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CVS Pathology > Infective Endocarditis and Rheumatic Heart Disease > Flashcards

Infective Endocarditis and Rheumatic Heart Disease Flashcards

1
Q

Infective endocarditis (IE) is an infection of either…..

A 
Endocardium 
Heart valves (prosthetic or native)
Interventricular septum 
Chordae tendinae 
Intra-cardiac devices
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2
Q

What is the endocardium?

A

The inner layer of the heart

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3
Q

Which gender gets IE? Which has a worse prognosis?

A

F > M

Females worse prognosis

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4
Q

What % of patients with IE have no underlying structural heart disease?

A

25%

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5
Q

Who gets IE?

A 
Older patients (generative aortic stenosis)
Rheumatic heart disease
Health care associated 
Invasive procedures
Intra cardiac devices
No previously known valve disease
Prosthetic valves 
Mitral valve prolapse
Bicuspid aortic valve 
Congenital heart disease
IVDU
Immunocompromised
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6
Q

Cardiac risk factors for IE

A 
MVP
VSD
AS
Rheumatic heart disease
Prosthetic heart valve 
Cardiac surgery for native IE
Prior native IE
Surgery for prosthetic IE
Congenital Heart disease 
- Cyanotic
- teratology of fallot
- VSD
- PDA
- Eisenmenger syndrome
- ASD, coarctation of aorta
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7
Q

Non cardiac risk factors for IE

A 
IVDU
Indwelling medical devices
DM
AIDS
Chronic skin infections/burns
Genitourinary infections of manipulation including pregnancy, abortion and delivery
Alcoholic cirrhosis
GI lesions 
Solid organ transplant 
Homeless, body live
Pneumonia, meningitis 
Contact with contaminated food or infected farm animals  
Dog / cat exposure
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8
Q

Common organisms causing IE with IVDU

A 
Staph aureus 
CNS
B haemolytic strep 
Fungi 
Aeorobic gram -ve bacilli 
Polymicrobial
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9
Q

Common organisms causing IE with indwelling medical devices

A

S aureus
CNS
B haemolytic strep
Strep pneumoniae

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10
Q

Common organisms causing IE with DM

A

S aureus
B haemolytic strep
Strep pneumoniae

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11
Q

Common organisms causing IE with AIDS

A

Salmonella
S pneumoniae
S aureus

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12
Q

Common organisms causing IE via chronic skin infections / burns

A

Staph areus
B haemolytic strep
Fungi
aerobic gram -ve bacilli

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13
Q

Common organisms causing IE via GU infections

A 
Enterococcus
GBS
Listeria monocytogenes
Aerobic gram negative bacilli 
Neisseria gonnorhoea
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14
Q

Common organisms causing IE via alcoholic cirrhosis

A 
Bartonella
Aeromonas
Listeria
S pneumonia
B haemolytic strep
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15
Q

Common organisms causing IE via GI lesions

A

Strep Bovis
Enterococcus
Clostridium septicum

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16
Q

Common organisms causing IE via solid organ transplant

A

S aureus
Aspergillus fumigatus
Candida
Enterococcus

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17
Q

Common organisms causing IE via homelessness and lice

A

Bartonella

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18
Q

Common organisms causing IE via pneumonia or meningitis

A

S pnuemoniae

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19
Q

Common organisms causing IE via contact with containerised milk or infected farm animals

A

Brucella
Pasteurella
Coxiella burnetti
Erysipelothrix

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20
Q

Common organisms causing IE through dog/cat exposure

A

Bartonella
Patueruella
C septicum

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21
Q

Possible pathologies of IE

A
  1. Adherence and invasion of non bacterial thrombotic endocarditis (a sterile fibrin platelet vegetation)
  2. Mechanical disruption of valve endothelium due to a variety of factors which favours infection by most types of organisms
  3. Physically normal endothelium (25%) - local inflammation
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22
Q

What can cause mechanical disruption of valve endothelium?

