Pericarditis/myocarditis/endocarditis

Question 1

Pericarditis

Answer 1

Retrosternal chest pain, pleuritic and relieved by sitting forward, worse on lying flat, SOB, fever

Causes:
1) uraemia
2) Viral or bacterial infection - coxsackie
3) Isoniazid, cyclosporin or post-RT
4) Post-MI (Dressler’s syndrome)
5) normal T wave, no irregular J point (fish-hook) V4

Examination:
Pericardial friction rub

ECG:
- widespread ST elevation and PR depression in limb leads and V2-6
- ST depression and PR elevation aVR +/- V1

Management:
- NSAIDs, pericardiocentesis if tamponade, Abx if infectious

Question 2

Myocarditis

Answer 2

Symptoms: fatigue, chest pain, fever, SOB

Can lead to dilated cardiomyopathy

Causes:
- viral (Coxsackievirus B (most common) HIV, Influenza A, HSV, adenovirus, covid)
- bacterial - mycoplasma, rickettsia, diphtheria (most common)
- immune - sarcoidosis, scleroderma, SLE< Kawasaki
- clozapine, amphetamines

ECG:
- widespread concave STE -pericarditic changes

Bloods: raised WCC, troponin, ESR, CRP

Admit

Question 3

Infective endocarditis - who is at increased risk?

Answer 3

At increased risk:
- acquired heart valve disease & valve replacement
- HOCM
- previous IE
- structural congenital heart disease (excluding isolated ASD, fully repaired VSD or fully repaired PDA)
- IVDU, central lines, poor oral hygiene/dental infections

Question 4

Prophylaxis against infective endocarditis

Answer 4

Not recommended routinely for:
- dental procedures
- GI / GU / respiratory / ENT / bronchoscopy surgery

Do not offer chlorhexidine mouthwash as prophylaxis for dental procedures

Question 5

Infective endocarditis: Early vs late prosthetic valve endocarditis

Answer 5

Early: within 12m surgery, staph.aureus

Late: > 12m, strep or staph.aureus

Question 6

Infective endocarditis:

Presentation

Answer 6

Presentation:
- fever
- tachycardia
- new/changing murmur
- splinter haemorrhages, nail bed petechial haemorrhages
- Osler’s nodes (tender nodules on fingers)
- Janeway lesions (painless macules on palms)
- Roth spots (boat-shaped retinal haemorrhages, pale in centre)
- clubbing
- mild splenomegaly
- bi-basal creps if HF
- emboli –> VA

Investigations:
- ECG
- urine dip - microscopic haemautira
- blood cultures
- bloods - FBC, CRP, U&E
- TT Echo, sometimes TTO Echo

Question 7

Duke criteria for IE

Answer 7

Major criteria

1) Positive blood cultures
- Positive for typical microorganisms on >= 2 separate occasions inc. strep viridans, strep Boris, HACEK, staph aureus, community acquired enterococci
- Persistently positive cultures for microorganisms consistent with IE - >=2 cultures drawn > 12h apart or all 3 or majority of >=4 with 1st and last drawn > 1h apart
- A single positive culture for coxiella brunette or high antibody titre

2) Evidence of endocardial involvement:
- intra-cardiac vegetation
- abscess
- new valvular regurgitation
- new partial dehiscence of prothetic valve

Minor criteria:
1) Risk factor
2) Fever > 38
3) Vascular phenomena: septic embolic, JW lesions, conjunctival haemorrhage, intracranial haemorrhage
4) Immunological phenomena: O nodes, R spots, positive rheumatoid factor
5) Microbiological evidence: positive cultures not meeting major criteria

Definite:
- direct evidence by histology of culture from vegetation
- 2 major
- 1 major + 3 minor
- 5 minor

Possible:
- 1 major + 1 minor
- 3 minor

Not endocarditis if:
- firm alternative Dx
- sustained symptoms resolution after < 4 days Abx

Treatment:
- prosthetic valves - 6 weeks IV Abx
- native valves - 2-6 weeks IV Abx
- day 1 = 1sst day of negative culture
- surgery