155: The Skin in Infective Endocarditis, Sepsis, Septic Shock, and Disseminated Intravascular Coagulation

Question 1

What is the definition of infective endocarditis?

Answer 1

Infective endocarditis is the inflammation of the endocardial lining of the heart caused by infection from bacteria or fungus.

Question 2

What are the common clinical features of infective endocarditis?

Answer 2

The most common clinical features include fever and a new cardiac murmur.

Question 3

What are the cutaneous findings associated with infective endocarditis?

Answer 3

Cutaneous findings include splinter hemorrhages, petechiae/purpura, Janeway lesions, and Osler nodes.

Question 4

What are splinter hemorrhages?

Answer 4

Red-brown or black streaks under the nail plate.

Question 5

What are petechiae/purpura?

Answer 5

Small red or purple spots on the skin.

Question 6

What are Janeway lesions?

Answer 6

Painless, irregular, nonblanchable erythematous maculopapules on palms and soles.

Question 7

What are Osler nodes?

Answer 7

Painful red papulonodules with a pale center on fingertips.

Question 8

What are the risk factors for developing infective endocarditis?

Answer 8

Risk factors include history of infective endocarditis, diabetes, cancer, congenital heart disease, dental procedures, HIV disease, and intravenous drug abuse.

Question 9

What are the complications associated with infective endocarditis?

Answer 9

The most concerning complications are neurologic, including ischemic lesions, hemorrhagic strokes, transient ischemic attacks, brain abscesses, and meningitis.

Question 10

What is the etiology of infective endocarditis?

Answer 10

Infective endocarditis is classified based on valve type (native vs. prosthetic) and source of infection (community-acquired vs. health care-acquired).

Question 11

What is the most common cause of infective endocarditis in high-income countries?

Answer 11

Staphylococcus aureus for both naive and prosthetic valves.

Question 12

What is the male-to-female ratio for infective endocarditis cases?

Answer 12

2:1.

Question 13

What is the significance of splinter hemorrhages in infective endocarditis?

Answer 13

They are longitudinal streaks under the nail plate and can indicate small capillary vasculitis or microemboli.

Question 14

What is the recommended management for infective endocarditis?

Answer 14

The management focuses on eliminating infection with appropriate antibiotics, early surgical intervention, and treatment of complications.

Question 15

What are the diagnostic methods used for infective endocarditis?

Answer 15

Diagnostic methods include bacterial cultures, echocardiography, EKG baseline, and cardiac CT.

Question 16

What is the mortality rate associated with right-sided infective endocarditis in IV drug users?

Answer 16

5% to 9% mortality rate.

Question 17

What are the most common causes of death in infective endocarditis patients?

Answer 17

Cerebral embolic disease and congestive heart failure.

Question 18

What is the significance of vegetations larger than 10 mm in infective endocarditis?

Answer 18

Vegetations larger than 10 mm are associated with a greater embolic risk.

Question 19

What are the poor prognostic indicators for infective endocarditis?

Answer 19

Poor prognostic indicators include left-sided infective endocarditis, vegetation size greater than 10 mm, prosthetic valves, older age, diabetes, immunosuppression, heart failure, renal failure, septic shock, and brain hemorrhage.

Question 20

What is the recommended treatment duration for infective endocarditis?

Answer 20

Long-term parenteral antibiotics for 4 to 6 weeks.

Question 21

What is the goal of surgical intervention in infective endocarditis?

Answer 21

To eliminate infection and reduce the risk of death, especially when vegetations are larger than 10 mm.

Question 22

What are the rare causes of infective endocarditis associated with HACEK organisms?

Answer 22

Rare causes may include HACEK organisms: Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, Kingella, and other organisms like Bartonella, Brucella, Coxiella species, and fungi like Candida.

Question 23

What is the embolic risk associated with vegetations larger than 10 mm?

Answer 23

Vegetations larger than 10 mm are associated with a greater embolic risk, leading to complications such as emboli to the CNS, resulting in stroke, brain abscess, and meningitis, which can be identified with MRI.

Question 24

How does the prognosis of infective endocarditis vary based on clinical factors?

Answer 24

The prognosis varies based on infecting organisms and associated clinical comorbidities. Poor prognostic indicators include left-sided infective endocarditis, vegetation size greater than 10 mm, presence of prosthetic valves, older age, diabetes, immunosuppression, heart failure, renal failure, septic shock, brain hemorrhage, and infections from MRSA, fungi, or polymicrobial sources.

