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Cardiology- Cardiac Infections Flashcards

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1
Q

Case 1
23 year HIV infected woman presents to casualty with c/o
Progressive peripheral edema
Abdominal swelling
Shortness of breath and fatigue

ROS reveals 1/12 of fever, night sweats and weight loss

On the basis of the history, what is the likely cause of this symptom complex?

A

TB pericarditis

Especially extrapulmonary TB (such as peritoneal TB), can cause fever, night sweats, weight loss, ascites, and fatigue.
Common co-infection in HIV patients due to immunosuppression.

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2
Q

What is pericarditis?

A

Pericarditis is inflammation of the pericardium, the fibrous sac surrounding the heart, often causing chest pain, pericardial friction rub, and ECG changes.

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3
Q

What are common causes of pericarditis?

A

Causes include viral infections (most common), bacterial infections, autoimmune diseases (e.g., lupus), post-myocardial infarction (Dressler’s syndrome), trauma, and uremia.

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4
Q

What are the characteristic clinical features of acute pericarditis?

A

Pleuritic chest pain (worsened by deep inspiration, relieved by sitting up/leaning forward), pericardial friction rub, and diffuse ST-segment elevation on ECG.

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5
Q

What is a pericardial effusion?

A

A pericardial effusion is the abnormal accumulation of fluid in the pericardial cavity, which can compress the heart and impair its function.

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6
Q

What are common causes of pericardial effusion?

A

Causes include pericarditis, malignancy, trauma, post-surgery, uremia, and hypothyroidism.

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7
Q

What are the signs of a large pericardial effusion?

A

Distant or muffled heart sounds, distended neck veins, and a “water-bottle” shaped heart on chest X-ray.

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8
Q

What is cardiac tamponade?

A

Cardiac tamponade is a life-threatening condition where fluid accumulation in the pericardium leads to increased pressure, restricting heart filling and reducing cardiac output.

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9
Q

What are the key clinical features of cardiac tamponade?

A

Beck’s triad: hypotension, distended neck veins (raised JVP), and muffled heart sounds. Pulsus paradoxus (exaggerated drop in blood pressure during inspiration) is also common.

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10
Q

What is the immediate treatment for cardiac tamponade?

A

The urgent treatment is pericardiocentesis, where fluid is drained from the pericardial sac to relieve the pressure on the heart.

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11
Q

What is constrictive pericarditis?

A

Constrictive pericarditis occurs when the pericardium becomes thickened and scarred, limiting the heart’s ability to expand and fill properly

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12
Q

What are the main causes of constrictive pericarditis?

A

Causes include chronic pericarditis, previous cardiac surgery, radiation therapy, infections (e.g., tuberculosis), and connective tissue disorders.

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13
Q

What are the key clinical features of constrictive pericarditis?

A

Features include right heart failure signs such as ascites, peripheral edema, hepatomegaly, and Kussmaul’s sign (elevated JVP that rises during inspiration).

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14
Q

How is constrictive pericarditis treated?

A

Definitive treatment involves pericardiectomy, surgical removal of the thickened pericardium.

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15
Q

What is Dressler’s syndrome?

A

Dressler’s syndrome, also known as post-myocardial infarction syndrome, is an autoimmune form of pericarditis that occurs weeks after a heart attack.

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16
Q

What are the clinical features of Dressler’s syndrome?

A

Features include fever, pleuritic chest pain, and a pericardial effusion, often with elevated inflammatory markers (ESR, CRP).

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17
Q

How is Dressler’s syndrome treated?

A

Treatment includes NSAIDs for inflammation, corticosteroids in more severe cases, and colchicine to prevent recurrence.

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18
Q

What is a pericardial rub?

A

A pericardial rub is a scratchy, grating sound heard during auscultation, caused by the friction between inflamed pericardial layers in pericarditis.

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19
Q

How can you differentiate a pericardial rub from other heart sounds?

A

A pericardial rub has three components (systolic and two diastolic phases) and is best heard with the patient leaning forward, unlike pleural rubs or normal heart sounds.

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20
Q

What is pulsus paradoxus, and in which pericardial syndrome is it seen?

