Pericarditis and Infective Endocarditis

Question 1

What is the distinctive rash that presents in pericarditis?

Answer 1

Hand foot and mouth - cocksackie virus (most common cause of pericarditis).

Question 2

What ECG changes are seen in pericarditis?

Answer 2

‘saddle-shaped’ ST elevation
PR depression: most specific ECG marker for pericarditis

Question 3

What is the gold standard investigation for pericarditis?

Answer 3

Transoesophageal echocardiogram is the mostsensitivediagnostic test.

Question 4

Treatment for pericarditis?

Answer 4

NSAIDs and Colchizine

Question 5

What are the differentials for this case:

A patient has had ‘chest pain’ for 4 days alongside some strange rashes. On further questioning the pain is sharp and central, relieved by leaning forwards.

Answer 5

▪Acute Pericarditis

▪Esophagitis

▪Costochondritis

▪ACS

▪Aortic dissection

▪Pneumonia

▪MI

Question 6

What are the most common causes of acute pericarditis?

Answer 6

Question 7

What is the treatment of acute pericarditis?

Answer 7

Usually self-resolving

Treat underlying cause

Combination of NSAIDs and colchichine

Symptom management

Question 8

What is pulsus paradoxus?

Answer 8

A fall in systolic BP of >10mmHg during inspiration.

Question 9

A women with acute pericarditis unfortunately she deteriorates… she had is short of breath and her heart is racing. You notice a pulsating high in her neck!!!

Answer 9

Question 10

Pulsus paradoxus is a sign of…?

Answer 10

Cardiac tamponade

Question 11

What is Libman sacks endocarditis and what is it associated with?

Answer 11

Autoimmune associated with SLE.

Question 12

What are the bacterial causes of infective endocarditis?

Where are they found?

Answer 12

• Streptococcus viridans - found in the mouth.
• Staph aureus - most common - especially common in IV drug users.
• Staph epidermis - likes prosthetic heart valves, or infected IV catheter.
• Enterococcus faecalis and streptococus bovis - found in the bowel spread via colorectal cancer / UC.

Question 13

How does IE present?

Answer 13

Fever and a murmur due to heart valve defects.

Splinter hemorrhages, janeway lesions and osler nodes.

Question 14

How is IE diagnosed?

Answer 14

Multiple positive blood cultures.

Echocardiogram

Question 15

What criteria is used to diagnose endocarditis?

Answer 15

Dukes criteria

Question 16

What is Dukes criteria?

Answer 16

1. Positive blood culture for a typic IE organism.
2. Predisposing heart condition
3. Temperature
4. Peripheral stigmata

Question 17

A man has a prosthetic aortic valve what is the most likely causative organism of his IE?

Answer 17

Staph epidermis

Question 18

Summary of the antibiotic treatments of IE:

Answer 18

• Streptococcal endocarditis is treated with benzylpenicillin +/- gentamicin for 2-6 weeks
• Staphylococcus aureus is treated with flucloxacillin for at least 4 weeks
• Enterococcus is treated with amoxicillin and gentamicin for 4-6 weeks

Question 19

Infective endocarditis in intravenous drug users most commonly affects what valve?

Answer 19

Infective endocarditis in intravenous drug users most commonly affects the tricuspid valve.

Question 20

What is the most common cause of IE?

Answer 20

Staph aureus

Note: Historically Streptococcus viridans was the most common cause of infective endocarditis. This is no longer the case, except in developing countries.

Question 21

Streptococcus viridans

Staphylococcus aureus (in intravenous drugs uses or prosthetic valves)

Staphylococcus epidermidis (in prosthetic valves)

Are all examples of what gram stain bacteria?

Answer 21

Gram positive cocci

Question 22

Most commonly affected valve in IE?

Answer 22

In infective endocarditis, the aortic valve is most commonly affected

Question 23

Treatment for acute peridcarditis:

Answer 23

A combination of NSAIDs and colchicine is now generally used for first-line for patients with acute idiopathic or viral pericarditis

Question 24

What are the clinical signs on of infective endocarditis?

Answer 24

• Janeway lesions
• Osler nodes
• Roth spots
• Microscopic haematuria and glomerulonephritis
• Splinter haemorrhages
• PR prolongation or complete AV block.

Question 25

What are Osler nodes?

Answer 25

Tender subcutaneous nodules on the finger pads and toes.

Question 26

What are Roth spots?

Answer 26

Exudative haemorrhagic retinal lesions with pale centres

Question 27

What are janeway lesions?

Answer 27

Non-tender macules on palms and soles.

Question 28

What is PR prolongation or complete AV block a sign of in infective endocarditis?

Answer 28

PR prolongation or complete AV block - sign of aortic root abscess.

Question 29

Complications of infective endocarditis:

Answer 29

• Acute valvular insufficiency causing heart failure
• Neurologic complications e.g. stroke, abscess, haemorrhage (mycotic aneurysm)
• Embolic complications causing infarction of kidneys, spleen or lung
• Infection e.g. osteomyelitis, septic arthritis

Question 30

What investigations should be carried out in infective endocarditis?

Answer 30

• ECG
• Chest X-ray
• Blood tests: FBC, U&E, LFT, CRP
• At least 3 sets of blood cultures should be taken at different times from various sites.
• Transthoracic echocardiogram is thefirst line imaging investigation
• Transoesophageal echocardiogram is the mostsensitivediagnostic test

Question 31

What finding on ECG can indicate the need for surgical intervention in infected endocarditis?

Answer 31

PR interval prolongation in a patient with Infective Endocarditis is an indication for surgery as it can be secondary to aortic root abscess.