Question 25

What is the 5-year mortality rate of infective endocarditis?

Answer 25

The 5-year mortality rate of infective endocarditis is approximately 40%.

Question 26

What are the recommended management strategies for infective endocarditis?

Answer 26

Management strategies include eliminating infection with appropriate antibiotics, early surgical intervention, and treatment of complications. Long-term (4 to 6 weeks) parenteral antibiotics, typically penicillin derivatives, are recommended. Surgical intervention is recommended within 48 hours of diagnosis if vegetations are larger than 10 mm to decrease the risk of death.

Question 27

What diagnostic tests are essential for detecting infective endocarditis?

Answer 27

Essential diagnostic tests include bacterial cultures (3 sets prior to antibiotics), echocardiography, EKG baseline, and imaging such as cardiac CT and F-fluorodeoxyglucose positron emission tomography CT.

Question 28

What are the key preventive measures for patients at risk of infective endocarditis (IE)?

Answer 28

Key preventive measures include good oral, dental, and skin hygiene, and IE prophylaxis for patients with a high risk of adverse outcomes associated with IE who are undergoing procedures involving contaminated or infected wounds, or surgery on oral or nasal mucosa.

Question 29

What defines sepsis?

Answer 29

Sepsis is defined as a life-threatening organ dysfunction resulting from a dysregulated host response to infection.

Question 30

What is septic shock?

Answer 30

Septic shock is a subset of sepsis where vasopressor therapy is required to maintain a mean arterial pressure of 65 mm Hg or greater, and there is a serum lactate level greater than 2 mmol/L persisting after fluid resuscitation.

Question 31

What are the clinical features of cutaneous findings in septic patients?

Answer 31

Clinical features include erythroderma, pustules, purpura, necrotizing fasciitis, and ecthyma gangrenosum.

Question 32

What are the noncutaneous findings associated with sepsis?

Answer 32

Noncutaneous findings include fever, prostration, oliguria, tachycardia, and tachypnea, with signs of pneumonia, meningitis, or peritonitis.

Question 33

What are the potential complications of sepsis?

Answer 33

Potential complications include death, loss of limbs due to hypoperfusion, and permanent organ dysfunction.

Question 34

What is the diagnosis for a patient with sepsis who has a serum lactate level of 3 mmol/L and requires vasopressors?

Answer 34

The diagnosis is septic shock.

Question 35

What is the most likely cause of erythematous papules that progress to purpuric lesions in an immunocompromised host?

Answer 35

The most likely cause is an opportunistic fungal infection, such as Aspergillus spp., Fusarium spp., or Candida spp.

Question 36

What are the risk factors for higher mortality in necrotizing fasciitis?

Answer 36

Risk factors include hospital-acquired infections, age >75 years, severe peripheral vascular disease, and coexistent sepsis or septic shock.

Question 37

What does a qSOFA score of 3 indicate?

Answer 37

A qSOFA score of 3 indicates a high risk of poor outcomes.

Question 38

What is the most common causative organism of ecthyma gangrenosum?

Answer 38

The most common causative organism is Pseudomonas aeruginosa, typically seen in neutropenic patients.

Question 39

What is the most likely causative organism for hemorrhagic bullous cellulitis in a patient with liver disease?

Answer 39

The most likely causative organism is Vibrio vulnificus.

Question 40

What is the most likely underlying infection in a patient with splenectomy who develops purpura fulminans?

Answer 40

The most likely underlying infection is Streptococcus pneumoniae.

Question 41

What should be avoided for 3 weeks if infective endocarditis is complicated by hemorrhagic strokes?

Answer 41

Surgery.

Question 42

What is the role of stress-responsive transcription factors in the pathogenesis of septic shock?

Answer 42

They activate inflammatory genes, leading to a 'genomic storm' characterized by increased production of mediators such as tumor necrosis factor-α, IL-6, IL-8, and nitric oxide.

Question 43

What are the key components of the SOFA score used in diagnosing septic shock?

Answer 43

The SOFA score includes components such as partial pressure arterial oxygen/fraction of inspired oxygen, mean arterial pressure, platelet count, bilirubin levels, Glasgow coma scale score, urine output, and creatinine levels.