A

Pulsus paradoxus is an exaggerated drop in systolic blood pressure (>10 mmHg) during inspiration. It is commonly seen in cardiac tamponade.

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21
Q

How is pulsus paradoxus detected clinically?

A

Pulsus paradoxus is detected by measuring the blood pressure and noting the difference in systolic pressure between inspiration and expiration.

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22
Q

How is the diagnosis of TB pericarditis established

A
  1. Confirm the presence of a pericardial effusion

CXR
ECG
ECHO

  1. Confirm the tuberculous etiology

Rule out alternative causes
PUS
Uremia
Hypothyroidism

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23
Q

Definitive diagnosis of TB pericarditis

A

Culture TB from pericardial fluid (low yield)

Granuloma on biopsy

Culture TB from sputum, lymph nodes etc

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24
Q

Probable diagnosis of TB pericarditis

A

Lymphocytic exudate

High ADA or Gamma Interferon

If no access to pericardium

Rule out alternative causes of effusion

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25
Complications of TB pericarditis
Tamponade Severe heart failure Constrictive Pericarditis
26
Treatment of TB pericarditis in an HIV infected individual
Pericardiocentesis-particularly if any hint of hemodynamic instability Anti Tuberculous therapy No corticosteroids
27
Treatment of TB in a non- HIV patient
Pericardiocentesis-particularly if any hint of hemodynamic instability Anti Tuberculous therapy Corticosteroids to reduce Constrictive pericarditis
28
Case 2 A 30-year-old presents to see you because she has been “sick” for 2/52 You take a brief history. What information about your patient would make you concerned that your patient could have Infective endocarditis?
29
Which of the following are not associated with a high risk for IE and why? Dilated cardiomyopathy VSD Constrictive Pericarditis Repaired Tetralogy of Fallot [TOF] Ischemic Heart Disease with Hx of CABG
Not associated with high risk: Dilated cardiomyopathy, constrictive pericarditis, and ischemic heart disease with a history of CABG. They don't involve the valves of the heart Associated with high risk: Ventricular septal defect (VSD) and repaired Tetralogy of Fallot (TOF). Patients with abnormal native heart valves, prosthetic heart valves , certain congenital defects, patches, and conduits are at high risk for developing IE
30
What is infective endocarditis?
Infective endocarditis (IE) is an infection of the endocardial surface of the heart, typically involving the heart valves, caused by bacteria, fungi, or other pathogens.
31
What are common risk factors for infective endocarditis?
Risk factors include pre-existing valvular heart disease, prosthetic heart valves, intravenous drug use (IVDU), previous infective endocarditis, and congenital heart disease.
32
What are the most common pathogens causing infective endocarditis?
The most common pathogens are Staphylococcus aureus, Streptococcus viridans, Enterococci, and coagulase-negative staphylococci. Fungi and other bacteria may also cause endocarditis, especially in immunocompromised patients or IVDU.
33
What is the pathophysiology of infective endocarditis?
IE begins with damage to the heart's endocardial surface, allowing bacteria from the bloodstream to adhere and form vegetations on heart valves. These vegetations can cause local tissue destruction, systemic emboli, and immune complex deposition.
34
What are the key clinical features of infective endocarditis?
Fever, heart murmur, fatigue, weight loss, and signs of embolic phenomena (e.g., petechiae, Janeway lesions, Osler’s nodes) are common clinical features.
35
What are common embolic manifestations of infective endocarditis?
Embolic manifestations include Janeway lesions (painless erythematous lesions on palms and soles), splinter hemorrhages under the nails, Roth spots in the eyes, and infarcts in major organs (e.g., brain, kidneys, spleen).
36
What are common immunological manifestations of infective endocarditis?
Immunological manifestations include Osler’s nodes (painful subcutaneous nodules on fingers or toes), Roth spots (retinal hemorrhages with pale centers), and glomerulonephritis.