A 
Turbulent blood flow/venturi effect
Electrodes
Catheters
Inflammation (rheumatic carditis)
Degenerative changes
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23
Q

Steps in bacterial colonisation in IE

A
  1. Exposed stromal cells and extracellular matrix proteins trigger deposition of fibrin-platelet clots to which streptococci bind
  2. Fibrin adherent streptococci attract monocytes and induce them to protect tissue factor activity (TFA) and cytokines; these mediators activate coagulation cascades, attract and activate blood platelets and induce cytokine, integrin and TFA production from neighbouring endothelial cells, encouraging vegetation growth
  3. Colonisation of inflamed valve - In response to local inflammation, endothelial cells express integrins that bind plasma fibronectin binding proteins, resulting in endothelial internalisation of bacteria, In response to invasion, endothelial cells produce TFA and cytokines, triggering blood clotting and extension of inflammation, and promoting formation of vegetation, internalised bacteria eventually lyse endothelial cells by secreting membrane active proteins such as haemolysins
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24
Q

Causes of transient bacteraemia

A

Brushing teeth

Bowel movements

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25
Q

Cardiac conditions at a higher risk of IE

A

Acquired valvular heart disease (stenosis, regurgitation)
Valve replacement
Structural congenital heart disease (not isolated ASD, fully repaired VSD or PDA, or closure devices that are endothelialised)
Hypertrophic cardiomyopathy
Previous IE

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26
Q

Which side of the heart is more affected in ICDU?

A

Right

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27
Q

Presentation of IE

A 
FEVER (very common)
Fatigue / malaise 
Weight loss
Headache
MSK pain 
Altered mentation 
MURMUR (very common)
Peripheral stigmata petechiae
Janeway lesions
Oslers nodes 
Splinter haemorrhages
Clubbing
Neurological manifestations
Roths spots
Splenomegaly or infarct
Vascular / immunological phenomena
Embolic phenomena
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28
Q

What vascular / immunological phenomena can be seen in IE?

A 
Splinter haemorrhages 
Vasculitic rash 
Roths spots 
Oslers nodes
Janeway lesions
Nephritis
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29
Q

What is a Vasculitic rash like?

A

Diffuse
Non blanching
Petechial
Purpuric

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30
Q

What are oslers nodes?

A 
Deep, red spots
Painful 
Raised
Finger pulps
Palms/soles
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31
Q

What are janeway lesions?

A 
Flat, macular
Echymotic
Palms / soles
Non tender 
Pathognomonic
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32
Q

What are the embolic phenomena possibly seen in IE?

A 
Focal neurological signs
Peripheral embolus / abscess (30%)
- renal 
- cerebral 
- splanchnic
- vertebral 
Pulmonary embolus/abscess 
- right sided IE
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33
Q

What would give you a high index of suspicion of IE? Fever with……

A 
New murmur
Pyrexia of unknown origin 
Known IE causative organism 
Prosthetic material (PPM, ICD, prosthetic valve, baffle/conduit)
Previous IE
Congenital heart disease
New conduction disorder
Immunocompromised/IVDA
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34
Q

Diagnosis of IE may be absent in….

A

Elderly
After antibiotic treatment
Immunocompromised
IE involving less virulent/atypical organisms

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35
Q

Markers of infection/inflammation

A

FBC (neutrophilia)
CRP
ESR

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36
Q

What does CRP stand for?

A

C-reactive protein

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37
Q

What does ESR stand for?

A

Erythrocyte sedimentation rate

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38
Q

Investigations for IE

A 
FBC, CRP, ESR
U + Es
Blood cultures (prior to Ax)
Urinalysis 
ECG
CXR
ECHO
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39
Q

What blood cultures need to be done?

A

3 sets from different sites with 6 or greater hours In between
For severe sepsis / septic shock, 2 sets from different sites within 1 hour

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40
Q

What would a CXR show in IE?

A

HF

Pulmonary abscess

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41
Q

Types of ECHO

A

TTE - transthoracic

TOE - transoesophageal

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42
Q

What % of IE has +ve blood cultures?

A

85%

43
Q

Causes of IE with -ve blood cultures

A

Prior Ax Tx
Fastidious organisms (fastidious gram -ve baciili HAEK group, nutritionally variant streptococci)
Intracellular bacteria

44
Q

What are the HACEK group?

A 
Haemophilus parainfluenzae
H aphrophilus 
H paraphrophilus
H influenzae 
Actinobacillus actinomycetemoitans 
Cardiobacterium hominis
Eikenella corrodens 
Kingella kingae 
K dentrificans
45
Q

What are the intracellular bacteria that can cause IE? What % of IE is this?