Question 44

What does hyperbilirubinemia indicate in septic patients?

Answer 44

Hyperbilirubinemia indicates hepatic dysfunction and is associated with a worse prognosis.

Question 45

What is the significance of early goal-directed therapy in the management of septic shock?

Answer 45

It aims to improve blood volume, cellular hypoxia, and tissue and organ perfusion within the first 6 hours, which is crucial for reducing mortality and improving outcomes.

Question 46

What is disseminated intravascular coagulation (DIC)?

Answer 46

DIC is an acquired syndrome characterized by consumptive hypercoagulation and insufficient anticoagulation, often triggered by infections and sepsis.

Question 47

What is the relationship between sepsis and septic shock?

Answer 47

Sepsis precedes septic shock in up to 50% of affected patients.

Question 48

What are common imaging techniques used in septic shock?

Answer 48

Common imaging techniques include chest radiography, ultrasonography, CT, and MRI.

Question 49

What is the mortality risk associated with septic shock?

Answer 49

In-hospital mortality has ranged from 15% to 30%, with septic shock associated with a higher risk of mortality (up to 50%).

Question 50

What are some basic infection control measures to prevent sepsis?

Answer 50

Routine hand washing and the minimization and regular replacement of indwelling catheters.

Question 51

How does age affect the incidence of DIC?

Answer 51

The incidence of DIC increases with age in both men and women, with men having a greater incidence than women.

Question 52

What are the key factors involved in the pathogenesis of septic shock?

Answer 52

Key factors include infectious agents, cytokines, transcription factors, microvascular dysfunction, and hypotension.

Question 53

What are cytokines involved in inflammatory responses?

Answer 53

Cytokines include interleukins (IL-1, IL-18) and Toll-like receptors that activate inflammatory responses.

Question 54

What role do transcription factors play in sepsis?

Answer 54

Transcription factors like nuclear factor κB lead to a genomic storm, increasing mediators such as tumor necrosis factor-α, IL-6, and nitric oxide.

Question 55

What causes microvascular dysfunction in sepsis?

Answer 55

Microvascular dysfunction results from injury and apoptosis, leading to organ dysfunction.

Question 56

What is hypotension in the context of sepsis?

Answer 56

Hypotension is caused by overproduction of cyclooxygenase-2 and nitric oxide, contributing to septic shock.

Question 57

What laboratory findings indicate poor prognosis in septic patients?

Answer 57

Laboratory findings indicative of poor prognosis include thrombocytopenia, hyperbilirubinemia, renal insufficiency, elevated serum lactate, and abnormal WBC count.

Question 58

What is the significance of the SOFA score in septic patients?

Answer 58

The SOFA score assesses the severity of sepsis and predicts outcomes, with scores greater than 2 suggesting a 10% mortality risk.

Question 59

What are primary management strategies for septic shock within the first 6 hours?

Answer 59

Primary management strategies include early goal-directed therapy, timely hemodynamic support, blood transfusion, adequate antibiotic administration, and continuous monitoring.

Question 60

How does disseminated intravascular coagulation (DIC) relate to sepsis?

Answer 60

DIC is a serious complication of sepsis characterized by consumptive hypercoagulation, leading to organ dysfunction and potential outcomes like organ failure and death.

Question 61

What is the most characteristic cutaneous finding in DIC?

Answer 61

Purpura fulminans is the most characteristic cutaneous finding in DIC, presenting as diffuse noninflammatory retiform purpura.

Question 62

What are noncutaneous findings associated with DIC?

Answer 62

Noncutaneous findings in DIC include chest pains, shortness of breath, headache, speech changes, paralysis, and bleeding diathesis.

Question 63

What complications are associated with DIC?

Answer 63

Complications of DIC include tissue necrosis, multiorgan failure, and development of Waterhouse-Friderichsen syndrome.

Question 64

What is the role of tissue factor in DIC?

Answer 64

Tissue factor binds to factor VIIa, activating downstream coagulation cascades and leading to systemic activation of coagulation.

Question 65

What laboratory findings are indicative of DIC?

Answer 65

Laboratory findings indicative of DIC include decreased platelet count, prolonged prothrombin time, elevated fibrin degradation products, and decreased protease inhibitors.