37
What criteria are used to diagnose infective endocarditis?
The Modified Duke Criteria are used, including major criteria (positive blood cultures, evidence of endocardial involvement on echocardiography) and minor criteria (fever, embolic events, predisposing heart condition, etc.).
38
What are the major Duke Criteria for infective endocarditis?
The major criteria include: Positive blood cultures with typical IE organisms from at least two separate cultures. Echocardiographic evidence of endocardial involvement (vegetation, abscess, new valvular regurgitation).
39
What are the minor Duke Criteria for infective endocarditis?
The minor criteria include: Fever > 38°C. Vascular phenomena (e.g., Janeway lesions, emboli). Immunologic phenomena (e.g., Osler’s nodes, Roth spots). Positive blood cultures not meeting the major criteria.
40
What are the key treatment principles for infective endocarditis?
Treatment includes prolonged intravenous antibiotics (typically 4-6 weeks), guided by blood culture results. Surgical intervention may be necessary for valve replacement or in cases of uncontrolled infection or complications.
41
What is the typical antibiotic regimen for infective endocarditis caused by Staphylococcus aureus?
For methicillin-sensitive S. aureus (MSSA), use nafcillin or oxacillin. For methicillin-resistant S. aureus (MRSA), use vancomycin or daptomycin.
42
What antibiotics are used for infective endocarditis caused by Streptococcus viridans?
Penicillin G or ceftriaxone, often combined with gentamicin, are used for S. viridans.
43
What are the indications for surgery in infective endocarditis?
- Heart failure due to valvular dysfunction. - Fungal or resistant infections. - Uncontrolled infection or abscess formation. - Recurrent embolic events despite antibiotics. - Prosthetic valve endocarditis.
44
What are common complications of infective endocarditis?
Complications include heart failure, systemic emboli (stroke, renal infarction), abscess formation, valvular damage, and conduction abnormalities (e.g., heart block).
45
Who requires prophylaxis for infective endocarditis before dental or surgical procedures?
Prophylaxis is recommended for patients with high-risk conditions such as prosthetic heart valves, previous infective endocarditis, congenital heart disease, and heart transplant recipients with valvulopathy.
46
What is the recommended antibiotic for endocarditis prophylaxis before dental procedures?
Amoxicillin 2 g orally 1 hour before the procedure. If allergic to penicillin, alternatives like clindamycin or azithromycin are used.
47
What is the prognosis for infective endocarditis?
Prognosis depends on the underlying cause, the presence of complications, and promptness of treatment. Mortality rates can be as high as 20-25%, especially in cases involving Staphylococcus aureus or in those with prosthetic valves.
48
Symptoms of infective endocarditis
FEVER NIGHT SWEATS RIGORS WEIGHT LOSS MALAISE ARTHRALGIA PALLOR
49
To confirm infective endocarditis what two tests should be done
1. Echocardiography 2. Blood culture - Central to the diagnosis and treatment - Whenever you entertain IE always remember to take blood cultures before empiric therapy with antibiotics - 3 sets one hour apart from different sites
50
Which organism commonly causes infective endocarditis (IE) from the oropharynx?
Streptococcus viridans
51
What is the portal of entry into the bloodstream for Streptococcus viridans in infective endocarditis?
The portal of entry is typically through dental procedures, poor oral hygiene, or oral trauma, allowing bacteria from the mouth to enter the bloodstream.
52
Which organism commonly causes infective endocarditis (IE) from the gastrointestinal tract?
Enterococci (specifically Enterococcus faecalis) are common pathogens causing IE from the gastrointestinal tract.
53
What is the portal of entry into the bloodstream for Enterococci in infective endocarditis?
The portal of entry is typically through gastrointestinal or genitourinary procedures or infections, such as manipulation of the bowel or urinary tract.
54
Which organism associated with the gastrointestinal tract commonly causes infective endocarditis (IE)?
