Endocarditis

Question 2

Definition of endocarditis

Answer 2

Infection of endocardium or parts of in. Sometimes but not always infection.

Question 3

Parts of endocardium more prone to infection

Answer 3

valve leaflets congenital defects the walls or chordae of the chambers paraprosthetic tissue the attachment of implanted shunts, conduits fistula,

Question 4

Can IE be seen on an XRay

Answer 4

No

Question 5

What conditions are more prone to endocarditis?

Answer 5

Valve or valve replacement, VSD, new regurgitant heart murmurs, mitral valve prolapse.

Question 6

What is the male/female ratio of endocarditis?

Answer 6

2/1

Question 7

What are the 2 components of the pathophysiology of IE?

Answer 7

Nonbacterial thrombotic endocarditis, transient bacteria.

Question 8

What are the pathologic effects of IE from infection?

Answer 8

Local tissue destruction and embolic phenomena

Question 9

What secondary autoimmune effects can result from IE?

Answer 9

Autoimmune: glomerulonephritis, vasculitis, arthritis.

Question 10

How has the incidence of IE changed over time?

Answer 10

Increased from more invasive procedures but decreased from less rheumatic heart disease so evens out overall.

Question 11

What are the obvious characteristic findings of IE?

Answer 11

Numerous positive blood cultures in the presence of a well recognized predisposing cardiac lesion , Evidence of endocardial involvement.

Question 12

How many patients have no identifiable predisposing cardiac lesion at disease onset?

Answer 12

1/4-1/3

Question 13

What needs to be checked in order to diagnose IE?

Answer 13

A careful history and physical examination, blood cultures and laboratory results, an electrocardiogram, a chest radiograph, an echocardiogram .

Question 14

What is significant on a physical exam for IE?

Answer 14

New regurgitant murmurs heart failure, classic clinical stigmata of endocarditis, including evidence of small and large emboli with special attention to the fundi, conjunctivae, skin, and digits, a neurologic evaluation, associated peripheral cutaneous or mucocutaneous lesions of IE include petechiae, splinter hemorrhages, Janeway lesions, Osler’s nodes, and Roth spots.

Question 15

What history is significant for IE?

Answer 15

Prior cardiac lesions , historical clues pointing towards a recent source of bacteremia such as indwelling intravascular catheters or intravenous drug use.

Question 16

Types of skin lesions in IE

Answer 16

Petechiae, splinter hemorrhages, Janeway lesions, Ostler nodes, Roth spots, other emboli.

Question 17

How do petechiae appear in IE?

Answer 17

not specific for IE
most common skin manifestation in IE
on the skin (usually on the extremities) or on mucous membranes (palate or conjunctivae)

Question 18

How do splinter hemorrhages appear in IE?

Answer 18

nonspecific for endocarditis
nonblanching, linear reddish-brown lesions found under the nail bed caused by emboli reaching end of finger.

Question 19

Janeway lesions in IE

Answer 19

more specific (but still not diagnostic) for IE, though less common (10% of patients).
 macular, blanching, nonpainful, erythematous, red lesions on the palms and soles.

Question 20

Osler’s nodes

Answer 20

more specific (but still not diagnostic) for IE, though less common
 painful, violaceous nodules/papulopustules found in the pulp of fingers and toes and are seen more often in subacute than acute cases of IE due to immune complexes.

Question 21

Roth spots

Answer 21

More specific (but still not diagnostic) for IE, though maybe present in other disorders, such as diabetes, Leukemia, anemia, hypertension and HIV
rare (5%)
exudative, edematous hemorrhagic lesions of the retina (a cotton wool spot (infarct) with surrpunding hemorrhage)

Question 22

Other organs affected by embolic events

Answer 22

focal neurologic deficits,
renal and splenic infarcts,
septic pulmonary infarct in right-sided IE.

Question 23

How should blood cultures be performed in IE?

Answer 23

A minimum of 3, spread out, prior to antibiotic treatment.

Question 24

The Duke Criteria: Typical causes of IE

Answer 24

Staphylococcus aureus,
Viridans group streptococci and Streptococcus bovis,
Enterococci ,
HACEK group organisms

Question 25

Staph aureus in IE

Answer 25

huge problem can be anywhere in the body, loves to sit on valves, esp prosthetic, only good outcomes are with IV drug users

Question 26

Strep viridans and bovis in IE

Answer 26

sit on teeth and can enter. 2 blood cultures are very suspicious but doesn't have to be.

