Endocarditis

Question 1

Pathologies of endocarditis

Answer 1

Prototypic Native Valve Endocarditis (NVE) lesion

Non-bacterial Thrombotic Endocarditis (NBTE)

Question 2

What are NVE lesions made up of?

Answer 2

Mass of platelets, fibrin, microbial microcolonies with scant inflammatory cells

Question 3

What are NBTE (AKA marantic endocarditis) made up of?

Answer 3

uninfected platelet-fibrin thrombus often a nidus for mocrobial adhesion during bacteremia

Question 4

Explain the Venturi effect

Answer 4

NBTE and NVE develop on sides of low-pressure sink just beyond the valve or intraventricular defect or stenosis (they glob on)

Question 5

T/F Cardiac valves have no dedicated blood supply?

Answer 5

T

Question 6

What effects does the lack of dedicated blood supply have on cardiac valves?

Answer 6

Host immune response blunted

Limited access of abx

Question 7

What cardiac locations are involved in endocarditis?

Answer 7

Native/prosthetic valves
Low-pressure side of ventricular septal deffect
Mural endocardium damaged by aberrant jets
Intracardiac devices

Question 8

What are the 2 older terms still used in some places to classify endocarditis?

Answer 8

Subacute Bacterial Endocarditis (SBE)

Acute Bacterial Endocarditis

Question 9

What is the classification system now preferred for endocarditis?

Answer 9

Incubation classification

Question 10

Incubation less than about_____ is considered short incubation?

Answer 10

Six weeks

Question 11

Inbuation greater than about ______ is considered long incubation?

Answer 11

Six weeks

Question 12

What are the most common current etiologies of endocarditis?

Answer 12

Congenital heard disease
Illicit IV drug use
Degenerative Valve dz
Intracardiac devices
Incidence notability increased in elderly

Question 13

What percent of cases of NVE are related to healthcare?

Answer 13

30-35%

Question 14

What percentage of endocarditis involves prostehtic valves?

Answer 14

16-30%

Question 15

during what time period is a patient with a valve replacement at greatest risk of endocarditis?

Answer 15

6-12 months

Question 16

What locations on the body can serve as possible soures of infective endocarditis?

Answer 16

Oral cavity
skin
upper respiratory tract
GI
GU

Question 17

What bacteria may result in endocarditis from oral cavity, skin, and upper respiratory tract?

Answer 17

Strep Viridans
Staphlococci
HACEK

Question 18

What bacteria may result in endocarditis from GI source?

Answer 18

Strep gallolyticus
Polyps
colon tumors

Question 19

What bacteria may result in endocarditis from a GU source?

Answer 19

Enterococci

Question 20

What bacteria may result in endocarditis from a nosocomial source?

Answer 20

Staph aureus
CoNS (coag neg staph)
Enterococci

Question 21

What procedures may result in procedure induced bacteremia?

Answer 21

Endoscopy
Colonoscopy
Barium enema 
Dental Extractions!!!
Transurethral resection of prostate (TURP)
TEE

Question 22

What is the timeline for recognizing a nosocomial infective endocarditis?

Answer 22

Exposure within 90 days

Question 23

What valve is most commonly involved in endocarditis in an IV drug user? And what pathogens are most common?

Answer 23

Tricuspid-S. aureus, commonly MRSA

Question 24

What percentage of patient’s have negative blood cultures? What is this due to?

Answer 24

5-15% come back negative (33-50% of this is due to premature initiation of tx.)

Question 25

Pathogenesis of E-carditis (4)

Answer 25

1. Adhesion molecules recognize MSCRAMMS 2. Platelet-fibrin vegetations form dense microcolonies of microbes 3. Organisms deep inside the vegetations are inactive and resistant 4. Surface organisms continuously shed into the blood stream

Question 26

It is the result of ___________ that causes the symptoms of Endocarditis?

Answer 26

Fighting the infection

Question 27

What symptoms result from the pathophys of endocarditis?