A

5%
Coxiella burnetti
Bartonella
Chlamydia

46
Q

Most common streptococci causing IE

A

Strep viridans

47
Q

What is the cause of health care associated IE?

A

Staph aureus

Staph epidermidis

48
Q

What bacteria is most likely to cause IE with a native valve?

A 
strep viridans (25-65%)
staph aureus (20-48%)
49
Q

What bacteria is most likely to cause IE if the patient is an IVDU?

A 
staph aureus (50-60%)
B haemolytic strep (10-25%)
50
Q

What bacteria is most likely to cause IE if have a prosthetic valve at 2 months?

A 
Staph epidermidis (33%)
Staph aureus (22%)
51
Q

What bacteria is most likely to cause IE if prosthetic valve present for 2 - 12 months?

A

Staph epidermidis

52
Q

What bacteria is most likely to cause IE if prosthetic valve present for >12 months?

A 
Strep viridans (31%)
Staph aureus (18%)
53
Q

What is the criteria used to diagnose IE?

A

Modified Duke Criteria

54
Q

What is the modified duke criteria?

A

Major criteria
1. Identifying organism
2. Providing evidence of infection anywhere within the heart
Minor criteria
1. Focus on the endocarditis complex of clinical findings

55
Q

What are the major criteria for the modified duke criteria?

A
  1. Blood cultures +ve for IE
    - 2 separate blood cultures with typical organisms consistent with IE
    - organisms consistent with IE from persistently +ve blood cultures (all 3 or majority of >4 separate cultures of blood)
    - single +ve blood culture for coxiella burnetti
  2. Evidence of endocardial involvement
    - Positive ECHO
    - new valvular regurgitation / murmur
56
Q

What would be involved in a +ve ECHO?

A

Any endocardial surface, including normal myocardium
Intracardiac / device mass
Para-annular abscess
New dehiscence of prosthetic valve

57
Q

What are the minor criteria for the modified duke criteria?

A 
Predisposition 
-  predisposing heart condition 
- Injection drug use 
Fever
Vascular phenomena 
Immunologic phenomena 
Microbiological evidence
58
Q

What is a common event that may happen before presenting with IE?

A

Recent dental appointment

59
Q

What are the vascular phenomena with IE?

A 
Major arterial emoboli 
Septic pulmonary infarcts
Mycotic aneurysm 
Intracerebral haemorrhages
Conjunctival haemorrhages
Janeway lesions
60
Q

What are the immunologic phenomena that can occur in IE?

A

Glomerulonephritis
Oslers nodes
Roth spots
Rheumatoid factor

61
Q

What microbiological evidence would be needed for the minor criteria for IE?

A

+ve blood cultures (do not meet major criterion)

Serological evidence of active infection with organism consistent with IE

62
Q

What things in the modified duke criteria mean definite IE?

A

2 major
1 major and 3 minor
5 minor

63
Q

What things in the modified duke criteria mean possible IE?

A

1 major

3 minor

64
Q

Treatment of IE

A

Antibiotics IV

+/- Surgery

65
Q

When should Ax for IE be started?

A

As soon as blood cultures taken

66
Q

What does the choice of Ax for IE depend on?

A 
Have they received prior Ax?
Native or prosthetic valve 
Local epidemiology of organisms 
Local antibiotic resistance
Specific culture negative pathogens
67
Q

What do slow growing, dormant microbes need?

A

Prolonged therapy - 6+ weeks

Removal of prosthetic material

68
Q

Treatment of IE if native valve and for how long

A

Gentamicin and amoxicillin and vancomycin

4 WEEKS

69
Q

Causative organisms of IE if native valve

A

Staph
Strep
HACEK species
Bartonella

70
Q

Treatment of IE if native valve and sepsis

A

Gentamicin and vancomycin

71
Q

Treatment of IE if prosthetic valve and for how long

A

Gentamicin and vancomycin and rifampicin

6 WEEKS

72
Q

Causative organisms of IE with prosthetic valves

A

MSSA
MRSA
Non HACEK -ve pathogens

73
Q

Who should rifampicin also be givenfor?

