Rheumatic fever
Systemic immune response after beta-hemolytic streptococcal infection of pharynx
What valve is the most commonly affected in rheumatic fever?
Mitral valve
Minor criteria for clinical manifestations in rheumatic fever
CAFE P C-CRP elevated A-Arthralgia F-Fever E-ESR elevated
P-Prolonged PR
Major criteria for clinical manifestations in rheumatic fever
CANCER Carditis/Valvulitis Arthritis Nodules (subcutaneous) Chorea Erythema marginatum Rheumatic fever
Ddx with rheumatic fever
Rheumatoid arthritis Osteomyelitis Endocarditis Meningitis SLE Lyme disease Sickle cell anemia
Jones Criteria
Diagnosis of rheumatic fever 2 major criteria OR 1 major and 2 minor criteria OR (if recurrent) 3 minor criteria
Rheumatic Fever Treatment
Supportive care- bed rest
Salicylates- Aspirin
Penicillin
Prevention of recurrences
How many patients will develop valvulopathy after the diagnosis of rheumatic fever?
2/3 after 10 yrs.
What is a poor prognosis of rheumatic fever?
Persistent carditis
Complications of rheumatic fever
Rheumatic valve disease Heart failure Arrhythmias Pericarditis w/ effusion Rheumatic pneumonitis
Rheumatic heart disease
Permanent heart valve damage subsequent to ARF
What is the major cause of CV dz in developing nations?
Rheumatic heart disease
Infective endocarditis
Microbial infection of valvular or endocardial surface of the heart
How does Infective endocarditis occur?
Bacteria will colonize on the valve and proliferate
–>start to have damage occur to the valve
Classifications of Infective endocarditis
Native valve endocarditis (own heart vavle)
Prosthetic valve endocarditis
Injection drug users
What valve is most likely to be involved in native valves?
Mitral
What valve is most likely to be involved in injection drug users?
Tricuspid
What organism causes infective endocarditis?
Staph aureus
What side of the heart is more likely to be involved in infective endocarditis?
Right side
What physical exam finding is very telling of infective endocarditis?
Regurgitant murmur or new murmur
What peripheral lesions would you expect to find with infective endocarditis?
Petechiae Splinter/subungual hemorrhages Osler nodes Janeway lesions Roth spots
What is the most important lab to test for suspected infective endocarditis?
Blood cultures
Duke Major criteria for infective endocarditis diagnosis
- Two positive blood cultures or persistent bacteremia
- Echo shows evidence of endocardial involvement
- New regurgitant murmur
Definitive Diagnosis for infective endocarditis
2 major criteria OR 1 major criterion and 3 minor criteria OR 5 minor criteria
Bacterial Endocarditis FIVE PM
B- Blood Culture +
E-Endocardial Involvement: +echo; new table regurgitation.
F-Feve
I-Immunologic: glomerulonephritis; Osler nodes; Roth spots; Rf
V-Vascular : cutaneous hemorrhages, aneurysm, systemic emboli, pulmonary infarction
E-Echocardiography findings
P-Predisposition: heart condition, IV drug user
M-Microbiolgic evidence
Empiric treatment of infective endocarditis
Vancomycin + Ceftriaxone
Empiric treatment of infective endocarditis in patients with a prosthetic valve
Vancomycin + Rifampin + Gentamicin
Viridans streptococci treatment in complicated infective endocarditis
Penicillin IV or Ceftriaxone IV
Viridans streptococci treatment in uncomplicated infective endocarditis
Penicillin IV or Ceftriaxone IV
+ Gentamicin IV
Viridans streptococci treatment in infective endocarditis with PV
Penicillin IV or Ceftriaxone IV x6 wks of + Gentamicin IV x2 wks
Other streptococci treatment in infective endocarditis with PV
Penicillin IV OR
Ceftriaxone IV OR
Cefazolin IV
Who do we treat prophylactically for infective endocarditis?
Prosthetic cardiac valve
Previous IE
Congenital heart disease
Heart transplant w/ valvulopathy
Cardiac conditions not needing Prophylaxis for infective endocarditis
MVP RHD Bicuspid valve disease Calcified AS Congenital heart disease – VSD, ASD, HOCM
Procedures needing prophylaxis for infective endocarditis
- Dental procedures that involve:
- Gingival tissue
- Periapical region
- Perforation of the oral mucosa - Respiratory tract procedures that involve incision of the respiratory mucosa
- Tonsillectomy
- Transbronchial biopsy - Procedures on infected skin, skin structure, or musculoskeletal tissue
- Abscess drainage
Procedures not needing prophylaxis in infective endocarditis
Ear or body piercing Tattooing Vaginal delivery Hysterectomy Routine (non-cleaning) dental work
What antibiotic would you use in prophylaxis with dental and respiratory procedures
Amoxicillin 2 gm PO
