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Kat's Pathology > PUO and Endocarditis > Flashcards

PUO and Endocarditis Flashcards

1
Q

What is the definition of pyrexia of unknown origin (PUO)

A

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

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2
Q

What are the causes of PUO (5)

A 
Infection 
Neoplasm
Connective Tissue disease 
Undiagnosed 
Miscellaneous causes
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3
Q

What are the subclasses of PUO (4)

A

Classical PUO
Healthcare associated PUO
Immune deficiency PUO
HIV related PUO (always do an HIV test in A&E)

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4
Q

What are the causes of classical PUO (8)

A 
Abscesses 
Endocarditis
Tuberculosis
Complicated urinary tract infections 
Fever in the returning traveller causes 
HIV
Connective tissue disease/Vasculitis
Neoplasms
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5
Q 
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?

A

Metastatic staphylococcal disease.

Management: MDT infection/cardiology/cardiothoracic

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6
Q

What is discitis

A

Abscess in epidural space

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7
Q

What is seen on echo of a patient with endocarditis

A

Vegetations on aortic valve

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8
Q

What are the most common causes of fever in a returning traveller (8)

A 
Malaria
Dengue
Typhoid
Richettsia
Bacterial diarrhoea
UTI
Brucella....indolent 
Viral haemorrhagic fever - RARE but think of it
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9
Q 
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)

A

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
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10
Q

What are spotted fevers

A

Emerging/re-emerging pathogens - RICKETTSIA

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11
Q

What are the vectors for spotter fevers (3)

A

Tick, mite, flea borne (ZOONOSES)

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12
Q

What type of bacteria is spotted fever

A

Small gram negative bacteria

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13
Q

What are two examples of spotted fevers (2)

A

Rocky Mountain Spotted Fever - USA

Spotted Fever - India

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14
Q

How is spotted fever diagnosed

A

Serology

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15
Q

What is the treatment for spotted fever

A

Doxycycline

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16
Q

What is the best clue to the cause of PUO in a returning traveller

A

CAREFUL travel history essential

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17
Q

What should you NOT do in healthcare associated PUO

A

Don’t just start antibiotics (unless septic)

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18
Q

What are the causes of healthcare associated PUO (6)

A

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

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19
Q

What gives you the best clue for the cause of healthcare associated PUO

A

Examining the patient

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20
Q

What does clostridium difficile do to WCC

A

Massively raised

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21
Q

What are some causes of hospital acquired pneumonia (3)

A

Mostly gram negative bacteria
Rarely legionella
Iatrogenic from infected staff and relatives (flu!)

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22
Q

What safety nets are in place to help reduce hospital causes of pneumonia (3)

A

DoH documents, White paper.
Care bundles now
Record all insertions of central lines

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23
Q

What is seen in immune deficiency pyrexia of unknown origin

A

Neutropenic fever

Neutrophils <0.5

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24
Q

What is the most common cause of neutropenic fever

A

Bone marrow transplant patients

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25
Q

What are the most common bacterial infection in BMT patients (2)

A

From lines commonly - pneumonia, mucositis

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26
Q

What are the mycobacterial causes of neutropenic fever in BMT patients (@)

A

MTB

Atypical pneumonia

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27
Q

What are the viral infections commonly in BMT patients (2)

A

CMV

Respiratory viruses

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28
Q

What are some non-infective causes of neutropenic fever in BMT patients (2)

A

Haemorrhage

PE

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29
Q

What increases the risk of fungal infections (neutropenic fever) (4)

A

Graft versus host disease….increase risk of moulds.
Higher risk of acute leukaemia, allografts
Drug fever
IRIS syndrome

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30
Q

What does the cause of PUO in HIV patients depend on

A

CD4 count

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31
Q

What are some causes of HIV PUO if CD4>200 (5)

A 
Seroconversion illness...also rash
Bacterial: Streptococcus pneumoniae
CMV
TB
Histoplasmosis (take travel history!!! - arizona desert, malaysia)
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32
Q

What are some causes of HIV PUO if CD4<200 (3)

A

Disseminated mycobacterium avium (MAI) complex
PCP
Cryptococcus

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33
Q

What are some CD4 independent causes of PUO in HIV patients (2)

A

Lymphoma

Drug fever

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34
Q

What is TB

A

Atypical mycobacteria

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35
Q

What are the classical features of PCP (4)

A

Cough
Hypoxia
Desaturation on exercise
Some shadowing around heart in CXR (but otherwise grossly normal CXR)

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36
Q

What steps are involved in the work up of PUO (7)

A

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

37
Q

What history is important in PUO (8)

A

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

38
Q

What should be done on a physical examination of a patient with PUO (7)

A

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?

39
Q

If you suspect secondary syphilis as the cause of PUO, what should you do? (2)

A

Get them seen by STD clinic

HIV test

40
Q

What does eosinophilia indicate in a patient with a fever

A

Think of worms!

