PUO and Endocarditis Flashcards
What is the definition of pyrexia of unknown origin (PUO)
Fever higher than 38.3 on several occasions, persisting without diagnosis for at least 3 weeks in spite of at least 1 weeks investigations in hospital
What are the causes of PUO (5)
Infection Neoplasm Connective Tissue disease Undiagnosed Miscellaneous causes
What are the subclasses of PUO (4)
Classical PUO
Healthcare associated PUO
Immune deficiency PUO
HIV related PUO (always do an HIV test in A&E)
What are the causes of classical PUO (8)
Abscesses Endocarditis Tuberculosis Complicated urinary tract infections Fever in the returning traveller causes HIV Connective tissue disease/Vasculitis Neoplasms
Male Age- 58, admitted June 2009 p/c: 3 week history of fever, chills , back pain Diabetic WCC 36; neut 33.7 CRP 169 Initial blood cultures negative. Discitis and endocarditis diagnosed via imaging. MSSA bacteraemia.
What is the diagnosis?
Metastatic staphylococcal disease.
Management: MDT infection/cardiology/cardiothoracic
What is discitis
Abscess in epidural space
What is seen on echo of a patient with endocarditis
Vegetations on aortic valve
What are the most common causes of fever in a returning traveller (8)
Malaria Dengue Typhoid Richettsia Bacterial diarrhoea UTI Brucella....indolent Viral haemorrhagic fever - RARE but think of it
60 year old woman p/c: Admitted with a 3 day history of headache fever and nausea Returned from a 10 day trip to India Past history of dengue Previous treated TB Purpuric rash on trunk
What could be causing the rash? (4)
Dengue
Malaria
Rickettsial infection
Typhoid
Malaria films –ve Dengue serology –ve Blood cultures -ve Serology; IgM and IgG antibodies against the rickettsia‘spotted fever group’ positive
What are spotted fevers
Emerging/re-emerging pathogens - RICKETTSIA
What are the vectors for spotter fevers (3)
Tick, mite, flea borne (ZOONOSES)
What type of bacteria is spotted fever
Small gram negative bacteria
What are two examples of spotted fevers (2)
Rocky Mountain Spotted Fever - USA
Spotted Fever - India
How is spotted fever diagnosed
Serology
What is the treatment for spotted fever
Doxycycline
What is the best clue to the cause of PUO in a returning traveller
CAREFUL travel history essential
What should you NOT do in healthcare associated PUO
Don’t just start antibiotics (unless septic)
What are the causes of healthcare associated PUO (6)
Post surgical - collection, wound infection
Catheter related UTI
Line related bacteraemia…peripheral
Ventilator associated pneumonia (VAP) in ITU
Clostridium difficile colitis in in elderly patients, antibiotics, hospital/healthcare contact
What gives you the best clue for the cause of healthcare associated PUO
Examining the patient
What does clostridium difficile do to WCC
Massively raised
What are some causes of hospital acquired pneumonia (3)
Mostly gram negative bacteria
Rarely legionella
Iatrogenic from infected staff and relatives (flu!)
What safety nets are in place to help reduce hospital causes of pneumonia (3)
DoH documents, White paper.
Care bundles now
Record all insertions of central lines
What is seen in immune deficiency pyrexia of unknown origin
Neutropenic fever
Neutrophils <0.5
What is the most common cause of neutropenic fever
Bone marrow transplant patients
What are the most common bacterial infection in BMT patients (2)
From lines commonly - pneumonia, mucositis
What are the mycobacterial causes of neutropenic fever in BMT patients (@)
MTB
Atypical pneumonia
What are the viral infections commonly in BMT patients (2)
CMV
Respiratory viruses
What are some non-infective causes of neutropenic fever in BMT patients (2)
Haemorrhage
PE
What increases the risk of fungal infections (neutropenic fever) (4)
Graft versus host disease….increase risk of moulds.