Question 66

What are management strategies for DIC?

Answer 66

Management strategies for DIC include platelet and plasma transfusion, anticoagulation, fibrinolytics, and possible excision of necrotic tissue.

Question 67

What is the significance of thrombocytopenia in DIC?

Answer 67

Thrombocytopenia in DIC is an independent predictor for organ failure and mortality.

Question 68

What causes purpura fulminans in sepsis?

Answer 68

Purpura fulminans is caused by extensive microvascular occlusion due to systemic activation of the coagulation cascade.

Question 69

What laboratory findings are characteristic of DIC?

Answer 69

Characteristic findings include decreased platelet count, prolonged prothrombin time, elevated D-dimer, and decreased fibrinogen.

Question 70

What is the most characteristic cutaneous finding in DIC?

Answer 70

The most characteristic cutaneous finding in DIC is purpura fulminans.

Question 71

What mechanisms lead to low antithrombin levels in DIC?

Answer 71

Low antithrombin levels result from continuous consumption, degradation by neutrophil elastase, and impaired synthesis due to liver failure.

Question 72

What does elevated D-dimer levels indicate in DIC?

Answer 72

Elevated D-dimer levels indicate increased fibrin degradation, reflecting ongoing coagulation and fibrinolysis.

Question 73

What coagulation abnormalities are typically seen in DIC?

Answer 73

Other abnormalities include prolonged activated partial thromboplastin time and decreased fibrinogen.

Question 74

What is the underlying cause of ischemic digits in DIC?

Answer 74

The underlying cause is extensive microvascular occlusion due to fibrin deposition.

Question 75

What is the role of protein C in coagulation?

Answer 75

Protein C is an anticoagulant that inhibits factors Va and VIIIa, and its deficiency contributes to hypercoagulability in DIC.

Question 76

What does elevated plasmin-antiplasmin complex levels indicate?

Answer 76

Elevated plasmin-antiplasmin complex levels indicate increased fibrinolytic activity.

Question 77

What is the significance of decreased ADAMTS13 activity in DIC?

Answer 77

Decreased ADAMTS13 activity contributes to microvascular thrombosis and is associated with thrombotic microangiopathy.

Question 78

What are common noncutaneous findings in DIC?

Answer 78

Common noncutaneous findings include chest pains, shortness of breath, headache, and paralysis.

Question 79

What complications can arise from DIC?

Answer 79

Complications of DIC include tissue necrosis, multiorgan failure, and death.

Question 80

What is the role of tissue factor in DIC?

Answer 80

Tissue factor activates downstream coagulation cascades, leading to systemic activation of the coagulation cascade.

Question 81

What laboratory findings are indicative of DIC?

Answer 81

Laboratory findings indicative of DIC include decreased platelet count, prolonged prothrombin time, and elevated fibrin degradation products.

Question 82

What is a significant risk factor for mortality in patients with DIC?

Answer 82

Thrombocytopenia (<50 × 10^9/L) increases the risk of bleeding and is an independent predictor for organ failure and mortality.

Question 83

What management strategies are used for DIC?

Answer 83

Management strategies for DIC include platelet and plasma transfusion, anticoagulation, and possible excision of necrotic tissue.

Question 84

What is the importance of prompt diagnosis in DIC?

Answer 84

Prompt diagnosis and treatment of causes can prevent severe complications and improve outcomes.

Question 85

What are the clinical features of purpura fulminans in DIC?

Answer 85

Purpura fulminans is characterized by diffuse noninflammatory retiform purpura, which can progress to gangrene if untreated.

Question 86

What complications can arise from DIC?

Answer 86

Complications of DIC include tissue necrosis, multiorgan failure, and death, potentially leading to Waterhouse-Friderichsen syndrome.

Question 87

How does systemic activation of the coagulation cascade contribute to DIC?

Answer 87

Systemic activation leads to fibrin deposition in the vasculature, causing organ ischemia and death.

Question 88

What management strategies are recommended for patients with DIC?

Answer 88

Management strategies for DIC include platelet and plasma transfusion, anticoagulation, and possible excision of necrotic tissue.

Question 89

What are the major criteria for a clinically definite case of infective endocarditis?

Answer 89

Major criteria include microbiologic evidence and evidence of endocardial involvement.

