Infective endocarditis & Rheumatic Heart Disease

Question 1

What is infective endocarditis?

Answer 1

Inflammation of the endocardium

Question 2

RECAP- what is the endocardium?

Answer 2

Inner layer of the heart

Question 3

What happens in infective endocarditis after the valve has been colonised by bacteria?

Answer 3

The vegetation enlarges by further cycles of platelet-fibrin deposition and bacterial proliferation

Question 4

What is the main characterisation of infective endocarditis?

Answer 4

The presence of vegetations

Question 5

What are some predisposing factors which can lead to infective endocarditis?

Answer 5

-Prosthetic valves
-Cardiac devices (permanent pacemakers, defribillators)
-Intravenous drug users
-Congenital Heart disease
-Rheumatic valve disease (developing countries)
-Mitral valve prolapse
-Immunosuppression
-Prolonged admission to ITU/hospital (health-care associated IE)

Question 6

What are some of the signs/ symptoms of infective endocarditis?

Answer 6

Fever (90%)
-Chills/Rigors
-Poor appetite
-Weight loss

Heart murmur (85%)

Question 7

What are some of the less common signs/ symptoms of IE?

Answer 7

Less frequent: myalgia, abdo/back pain, confusion

Embolic complications (phenomena) 25%.

Question 8

What might you see upon clinical examination in those with IE?

Answer 8

Osler nodes
Janeway lesions
Splinter haemorrhages
Roth Spots

Question 9

Describe Osler Nodes

Answer 9

Red-purple, slightly raised, tender lumps, often with a pale centre.
Pain often precedes thedevelopmentof the visiblelesionby up to 24 hours.

Question 10

Where are Osler Nodes usually found?

Answer 10

They are typically found on the fingers and/or toes.

Question 11

Describe Janeway lesions

Answer 11

Rare, non-tender, smallerythematousorhaemorrhagicmacular,
papularornodularlesions
Few mm in dimeter

Question 12

Where are Janeway lesions usually found?

Answer 12

Palms or soles

Question 13

Describe splinter haemorrhages.

Answer 13

Looklike thin, red to reddish-brown lines of blood under the nails.

Question 14

Describe Roth Spots.

Answer 14

White centered retinal hemorrhage

Question 15

What are some of the laboratory signs of all infection helping with the diagnosis found in blood tests?

Answer 15

Elevated C-reactive protein
Erythrocyte sedimentation
Leucocytosis
Anaemia
Microscopic haematuria

Question 16

What must be taken before antibiotic therapy is commenced in IE?

Answer 16

Three sets of blood cultures, 30 mins apart

Question 17

What is the point of during three sets of blood cultures before starting antibiotics in those w IE?

Answer 17

It isolates the pathogen so we know what to treat

Question 18

Which two bacteria most commonly cause IE?

Answer 18

Staphyloccus aureus.
Streptococci (Viridans, gallolyticus)

Question 19

Name tow other bacteria which can cause IE but less commonly.

Answer 19

Enterococci
Coagulase negative Staphylococci.

Question 20

If a patient has a negative cultures for endocarditis?

Answer 20

They may still have it, it just may not be caused by one of the common pathogens

Question 21

List some of the bacteria/fungi which can cause IE but are identified after the first more generic blood culture has been taken.

Answer 21

Brucella spp
Coxiella burnetti
Bartonella spp
Tropheryma whipplei
Mycoplasma spp
Legionella spp
Fungi (Candida and Aspergillus)

Again, just read through and try to remember a couple, idk how essential this is

Question 22

Which types of imaging are usually used in the diagnosis of IE?

Answer 22

Transthoracic echocardiogram- most important
Transoesophageal echo
CT/MRI
Positron emission tomography- helpful if diagnosis is unclear

Question 23

Which criteria is used for the diagnosis of IE?

Answer 23

Modified Duke criteria

Question 24

How many of the major/minor criteria from Modified Duke criteria gives a diagnosis of definite IE?

Answer 24

2 major

OR

1 major and 3 minor

OR

5 minors

Question 25

How many of the major/minor criteria from Modified Duke criteria gives a diagnosis of possible IE?

Answer 25

1 major and one minor

OR

3 minors

Question 26

What are some of the major criteria from Modified Duke classification for when it comes to diagnosing IE?

Answer 26

Positive blood culture
ECHO showing valvular vegetation

Question 27

What are some of the minor criteria from Modified Duke classification for when it comes to diagnosing IE?

Answer 27

Predisposing cardiac lesion
IV drug use
Fever
Embolic phenomena
Immunologic phenomena
Positive blood culture but not one of the main bacteria causing IE.

Question 28

In terms of prognosis, what are some of the patient characteristics of IE which indicate a poor prognosis?

Answer 28

Older age
Comorbidities
Diabetes

Question 29

In terms of prognosis, what are some of the infective microorganisms of IE which indicate a poor prognosis?

Answer 29

Staph aureus
Fungi

Question 30

In terms of prognosis, what are some of the cardiac/non-cardiac complications of IE which indicate a poor prognosis?

Answer 30

HF, renal failure, ischemic stroke, shock

Question 31

In terms of prognosis, what are some of the ECHO findings of IE which indicate a poor prognosis?

Answer 31

Periannular complications
Severe valve regurgitation,
low systolic function, large vegetations

Question 32

What is the treatment for IE?

Answer 32

Antibiotics- usually a long course, approx. 4 weeks

Question 33

What is the usual antibiotic for those with a Streptococci/strepotcoccal bovis infection?

Answer 33

Penicillin or amoxicillin or ceftriaxone

Question 34

What is the usual antibiotic for those with a Streptococci/strepotcoccal bovis infection in pateints with a beta-lactam allergy?

Answer 34

Vancomycin

Question 35

What is the usual antibiotic for those with a Staph aureus infection?

Answer 35

Flucloxacillin or oxacillin

Question 36

What is the usual antibiotic for those with a Staph aureus infection in patients w a penicillin allergy?

Answer 36

Vancomycin

Question 37

Describe the antibiotic treatment for prosthetic valves.

Answer 37

At least 6 weeks of therapy.
Might have to add Rifampicin and/or Gentamicin

Question 38

Name some indications for surgery for patients w IE.

Answer 38

-Heart failure with valvular dysfunction or cardiac complications
-Uncontrolled infection
-Prevention of embolism

Question 39

What are the criteria for surgery in terms of prevention of embolism?

Answer 39

If the vegetation is persistently large (>10mm).
One or more embolic episodes