Higher risk of acute leukaemia, allografts
Drug fever
IRIS syndrome
What does the cause of PUO in HIV patients depend on
CD4 count
What are some causes of HIV PUO if CD4>200 (5)
Seroconversion illness...also rash Bacterial: Streptococcus pneumoniae CMV TB Histoplasmosis (take travel history!!! - arizona desert, malaysia)
What are some causes of HIV PUO if CD4<200 (3)
Disseminated mycobacterium avium (MAI) complex
PCP
Cryptococcus
What are some CD4 independent causes of PUO in HIV patients (2)
Lymphoma
Drug fever
What is TB
Atypical mycobacteria
What are the classical features of PCP (4)
Cough
Hypoxia
Desaturation on exercise
Some shadowing around heart in CXR (but otherwise grossly normal CXR)
What steps are involved in the work up of PUO (7)
Observation of fever
Medical history (travel/exposure/hobbies)
Physical examination
Lab tests - 3 sets of blood cultures, prolonged incubation…HIV test
Inflammatory markers - EBC, CRP, pro-calcitonin
Non-invasive procedures
Invasive procedures
What history is important in PUO (8)
Recent/old travel- malaria, dengue/filiaria, histoplasmosis
Animal exposure - brucellosis, cat fleas
Food exposure
Contacts - HIV, syphilis
Family history- familial mediterranean fever
Recreation- Water: Lyme, leptospirosis
Past medical history…Ct disease, MEN..FHx
Drug history
What should be done on a physical examination of a patient with PUO (7)
Confirm the presence of fever…charts
Skin and nails - splinter haemorrhages, rashes, ulcers
Fundi - choroid tubercle (TB), roth spots
Heart - murmurs
Abdominal examination - hepatosplenomegaly
Lymph nodes
Pelvic examination - PID?
If you suspect secondary syphilis as the cause of PUO, what should you do? (2)
Get them seen by STD clinic
HIV test
What does eosinophilia indicate in a patient with a fever
Think of worms!
They travel through tissue - local histamine –> eosinophils up
Can carry them asymptomatically for years
What are some parasitic infections (3)
Filaria
Strongloides
Schistosomiasis
20 year old man admitted with a 3 week history of fever and headache. Has been travelling in the Middle East. Has drunk unpasteurised milk. Blood culture has grown a Gram negative coccobacillus
Brucellosis
What are some non-invasive imaging investigations (4)
CXR
Ultrasound, CT or MRI to localise abnormalities
PET/CT scan
Echocardiogram
What are some invasive investigations to identify source of fever (3)
Biopsy of any tissue involved for histology and culture (e.g. skin, n meningitidis) - can be CT guided
Endoscopies
Bone marrow - histology and culture
When should therapy be started immediately in a patient
Septic
What is the management in febrile neutropenia
ASAP start of empirical treatment after taking samples
How many blood cultures should be taken for diagnosis
At least 2, preferably 3
What specific serology tests are important in PUO (4)
Vasculitis screen
ANCA, c and p, Ro, La, etc…
Bence Jones/protein electrophoresis
Dip urine/casts
Where is histoplasmosis found
Temperate climates - e.g. malaysia
What is histoplasmosis
Dimorphic fungus
What is the incidence of infective endocarditis
1.7/100,000
What is the median age for infective endocarditis
58 years
What is the M:F ratio for infective endocarditis
1.7:1
What are the two classifications of infective endocarditis (2)
Native
Prosthetic
What are risk factors for infective endocarditis (7)
Structural heart disease
Rheumatic fever
Poor dentition
Instrumentation if valve problem
Bowel/GI issues - diverticular, bowel lesion
Lines, especially long term
Prior bacteraemias, especially staphylococcus aureus, enterococcus, rarely gram negatives
What is a common cause of infective endocarditis
Rheumatic fever used to be common in the UK
What type of heart valve has a higher rate of infective endocarditis
Prosthetic valves
What are the most common valves involved in infective endocarditis (2)
Mitral valve
Aortic valve
What is the general pathophysiology of infective endocarditis (5)
Trauma Bacteraemia/non-bacterial thrombotic endocarditis Adherence Colonisation Mature vegetation
When should you worry about infective endocarditis vegetations
Over 20mm
What are the symptoms of infective endocarditis (4)
Fever
Chills
Weakness
Dyspnoea
What are the signs of infective endocarditis (9)
Fever Heart murmur Changing heart murmur Embolic lesions Oslers nodes Splinter haemorrahges Splenomegaly Clubbing Weight loss??
78 year old lady Diabetic Tissue MVR, CABG in 1999 4 day history of fever Pansystolic murmur on examination TTE- small mobile mass on mitral valve Blood cultures grew strep oralis.
What was the treatment?
Patient commenced on iv benzylpenicillin and gentamicin (BSAC guidelines)
Continued to spike a fever 4 weeks after starting antibiotics
Echo- aortic root abscess!!!