Streptococcus bovis (also known as Streptococcus gallolyticus) is linked to IE.
55
What is the portal of entry into the bloodstream for Streptococcus bovis in infective endocarditis?
The portal of entry is often from the colon, and its presence in the bloodstream may be associated with colonic malignancy or polyps.
56
Which skin organism commonly causes infective endocarditis (IE)?
Staphylococcus aureus is the most common skin organism responsible for IE, especially in intravenous drug users.
57
What is the portal of entry into the bloodstream for Staphylococcus aureus in infective endocarditis?
The portal of entry is typically through skin breaches (e.g., IV drug use, central line insertion, skin infections, or surgical wounds).
58
Which coagulase-negative organism from the skin can cause infective endocarditis (IE)?
Coagulase-negative staphylococci (CoNS), particularly Staphylococcus epidermidis, can cause IE.
59
What is the portal of entry for Coagulase-negative Staphylococci in infective endocarditis?
The portal of entry is often from medical devices such as prosthetic valves, catheters, or pacemakers, where CoNS can colonize and enter the bloodstream.
60
Which organism from the uro-genital tract can cause infective endocarditis (IE)?
Neisseria gonorrhoeae, the bacteria responsible for gonorrhea, can cause infective endocarditis, although this is rare.
61
What is the portal of entry into the bloodstream for Neisseria gonorrhoeae in infective endocarditis?
The portal of entry is through the uro-genital tract during disseminated gonococcal infection.
62
Which organism from the uro-genital tract can cause infective endocarditis (IE)?
Group B Streptococcus (Streptococcus agalactiae) is associated with IE, particularly in pregnant women or newborns.
63
What is the portal of entry into the bloodstream for Group B Streptococcus in infective endocarditis?
The portal of entry is often via the uro-genital tract, commonly during childbirth or urogenital infections.
64
Finding on investigation on a patient with infective endocarditis
Full blood count: 80% anemia (normochromic/ cyctic) ESR, CRP: elevated Serum biochemistry: urea, creatinine and electrolytes Urine: hematuria casts, proteinuria Immunology: immune complexes positive, rheumatoid factor positive, complement low
65
Modified Duke Criteira
1. Microbiological evidence. 2. Echo evidence of a vegetation 3. New valve regurgitation 1. Predisposing condition 2. Fever >38 3. Microbiological evidence not meeting major criteria 4. Elevated inflammatory markers 5. Embolic phenomena (splenomegaly, stroke etc) 6. Immunological phenomena(, splinter hemorrhages, GN, Roth spots + rheumatoid factor complement consumption) 7. Suspicious echo 2 major OR 1 major + 3 minor OR 5 minor
66
Cardiac complications of endocarditis
1-Severe valve regurgitation. 2- Heart Failure 3-Heart Block 4-Abscess formation
67
Extra cardiac complications of infective endocarditis- Neurological
Mycotic aneurysms Embolic stroke Meningitis encephalitis
68
Extra cardiac complications of infective endocarditis- Renal
Glomerulonephritis Embolic infarction
69
Extra cardiac complications of infective endocarditis- Metastatic
Septic emboli with Abscess formation Spleen, brain, kidney
70
Extra cardiac complications of infective endocarditis- Musculoskeletal
Arthralagia Arthritis Lumbar back ache Limb ischemia
71
Principles of treatment of infective endocarditis
1. IDENTIFY THE ORGANISM 2. ADEQUATE ANTIBIOTIC (I.V.) IN APPROPRIATE DOSE FOR A PROLONGED PERIOD (WEEKS). 3. ENSURE THAT BACTERICIDAL LEVELS ARE ACHIEVED. 4. OBSERVE CAREFULLY DURING AND AFTER TREATMENT FOR COMPLICATIONS. 5. MONITOR METICULOUSLY AFTER TREATMENT TO ENSURE INFECTION ERADICATED.
72
When should you consider surgical cure for your patient?
Signs of infection not resolving despite Rx with appropriate ABX Refer to an expert if any cardiac, or extra-cardiac complication
73
Prevention of infective endocarditis
Regular tooth brushing, dental floss or other plaque removing devices should be encouraged and recommended to all susceptible patients, and where available/affordable, regular visits to an oral hygienist
74
Anti- biotic prophylaxis
