Infections of Cardiology (Exam 4)

Question 1

What is myocarditis?

Answer 1

Focal or diffuse inflammation of the myocardium. Most cases are infectious and often follow a URI.

Question 2

What is the most common cause of myocarditis in the US?

Answer 2

Viral (adenovirus, coxsackie virus, parvovirus B19, HIV, CMV)

Question 3

What are some other causes of myocarditis?

Answer 3

Bacteria (Brucellosis, strep pneumo, Legionella, Staph, Strep, Mycoplasma)
OR
Fungus (Candida, Aspergillus)

Question 4

Symptoms of myocarditis.

Answer 4

Acute heart failure without previous symptoms.
Pleural/pericardial pain
Tachycardia

Question 5

Diagnostic studies of myocarditis.

Answer 5

EKG: Nonspecific ST changes, ventricular ectopy

Chest XR: often shows cardiomegally

Question 6

Treatment of myocarditis

Answer 6

If bacterial or fungal, treat with antimicrobial.
Treat symptoms of HF
Transplant

Question 7

What is pericarditis?

Answer 7

Infection/inflammation of the pericardium. Often occurs in conjunction with myocarditis.

Question 8

Causes of pericarditis?

Answer 8

Same as myocarditis.
Viral (adenovirus, coxsackie virus, parvovirus B19, HIV, CMV)
Bacteria (Brucellosis, strep pneumo, Legionella, Staph, Strep, Mycoplasma)
Fungus (Candida, Aspergillus)

Question 9

Symptoms of pericarditis?

Answer 9

Chest pain, symptoms of myocarditis (Heart failure, tachycardia)

Question 10

Physical exam finding consistent with pericarditis?

Answer 10

Will be able to auscultate a rub.

Question 11

What is endocarditis?

Answer 11

Infection of the endocardial surfaces of the heart valves.

Question 12

What patient populations are at higher risk for endocarditis?

Answer 12

IV drug users
Pt’s after prosthetic valve replacement
History of rheumatic fever
Male: female ratio 2: 1

Question 13

Most common bacteria involved with endocarditis?

Answer 13

Strep Viridans, Staph, Gram negative rods, Enterococci

Question 14

Most common causes of native valve endocarditis?

Answer 14

Acute usually do to Staph or Group B Strep

Subacute usually alpha hemolytic strep (strep Viridans)

Question 15

Most common cause of prosthetic valve endocarditis?

Answer 15

Occurs within 60 days of replacement: Staph and Candida

Occurs later than 60 days after replacement: staph and alpha hemolytic strep

Question 16

What valve is most often infected in IV drug users?

What bacteria is most commonly responsible?

Answer 16

Tricuspid valve.

Most commonly Staph Aureus (60%)

Question 17

Physical exam findings consistent with endocarditis?

Answer 17

New heart murmur or worsening of an old murmur. Peripheral stigmata (splinter hemorrhages, Osler nodes, Janeway lesions, Roth spots), embolic findings

Question 18

Symptoms of endocarditis

Answer 18

Fever and chills most common

Others include anorexia, weight loss, night sweats, headache, myalgias, SOB

Question 19

What are Osler nodes?

Answer 19

Painful raised lesions on hands and feet

Question 20

What are Janeway lesions?

Answer 20

Flat, painless, purple lesion on hands or feet

Question 21

What are Roth spots?

Answer 21

Retinal hemorrhages with white or pale centers

Question 22

What diagnostics might you order if you suspect endocarditis?

Answer 22

Echocardiogram -60% sensitive
Transesophageal echocardiogram- 90% sensitive
Blood cultures, CBC, ESR(elevated in 90% of cases)

Question 23

If you highly suspect endocarditis, yet blood cultures are negative, what might you order?

Answer 23

Serologies for chlamydia, q fever, bartonella, fungal culture, and HACEK culture.

Question 24

What are HACEK organisms?

Answer 24

HACEK stands for the bacteria that are slow growing.

Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella

Question 25

How do you use the Duke Criteria?

Answer 25

Use the Duke Criteria to diagnose endocarditis. A patient must meet either 2 major criteria, 1 major and 3 minor criteria, or 5 minor criteria.

Question 26

What are the major Duke Criteria?

Answer 26

Blood culture positive from 2 separate cultures consistent with organisms that cause IE. Positive echocardiogram.

Question 27

What are the minor Duke Criteria

Answer 27

``` Predisposition for IE Fever Vascular phenomena (peripheral stigmata) Immunologic phenomena Microbiologic evidence Echo results showing valve thickening without vegetation ```

Question 28

Does this patient meet Duke Criteria? | One positive blood culture growing Eikenella and a positive echocardiogram?

Answer 28

No! Patient must have 2 separate cultures in order to meet the major criteria.

Question 29

Does this patient meet Duke Criteria? | Blood cultures pending. Positive echocardiogram. Fever, Osler nodes, and the patient has hx of rheumatic fever.

Answer 29

Yes, this patient has 1 major and 3 minor criteria(Fever, vascular phenomena, and predisposition for IE).

Question 30

What antibiotics would you use to treat a patient with IE before you have culture results?

Answer 30

Vancomycin and Cephtriaxone are used for empiric treatment

Question 31

What might you use for IE caused by strep and why?

Answer 31

Penicillin and gentamycin, because they work synergistically

Question 32

What antibiotic would you use for IE caused by MSSA?

Answer 32

Nafcillin

Question 33

What antibiotic would you use for an infection of a prosthetic valve and why?

Answer 33

Daptomycin 6mg/kg. It is effective against biofilms.

Question 34

How long do you treat for IE?

Answer 34

At least 2 weeks, 6 weeks if blood cultures are negative.

Question 35

Last resort treatment?

Answer 35

Surgery

Question 36

What valve(s) is most likely to be infected in a patient with peripheral stigmata?

Answer 36

Left sided valves: Aortic or mitral. Emboli get stuck in capillaries of hands and feet causing splinter hemorrhages, Janeway lesions, Osler nodes

Question 37

What valve(s) is most likely to be infected in a person with PE's.

Answer 37

Right sided valves: tricuspid or pulmonic | Emboli break off and get stuck in capillaries of lungs causing PE's.

Question 38

What might you consider if a pt has IE due to enterococci?

Answer 38

Consider GI tract as source, rule out colon cancer.

Question 39

What is the most commonly infected valve? | What is the least common?

Answer 39

Most common: Mitral | Least common: Pulmonic