Referred to cardiothoracic surgeons for urgent valve replacement.; USA and European guidelines
What are osler’s nodes
Small painful nodular lesions
What are janeway lesions
Hemorrhagic, painless macular lesions - caused by septic emboli, subcutaneous abscesses.
What are roth spots
Retinal lesions surrounded by haemorrhage near the optic disc
What condition can splenic infarcts be associated with
Infective endocarditis
What are the renal complications of infective endocarditis (3)
Abscesses
Infarction
Glomerulonephritis
Don’t forget to dip urine/microscopy
What CNS effects can infective endocarditis have
Cerebral abscesses
What is the most common cause of infective endocarditis in IVDU
Straphylococcus aureus
What valve is most often affected in IVDU infective endocarditis
Tricuspid valve is affected in 52.2%
What increases the risk of infective endocarditis in IVDU
HIV
What is more common in IVDU associated infective endocarditis
Polymicrobial infection
What is the cause of most prosthetic valve endocarditis
Coagulase negative staphylococcus
What are the causes of infective endocarditis (microbiology) (6)
Viridans streptococci Entercocci Staph aureus Gram negative bacilli Fungi RARE: rothia, cardiobacrterium
What are the common causes of infective endocarditis in a native valve (7)
Streptococcus viridans, anginosis, oral streps most common.
Streptococcus bovis…malignancy related.
RareL MSSA, strep pneumoniae
What are the common causes of infective endocarditis in a prosthetic valve (4)
CNS
Staph epidermiditis
Staph aureus
Gram negatives
What is the most appropriate treatment for prosthetic valve infective endocarditis
Surgery
What is the MOST COMMON cause of culture negative endocarditis
Cultures taken AFTER commencing antibiotics…fucking idiots
What are some microbiological causes of culture negative infective endocarditis (6)
Brucella Coxiella Chlamydia Mycoplasma Bartonella HACEK organisms
What investigations are indicated in infective endocarditis (6)
Multiple blood cultures : at least 3 blood cultures in the first 24hrs off antibiotics..SPEAK TO MICRO/ID
Echo and ECG(?carditis)
FBC ( anaemia)
ESR (usually raised)
CRP ( useful to monitor therapy)
Serology if culture negative- brucella, bartonella, chlamydia, coxiella
What is the DUKE criteria for infective endocarditis
A Pathologic criteria
- Microoraginsms demonstrated by culture or histologic examination of a vegetation, a vegetation that has embolised, or an intracardiac abscess specimen
- Pathologic lesions: vegetation or intracardiac abscess confirmed by histologic examination showing active endocarditis..\BIT LATE!!
B Clinical criteria
Two major criteria
One major and 3 minor criteria
Five minor criteria
What are the major criteria in the Duke criteria
- Positive blood culture for IE
A Typical microorganism consistent with IE from 2 separate blood cultures e.g viridans streptococcus, Strep bovis, Staph. aureus,enterococci
B Microorganisms consistent with IE from persistently positive blood cultures defined as
- at least 2 positive blood cultures drawn >12 hrs apart
- All 3 or a majority of 4 or more separate cultures of blood
2. Evidence of endocardial involvement A Positive echo - oscillating mass on valve - Abscess - New partial dehiscence B New valvular regurgitation
What is the minor criteria for the duke criteria for infective endocarditis (6)
- Predisposing heart condition or iv drug use
- Fever > 38ºC
- Vascular phenomena: major arterial emboli, septic pulmonary infarcts etc
- Immunological phenomena e.g glomerulonephritis, oslers nodes, janeway lesions
- Microbiological evidence: positive blood culture but does not meet a major criterion
- Echo findings consistent with endocarditis but do not meet major criterion
What is the treatment for strep viridans endocarditis (2)
combination of benzylpenicillin and gentamicin ( synergy between penicillin and gentamicin was found to eradicate bacteria from cardiac vegetations in the rabbit model)
What is the treatment for enterococcal endocarditis (2)
use a combination of ampicillin and gentamicin
What is the treatment for MSSA endocarditis (2)
flucloxacillin for 4-6 weeks at least…watch for abscesses!!!!
->Early referral to Cardiac Surgery!!!
What is the treatment for MRSA endocarditis (2)
Vancomycin and gentamicin or rifampicin or fucidin
What are the indications for surgical therapy in endocarditis (6)
More than 1 serious systemic emboli Uncontrolled infection Significant valve dysfunction Lack of response to antibiotics Local suppurative complications e.g perivalvular abscesses Congestive heart failure