A

Prosthetic valves

74
Q

S/Es of gentamicin

A

Ototoxic

Nephrotoxic

75
Q

Treatment of MSSA causing IE in a native valve and for how long

A

Flucloxacillin 4 weeks

76
Q

Treatment of MSSA causing IE if prosthetic valve and for how long

A

Flucloxacillin
Rifampicin
Gentamicin
6 weeks

77
Q

Treatment of IE caused by strep and for how long

A

Benzylpenicillin 4 - 6 weeks

78
Q

Treatment of IE caused by strep if penicillin allergy and for how long

A

Vanc 4 - 6 weeks

Gent > 2 weeks

79
Q

Treatment of IE caused by enterococcus and for how long

A 
Amoxycillinn and Gent (4 - 6 weeks)
OR 
Gent and BenPen (4 - 6 weeks)
OR if penicillin allergy 
Vanc and Gent (4-6 weeks)
80
Q

Who are the most worrying group of patients with IE?

A

Those caused by fungal infection

81
Q

How do patients get IE caused by fungi?

A

PVE
IVDU
Immunocompromised

82
Q

What does PVE stand for?

A

Prosthetic valve endocarditis

83
Q

Which fungi cause IE?

A

Candida

Aspergillus

84
Q

Mortality of fungi causing IE

A

Very high (>50%)

85
Q

Treatment of fungi causing IE

A

Dual anti fungals

Valve replacement

86
Q

Complications and Indications for surgery in IE

A 
HF 
Fistula formation 
Leaflet formation 
Uncontrolled infection 
Enlarging vegetation despite Tx
Abscess formation 
AV heart block 
Embolism 
Prosthetic valve dysfunction / dehiscence
Embolism and vegetation > 10mm
Isolated vegetation >15mm
87
Q

What would indicate an uncontrolled infection?

A 
Persisting fever, + ve blood cultures > 7 - 10 days
Inadequate Ax Tx
Resistant organisms
Infected lines
Locally uncontrolled infection 
Embolic complications
Extracardiac site of infection 
Adverse reaction to Ax
88
Q

What is the most severe form of IE?

A

PVE

89
Q

Treatment of PVE

A

Take out prosthetic material

IV Ax

90
Q

Who gets prophylaxis of IE?

A

Those at highest risk of IE and at risk of highest adverse outcomes of IE

91
Q

What is important in the prophylaxis of IE?

A

Good oral hygiene

Regular dental review

92
Q

Is antibiotic prophylaxis recommended for IE?

A

NO

93
Q

When should prophylaxis for IE be offered?

A

An Ax that covers organisms that cause IE
If the person is at risk of IE
Is receiving Antimicrobial therapy
Due to undergoing a GI or GU procedure
At a site where there is suspected infection

94
Q

What % of IE are due to healthcare associated IE?

A

30%

95
Q

Mortality of IE

A

9.6 - 265

96
Q

Poor outcomes in IE if….

A 
Older
Prosthetic valve IE
Insulin dependent DM
Comorbidity 
IVDU
Presence of complications
S aureus, fungi or gram -ve bacilli 
ECHO findings - HF, periannular complications
97
Q

Criteria for urgent valvular replacement in IE

A

Severe congestive cardiac failure
Overwhelming sepsis despite Ax therapy (+/- perivalvular abscess, fistulae, perforation)
Recurrent embolic episodes despite Ax therapy
Pregnancy

98
Q

What valve is most commonly affected in IVDUs who have IE?

A

Tricuspid valve

99
Q

What is an ECG change diagnostic of rheumatic fever?

A

Prolonged PR interval

100
Q

Why does rheumatic fever occur?

A

Develops following an immunological reaction to recent (2 - 6 weeks ago) strep pyogenes infection

101
Q

Diagnostic criteria for rheumatic fever

A

Evidence of recent strep infection
2 major criteria
1 major with 2 minor criteria

102
Q

How can you get evidence of recent streptococcal infection?

A

Raised or rising streptococci Abs
Positive throat swab
Positive rapid group A streptococcal antigen test

103
Q

Major criteria for diagnosis of rheumatic fever

A

Erythema marginatum (10% of children, rare in adults)
Syndenhams chorea (often late feature)
Polyarthritis
Carditis and valvulitis (e.g. pancarditits)
Subcutaneous nodules

104
Q

Minor criteria for diagnosis of rheumatic fever

A

Raised ESR or CRP
Pyrexia
Arthralgia (not if arthritis major criteria)
Prolonged PR interval

CVS Pathology (19 decks)

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