A

Small (up to 0.5cm) are non-tender, mobile and firm

Occur over bony prominence

44
Q

What is the name for nodules that are larger that subcutaneous nodules that are painful?

Where do these occur and how do they appear?

A

Erythema nodosum

Over shins

Appear as deep pink/red nodules that are tender on palpation

45
Q

What type of erythema occurs in 65% of RF patients?

A

Erythema marginatum

46
Q

What is invariably (always) seen in association with carditis? in patients with RF

A

Erythema Marginatum

47
Q

What does an erythema marginatum rash look like?

A

Serpiginous edge (wavy) with a fading centre, and spreads over the trunk and limbs.

Painless and non-itchy (non-pruritic)

48
Q

What is infective endocarditis?

A

Infection of the endocardial surface of heart or valves - usually bacterial (occasionally fungal).

49
Q

What is the morbidity and mortality rate of infective endocarditis (IE)?

A

20-30%

50
Q

What is the annual incidence in the UK for IE?

A

6-7 per 100,000

51
Q

Give 4 suggestions as to why the incidence of IE may be rising?

A
  • Increasing number of elderly people (& hence abnormal/prosthetic valves)
  • Increasing number of invasive procedures both diagnostic and therapeutic
  • Increased number of children with CHD survive
  • Increase in IV drug abuse
52
Q

Endocarditis is usually of a consequence of which 2 factors?

A
  • Abnormal cardiac endothelium facilitating bacterial adherence and growth
  • Presence of organisms in blood
53
Q

Give 3 examples of a bacterial source that may cause endocarditis

A 
Infected needle 
Open wound 
Dental procedure
Cardiac Device 
Surgery 
Intravascular catheter
54
Q

What is the bacteria that’s most likely to cause endocarditis?

A

Staph aureus

55
Q

What in the heart may provide an abnormal substrate for endocarditis to occur?

A

Prosthetic valve - sutures and endothelial damage

Native Valve damage - endothelial damage (exposed collagen)

56
Q

What is the significance of abnormal endothelium in the occurrence of endocarditis?

A

Non-laminar blood flow (turbulent), promoting fibrin and platelet deposition

This creates small thrombi (clots) which allow organisms to adhere and grow

Leads to characteristic infected vegetations

57
Q

Name (in order) the top 4 organisms that are involved in the pathogenesis of IE

A

Streptococci 63%
Viridans groups 50%
Staphylococci 26%
Fungi 4%

58
Q

When trying to culture the organisms that cause IE - the culture is negative in approx 5-10%, why is this? (2)

A
  • Possibly due to previous AB therapy

- Fastidious organisms that fail to grow in normal blood cultures

59
Q

What are the early signs of infection in IE? (5)

A

Fever, sweats, loss of appetite, weight loss, malaise

60
Q

What are the late signs of infection in IE? (3)

A

Splenomegaly, clubbing, anaemia

61
Q

What are the 3 signs of heart disease in IE?

A

Development of new murmur
Change to an existing murmur
Heart failure

62
Q

What are signs of embolism in IE?

A

Septic arthritis
Osteomyelitis
Splenic abscess
CNS - meningitis, miliary brain abscess, TIA (transient ischemic attack), stroke

63
Q

What may you see that may indicate that a patient has IE?

A

On the skin: Osler’s nodes (painful, red, raised lesions found on the hands and feet), splinter haemorrhage (tiny blood spots that appear underneath the nail)

In urine: blood (haematuria - renal issue)

Eyes - Roth’s spots (non-specific red spots with white or pale centres, seen on the retina)

64
Q

What are the 6 investigations you can do to investigate IE?

A
  • Urine testing: microscopic haematuria
  • Blood cultures: positive in 75% of cultures
  • Bloods: FBC (raised white cell count), ESR/CRP (raised), LFT (mild disturbance, alkaline phosphatase raised), serum immunoglobulins (raised), complement and C3 (decreased).
  • Chest radiograph: cardiomegaly and signs of heart failure
  • Electrocardiogram
  • Echocardiogram
65
Q

Outline IE treatment with drug therapy

A

Drug therapy: pharmacotherapy

  • Bactericidal antibiotics chosen on basis of blood culture and antibiotic sensitivity assessment
  • Treatment should continue for 4-6 weeks and at least the first 2 weeks should be parenteral (not delivered via GI tract - i.e. IV)
66
Q

Name the 2 ways IE can be treated

A

Drug therapy

Surgery

67
Q

Outline when surgery may be used to treat IE (6)

A 
Extensive damage to valve. 
Infection damage to a valve. 
Worsening renal failure. 
Persistent infection but failure to culture an organism.
Embolisation.
Large vegetations
68
Q

Give 4 situations where prognosis for IE surgery may be worse

A
  1. organism cannot be identified
  2. Cardiac failure is present
  3. Infection occurs on prosthetic valve
  4. Microorganisms found are resistant to therapy
69
Q

When would antibiotic prophylaxis NOT be recommended (according to NICE guidelines)? (4)

A
  • People undergoing dental procedures
  • People undergoing procedures in the upper and lower GI tract
  • People having procedures in Genitourinary tract: including urological, gynaecological and obstetric procedures and childbirth
  • People having procedures in upper and lower resp tract: including ear, nose and throat procedures and bronchoscopy.
70
Q

What else should not be offered as prophylaxis against IE to people at risk when undergoing dental procedures?

A

Chlorhexidine mouthwash

71
Q

What puts a patient more at risk of IE? (6)

A
  • Structural cardiac defects
  • Acquired valvular heart disease with stenosis or regurgitation
  • Hypertrophic cardiomyopathy
  • Previous infective endocarditis
  • Structural congenital heart disease (including corrected conditions)
  • Valve replacement
72
Q

What advice and information should be given to patients that are of increased risk? (4)

A
  1. Benefits and risks of AB prophylaxis - give explanation why AB prophylaxis is no longer routinely recommended
    - Importance of maintaining good oral health
    - Symptoms that may indicate IE and when to seek expert advice
    - The risks of undergoing invasive procedures, including non-medical procedures such as body piercing or tattooing.

HHAD: Human Disease (20 decks)

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