Question 90

What are the minor criteria for diagnosing infective endocarditis?

Answer 90

Minor criteria include predisposition, fever, vascular phenomena, immunologic factors, and serologic evidence.

Question 91

What are some differential diagnoses for splinter hemorrhages?

Answer 91

Differential diagnoses include atopic dermatitis, endocarditis, and vasculitis.

Question 92

What are some settings in which DIC can occur?

Answer 92

Settings include hepatic failure, sepsis, transfusion reactions, and vascular abnormalities.

Question 93

What is one of the major microbiologic criteria for infective endocarditis?

Answer 93

Two separate blood cultures positive for typical microorganisms.

Question 94

What is a minor criterion for infective endocarditis related to predisposition?

Answer 94

Predisposition to infective endocarditis.

Question 95

What are the major criteria for a clinically definite diagnosis of infective endocarditis?

Answer 95

1. Microbiologic: Two separate blood cultures positive for typical microorganisms, or persistently positive blood culture for typical microorganisms, or single positive blood culture for *Coxiella burnetii* or a Phase I immunoglobulin G antibody titer greater than 1:800. 2. Evidence of endocardial involvement: New valvular regurgitation, or positive echocardiogram showing oscillating echogenic intracardiac mass at the site of endocardial injury, a periannular abscess, or new dehiscence of a prosthetic valve.

Question 96

What are the minor criteria for diagnosing infective endocarditis as per the Modified Duke Criteria?

Answer 96

1. Predisposition to infective endocarditis 2. Fever 3. Vascular phenomena such as Osler nodes or Roth spots 4. Immunologic factors such as a positive rheumatoid factor or glomerulonephritis 5. Serologic evidence of active infection not meeting microbiologic major criteria.

Question 97

What are some differential diagnoses for splinter hemorrhages?

Answer 97

Differential diagnoses for splinter hemorrhages include: Atopic dermatitis, Cryoglobulinemia, Drug-induced, Vascular endothelial growth factor receptor inhibitors, Tetracyclines, Endocarditis, Idiopathic, Internal malignancy, Psoriasis, Scurvy, Thyrotoxicosis, Trauma, Trichinosis, Vasculitis.

Question 98

In which settings can disseminated intravascular coagulation (DIC) occur?

Answer 98

DIC can occur in the following settings: Hepatic failure, Immunologic reaction to drugs or toxins, Malignancy, Obstetrical complications (e.g., amniotic fluid embolism, placental abruption), Protein C or protein S deficiency, Sepsis, Transfusion reactions, Transplant reactions, Trauma, Vascular abnormalities (e.g., aortic aneurysm, cardiac arrest).

Question 99

What are Janeway lesions?

Answer 99

Painless, irregular, nonblanchable, erythematous maculopapules that appear on the palms and soles and last days to weeks seen in infective endocarditis (IE).

Question 100

What are Osler nodes?

Answer 100

Painful red papulonodules with a pale center on the fingertips lasting days to weeks seen in infective endocarditis (IE).

Question 101

What are the most concerning and severe complications of infective endocarditis (IE)?

Answer 101

Heart failure, embolic events, and abscess formation.

Question 102

What is the most common cause of infective endocarditis (IE) in high-income countries for both naïve and prosthetic valves?

Answer 102

Staphylococcus aureus.

Question 103

What begins as an erythematous papule that expands and eventually becomes a necrotic bulla, most commonly seen between the umbilicus and the knees?

Answer 103

Ecthyma gangrenosum.

Question 104

What is Disseminated Intravascular Coagulation (DIC)?

Answer 104

The acquired reactive syndrome of consumptive hypercoagulation, insufficient anticoagulation, hemorrhage, systemic vascular inflammation, and endothelial dysfunction.

Question 105

What is the most characteristic cutaneous finding in Disseminated Intravascular Coagulation (DIC)?

Answer 105

Diffuse noninflammatory retiform purpura from extensive microvascular occlusion.

Question 106

Early goal-directed therapy in sepsis focuses on improving blood volume, cellular hypoxia, and tissue and organ perfusion within the first how many hours?

Answer 106

6 hours.

Question 107

What does DIC in the neonatal period suggest?

Answer 107

Infection or congenital abnormalities.

Question 108

Vegetations larger than how many mm are associated with a greater embolic risk?

Answer 108

3 mm.