Answer 27

``` Constitutional - cytokine production Damage to intracardiac structure Embolization of veg fragments - leading to infection or infarction Bacteremia Tissue injury ```

Question 28

cadiac presentation of E-card?

Answer 28

murmurs may not start right away but occur eventually in 85% CHF (30-40%)-from valvular dysfunction Intracardiac fistula MI-dt emboli (2%)

Question 29

Classic presentation seen in 50% of endocarditis pt's?

Answer 29

``` Petechiae subungual (splinter) hemorrhages Osler nodes Janeway lesions Roth spots ```

Question 30

Define Osler nodes

Answer 30

Tender subcutaneous nodules usually distal pads of the digits

Question 31

Define Janeway Lesions

Answer 31

Nontender maculae on palms and soles

Question 32

Define Roth spots

Answer 32

Retinal hemorrhages w/ small clear centers (rare)

Question 33

CNS diseases that can present with endocarditis?

Answer 33

Embolic stroke Intracerebral hemorrhage Multiple microabcesses Seizures

Question 34

What might be seen on CXR in a patient with septic pulmonary emboli?

Answer 34

solid and cavitary lesions "circles of crud"

Question 35

What might be seen on EKG secondary to IE?

Answer 35

Complete heart block-dissociation

Question 36

Signs of IE?

Answer 36

``` Splenomegaly stiff neck delirium paralysis, hemi, aphasia conjunctival hemorrhage pallor gallops rales cardiac arrhythmia pericardial rub pleural friction rub subacute native valve endocarditis ```

Question 37

What are the signs of subacute native valve endocarditis?

Answer 37

``` Low grade fever anorexia weight loss flu-like symptoms polymyalgia-like syndromes pleuritic pain syndromes similar to rheumatic fever abd. symptoms (ruq pain, vomiting, postprandial distress) ```

Question 38

What are Most common pathogens of IE?

Answer 38

Staph aureus (MC) CoNS Gram negative bacilli **remember the culture can come back negative in many patients

Question 39

What is the test of choice for a pt with endocarditis?

Answer 39

ECHO (TEE GOLD!!!)

Question 40

What is true about the risk of doing a TTE on a pt?

Answer 40

TEE carries a risk of providing a source for Endocarditis.

Question 41

Duke's criteria for definite Endocarditis

Answer 41

2 major criteria 1 major and 3 minor or 5 minor

Question 42

Duke's criteria for possible endocarditis

Answer 42

1 major and 1 minor | or 3 minor

Question 43

Major criteria for Dukes:

Answer 43

Positive blood culture | Positive Echo

Question 44

Minor criteria for Dukes:

Answer 44

``` Predisposition Fever Vascular phenomena Immunologic phenomena (Roth's spots etc.) Microbiological evidence ```

Question 45

What are we looking for on Echo?

Answer 45

Vegetation

Question 46

Indications for REQUIRED surgical intervention for pt's with endocarditis?

Answer 46

Mod to severe CHF Partially dehisced unstable prosthetic valve Persistant bacteremia despite ABX Lack of effective microbial tx (fungal) S. Aureus prosthetic valve with intracardiac complication (Fistula) Relaphse after optimal abx. tx.

Question 47

Once surgery is decided upon what indications require that surgery to be done EMERGENTLY (same day)

Answer 47

Acute aortic regurgitation plus pre-closure of mitral valve Sinus of valsalva abscess ruptured into R heart Rupture of pericardial sac

Question 48

What patients must have prophylaxis prior to dental procedures?

Answer 48

Prosthetic heart valves Prior endocarditis Unrepaired cyanotic congenital heart disease completely repaired congenital heart defects during 6mos after repair Incompletely repaired congenital heart disease w/ residual defects adjacent to prosthetic material (valvulopathy developing after cardiac transplantation-this is changing and less necessary)

Question 49

What is the standard oral regiment of abx prophylaxis for pt's who require it prior to dental procedures?

Answer 49

Amoxicillin: 2 g PO 1 h before procedure

Question 50

If left untreated what is the mortality of IE?

Answer 50

14.5%

Question 51

What increases the mortality rate for IE?

Answer 51

``` Increased age Involvement of Aortic Valve CHF CNS complications Underlying chronic medical conditions e.g. DM Rates vary dependent upon microbe ```