They travel through tissue - local histamine –> eosinophils up
Can carry them asymptomatically for years

41
Q

What are some parasitic infections (3)

A

Filaria
Strongloides
Schistosomiasis

42
Q

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

A

Brucellosis

43
Q

What are some non-invasive imaging investigations (4)

A

CXR
Ultrasound, CT or MRI to localise abnormalities
PET/CT scan
Echocardiogram

44
Q

What are some invasive investigations to identify source of fever (3)

A

Biopsy of any tissue involved for histology and culture (e.g. skin, n meningitidis) - can be CT guided
Endoscopies
Bone marrow - histology and culture

45
Q

When should therapy be started immediately in a patient

A

Septic

46
Q

What is the management in febrile neutropenia

A

ASAP start of empirical treatment after taking samples

47
Q

How many blood cultures should be taken for diagnosis

A

At least 2, preferably 3

48
Q

What specific serology tests are important in PUO (4)

A

Vasculitis screen
ANCA, c and p, Ro, La, etc…
Bence Jones/protein electrophoresis
Dip urine/casts

49
Q

Where is histoplasmosis found

A

Temperate climates - e.g. malaysia

50
Q

What is histoplasmosis

A

Dimorphic fungus

51
Q

What is the incidence of infective endocarditis

A

1.7/100,000

52
Q

What is the median age for infective endocarditis

A

58 years

53
Q

What is the M:F ratio for infective endocarditis

A

1.7:1

54
Q

What are the two classifications of infective endocarditis (2)

A

Native

Prosthetic

55
Q

What are risk factors for infective endocarditis (7)

A

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

56
Q

What is a common cause of infective endocarditis

A

Rheumatic fever used to be common in the UK

57
Q

What type of heart valve has a higher rate of infective endocarditis

A

Prosthetic valves

58
Q

What are the most common valves involved in infective endocarditis (2)

A

Mitral valve

Aortic valve

59
Q

What is the general pathophysiology of infective endocarditis (5)

A 
Trauma 
Bacteraemia/non-bacterial thrombotic endocarditis 
Adherence 
Colonisation 
Mature vegetation
60
Q

When should you worry about infective endocarditis vegetations

A

Over 20mm

61
Q

What are the symptoms of infective endocarditis (4)

A

Fever
Chills
Weakness
Dyspnoea

62
Q

What are the signs of infective endocarditis (9)

A 
Fever
Heart murmur 
Changing heart murmur 
Embolic lesions 
Oslers nodes
Splinter haemorrahges 
Splenomegaly 
Clubbing 
Weight loss??
63
Q 
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?

A

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

64
Q

What are osler’s nodes

A

Small painful nodular lesions

65
Q

What are janeway lesions

A

Hemorrhagic, painless macular lesions - caused by septic emboli, subcutaneous abscesses.

66
Q

What are roth spots

A

Retinal lesions surrounded by haemorrhage near the optic disc

67
Q

What condition can splenic infarcts be associated with

A

Infective endocarditis

68
Q

What are the renal complications of infective endocarditis (3)

A

Abscesses
Infarction
Glomerulonephritis

Don’t forget to dip urine/microscopy

69
Q

What CNS effects can infective endocarditis have

A

Cerebral abscesses

70
Q

What is the most common cause of infective endocarditis in IVDU

A

Straphylococcus aureus

71
Q

What valve is most often affected in IVDU infective endocarditis

A

Tricuspid valve is affected in 52.2%

72
Q

What increases the risk of infective endocarditis in IVDU

A

HIV

73
Q

What is more common in IVDU associated infective endocarditis

A

Polymicrobial infection

74
Q

What is the cause of most prosthetic valve endocarditis

A

Coagulase negative staphylococcus

75
Q

What are the causes of infective endocarditis (microbiology) (6)

A 
Viridans streptococci 
Entercocci
Staph aureus 
Gram negative bacilli
Fungi 
RARE: rothia, cardiobacrterium
76
Q

What are the common causes of infective endocarditis in a native valve (7)

A

Streptococcus viridans, anginosis, oral streps most common.
Streptococcus bovis…malignancy related.
RareL MSSA, strep pneumoniae

77
Q

What are the common causes of infective endocarditis in a prosthetic valve (4)

A

CNS
Staph epidermiditis
Staph aureus
Gram negatives

78
Q

What is the most appropriate treatment for prosthetic valve infective endocarditis

A

Surgery

79
Q

What is the MOST COMMON cause of culture negative endocarditis

A

Cultures taken AFTER commencing antibiotics…fucking idiots

80
Q

What are some microbiological causes of culture negative infective endocarditis (6)

A 
Brucella
Coxiella
Chlamydia
Mycoplasma 
Bartonella 
HACEK organisms
81
Q

What investigations are indicated in infective endocarditis (6)

A

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

82
Q

What is the DUKE criteria for infective endocarditis

A

A Pathologic criteria

  1. Microoraginsms demonstrated by culture or histologic examination of a vegetation, a vegetation that has embolised, or an intracardiac abscess specimen
  2. 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

83
Q

What are the major criteria in the Duke criteria

A
  1. 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
84
Q

What is the minor criteria for the duke criteria for infective endocarditis (6)

A
  1. Predisposing heart condition or iv drug use
  2. Fever > 38ºC
  3. Vascular phenomena: major arterial emboli, septic pulmonary infarcts etc
  4. Immunological phenomena e.g glomerulonephritis, oslers nodes, janeway lesions
  5. Microbiological evidence: positive blood culture but does not meet a major criterion
  6. Echo findings consistent with endocarditis but do not meet major criterion
85
Q

What is the treatment for strep viridans endocarditis (2)

A

combination of benzylpenicillin and gentamicin ( synergy between penicillin and gentamicin was found to eradicate bacteria from cardiac vegetations in the rabbit model)

86
Q

What is the treatment for enterococcal endocarditis (2)

A

use a combination of ampicillin and gentamicin

87
Q

What is the treatment for MSSA endocarditis (2)

A

flucloxacillin for 4-6 weeks at least…watch for abscesses!!!!
->Early referral to Cardiac Surgery!!!

88
Q

What is the treatment for MRSA endocarditis (2)

A

Vancomycin and gentamicin or rifampicin or fucidin

89
Q

What are the indications for surgical therapy in endocarditis (6)

A 
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

Kat's Pathology (105 decks)

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