Question 27

Enterococci in IE

Answer 27

Very hard to treat, lots of complications

Question 28

HACEK organisms in IE

Answer 28

Fastidious gram-negative bacilli, need to grow for 2-3 weeks to see: Haemophilus aphrophilus Actinobacillus actinomycetemcomitans Cardiobacterium hominis Eikenella corrodens Kingella kingae.

Question 29

Other pathogens in IE

Answer 29

culture negative endocarditis (8%-unknown antibiotic) polymicrobial (1%) a variety of other organisms (3%-including Brucellosis in the Negev, other gram negatives) Fungus (usually candida)

Question 30

Definite criteria for IE

Answer 30

Question 31

Diagnostic criteria for IE

Answer 31

Question 32

Why is echo used for IE?

Answer 32

because of its high sensitivity for valvular vegetations and complications of IE, is considered mandatory in the clinical diagnosis and treatment of this disorder

Question 33

What are the major criteria involving echo structural findings?

Answer 33

presence of an oscillating intracardiac mass/valvular vegetation presence of an abscess partial dehiscence of a prosthetic valve (New valvular regurgitation is also a major criterion)

Question 34

What are the disadvantage of the Transthoracic Echo (TTE)

Answer 34

sensitivity (62-79%), less sensitive than TEE (92%) measurements of structures in echo studies are limited by lower image resolution underestimates the size and complexity of large vegetations fails to detect small vegetations (\<3 mm in diameter)

Question 35

What are the disadvantage of TEE (transesophageal echo)

Answer 35

Invasive, expensive.

Question 36

When is a TEE indicated over a TTE?

Answer 36

When TTE is nondiagnostic or to diagnose prosthetic valve endocarditis and assess complications.

Question 37

Noninfectious causes of endocarditis

Answer 37

Libman-Sacks endocarditis (also known as verrucous, marantic, or nonbacterial thrombotic endocarditis) Loeffler's endocarditis Granulomatous diseases Scleroderma Lupus

Question 38

What are the criteria for culture-negative IE?

Answer 38

Endocarditis without etiology following inoculation of at least three independent blood samples in a standard blood culture system with negative cultures after seven days of incubation and subculturing

Question 39

What are the main causes for culture-negative IE?

Answer 39

Previous administration of antimicrobial agents Inadequate microbiological techniques Infection with highly fastidious bacteria or nonbacterial pathogens (eg, fungi). The HACEK organisms (Haemophilus aphrophilus; Actinobacillus actinomycetemcomitans; Cardiobacterium hominis; Eikenella corrodens; and Kingella kingae) Fastidious organisms [e.g., zoonotic agents (Bartonella spp., Coxiella burnetii, Brucella spp.) and fungi] Streptococcal spp. in patients who have received previous antibiotic treatment

Question 40

How can culture-negative IE be diagnosed?

Answer 40

Special culturing techniques (eg, shell vial and lysis centrifugation) Molecular techniques (eg, polymerase chain reaction and serologic assays) Histopathology evaluation of valvular tissue when surgical excision is performed.

Question 41

What is the survival rate of IE?

Answer 41

Approximately 80% of patients with endocarditis now survive their infections (1/6 patients with IE does not survive the initial hospitalization), and up to 1/3 of patients infected with highly virulent organisms (such as Staphylococcus aureus) may die as a direct or indirect result of their valvular infection.

Question 42

What is the treatment for IE?

Answer 42

Only bactericidal, not bacteriostatic therapy is effective in treating endocarditis Antimicrobial therapy should be administered in a dose designed to give sustained bactericidal (not bacteriostatic) serum concentrations throughout much or the entire dosing interval. Most is IV. Often empirical therapy: only after 2-3 cultures obtained. Monitor other complications and response to antibiotics after treatment begins.

Question 43

Complications of IE

Answer 43

Myocardial infarction, pericarditis, cardiac arrhythmia Cardiac valvular insufficiency Congestive heart failure Sinus of Valsalva aneurysm Aortic root or myocardial abscesses Arterial emboli, infarcts, mycotic aneurysms Arthritis, myositis Glomerulonephritis, acute renal failure Stroke syndromes Mesenteric or splenic abscess or infarct