Prosthetic valves Previous infective endocarditis Complex congenital heart disease: - Cyanotic congenital heart disease without surgical repair, or those with residual defects, shunts or conduits - Congenital heart disease with complete repair with prosthetic material up to 6 months post procedure - Persisting residual defect despite intervention Those with Rheumatic Valvular disease
75
Regarding TB pericarditis, which of the following is NOT recommended in HIV infected patients? A. NSAIDs (non-steroidal anti-inflammatory drugs) B. Pericardiocentesis C. Anti-TB therapy D. Corticosteroids
D. Corticosteroids
76
Which of the following is NOT a complication of infective endocarditis? A. Heart block B. Pericardial effusion C. Glomerulonephritis D. Meningitis
B. Pericardial effusion
77
Which of the following is NOT associated with a high risk for infective endocarditis? A. Intravenous drug use B. Prosthetic valves C. Ischaemic heart disease D. Congenital heart disease
C. Ischaemic heart disease
78
Which of the following will yield a probable diagnosis of TB pericarditis in suspected cases? A. High ADA (adenosine deaminase) B. TB culture from sputum or lymph nodes C. Caseous granuloma on pericardial tissue biopsy D. TB culture from pericardial fluid
A. High ADA (adenosine deaminase)
79
In which procedure is antibiotic prophylaxis against infective endocarditis recommended? A. Local anaesthetic injections in non-infected tissue B. Placement of removable prosthodontics or orthodontic appliance or braces C. Treatment of superficial dental caries D. Procedures requiring manipulation of the gingival or per-apical region of the teeth
D. Procedures requiring manipulation of the gingival or per-apical region of the teeth
80
What is the recommended antibiotic prophylaxis regimen for infective endocarditis in a patient without penicillin allergy? A. Amoxicillin 2 grams orally 60 minutes before procedure B. Ceftriaxone 500mg intravenously 60 minutes before procedure C. Amoxicillin 3 grams orally 30 minutes before procedure D. Ceftriaxone 1 gram intravenously 30 minutes before procedure
A. Amoxicillin 2 grams orally 60 minutes before procedure
81
Which of the following does NOT form part of the major Modified Duke’s Criteria in the diagnosis of infective endocarditis? A. Echo evidence of a vegetation B. New valvular regurgitation C. Positive blood culture D. Predisposing cardiac condition
D. Predisposing cardiac condition
82
To make a diagnosis of infective endocarditis using Modified Duke’s Criteria which of the following is INCORRECT? A. 1 major and 1 minor criterion needed B. 2 major criteria needed C. 5 minor criteria needed D. 1 major and 3 minor criteria needed
A. 1 major and 1 minor criterion needed
83
Which of the following is NOT suggestive of a massive pericardial effusion on ECG? A. T wave inversion in the precordial leads B. Electrical alternans C. Low QRS voltage D. Sinus tachycardia
A. T wave inversion in the precordial leads
84
What is the definitive investigation for the diagnosis of pericardial effusion? A. Chest X-ray B. Holter ECG C. ECG (electrocardiogram) D. Echocardiogram
D. Echocardiogram
85
Which of the following is the LEAST likely cause of fibrinous stranding seen on echocardiography? A. Uraemic pericarditis B. Staphylococcus aureus pericarditis C. Streptococcus pneumoniae pericarditis D. Lupus pericarditis
D. Lupus pericarditis
86
Which of the following is NOT suggestive of pericarditis on ECG? A. S1Q3T3 phenomenon B. PR depression in the precordial leads C. Sinus tachycardia D. Diffuse ST segment elevation in the precordial leads
A. S1Q3T3 phenomenon
87
Which of the following does NOT form part of the minor Modified Duke’s Criteria in the diagnosis of infective endocarditis? A. Embolic phenomena B. Elevated inflammatory markers C. Fever D. Weight loss
D. Weight loss
88
Which of the following signs is MOST COMMONLY found in patients with TB pericarditis? A. Pyrexia B. Hypotension C. Amphoric breath sounds D. Palpable pulsus paradoxus
A. Pyrexia
89
Which of the following is NOT a common complication of TB pericarditis? A. Pulmonary embolism B. Cardiac tamponade C. Severe heart failure D. Constrictive pericarditis
A. Pulmonary embolism

Cardiology (4 decks)

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