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Clin Med 2 - CARDS > Infections of the Heart > Flashcards

Infections of the Heart Flashcards

1
Q

what is endocarditis

A

aka infective endocarditis (IE)
infection of the endocardium - usually talking about the valve leaflets

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2
Q

what is the typical population that endocarditis is seen in

A

58 yo
M>W
no obvious racial/ethnic predilection
50-60% have some underlying cardiac condition

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3
Q

Who are at high risk of developing endocarditis

A

IVDU
hemodialysis
DM
HIV
immunosuppression
dental procedures
valvular heart disease
endovascular hardware

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4
Q

What is the most common location for endocarditis

A

Left sided > Right sided

EXCEPT in IVDU which is Right > Left

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5
Q

why is the left side of the heart more susceptible to endocarditis

A

there is more pressure (turbulent flow)
More O2 (bacterial growth)
Valvular disorders are more common

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6
Q

why are IVDU more susceptible to right sided endocarditis

A

direct venous inoculation

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7
Q

What microbes are most common with a native valve endocarditis

A

Staph aureus
strep viridans
enterococci
HACEK organisms

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8
Q

what are HACEK organisms

A

Haemophilus
Aggregatibacter
Cardiobacterium
Eikenella corrodens
Kingella

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9
Q

What microbes are most common with IVDU endocarditis

A

Staph aureus
enterococci
streptococci
gram negative aerobic bacilli
fungi
other ‘weird’ bugs

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10
Q

what microbes are most common in prosthetic valve endocarditis

A

Staph aureus
coagulase negative staph
streptococci
gram negative organisms
fungi

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11
Q

what is acute endocarditis

A

more virulent organisms (s. aureus)
normal or damaged valves
symptoms within days
high Fever (102-104)
rapidly progressive
more severe symptoms (look sick)

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12
Q

what is the number one cause of endocarditis

A

staph aureus

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13
Q

what is subacute endocarditis

A

less virulent organisms (steptococci, enterococci, other bacteria, fungi)
often predisposed valves
symptoms between days - weeks
milder fever (99-101)
slower progression
more mild symptoms (look stable)
less likely to develop complications

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14
Q

What is Osler’s nodes

A

painful raised red lesions on the hands and feet

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15
Q

what are janeway lesions

A

non-tender, flat, small red lesions on hands/feet

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16
Q

what are Splinter hemorrhages

A

capillary hemorrhages under the fingernail

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17
Q

what are classic manifestations of endocarditis

A

oslers nodes
janeway lesions
splinter hemorrhages
petechiae (palate or conjunctiva)
clubbing
roth spots (retinal hemorrhages with pale centers)

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18
Q

What are Roth spots

A

retinal hemorrhages with pale centers

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19
Q

how do you work up endocarditis

A

blood cultures (2-3 sets from 2 different locations)
Echocardiogram (TTE with follow up TEE if positive or high risk)
Duke Criteria (2major, 1 major + 3 minor, 5 minor)
Possible IE (1 major + 1 minor, 3 minor)

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20
Q

what is the treatment of endocarditis

A

EARLY infectious disease consult
empiric antibiotics (broad spectrum, based on organism)
Treatment length somewhere between 2-6 weeks

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21
Q

What are the treatment options for staph endocarditis

A

MSSA: nafcillin, oxacillin or cefazolin
MRSA: vancomycin or daptomycin
if PVE: Add Rifampin + Gentamycin

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22
Q

What are the treatment options for viridans strep endocarditis

A

PCN, Cefritaxone or vancomycin PLUS Gentamycin

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23
Q

What are the treatment options for enterococcus endocarditis

A

ampilcillin or PCN PLUS gentamycin or ceftriaxone

Vancomycin PLUS gentamycin

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24
Q

when is surgical intervention considered for endocarditis

A

large vegetations (>20mm)
septic pulmonary emboli
highly resistant organism
persistent bacteremia (source control)
severe tricuspid regurg - R heart failure resistant to treatment

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25
Q

what are complications of endocarditis

A

IVDU high risk for septic emboli - stroke, PE (mimic PNA), no benefit from anticoagulation or antiplatelet therapies
High risk of metastatic infections (PJI, spine infections, splenic abscess)

26
Q

how are IVDU endocarditis treated differently

A

they often are unwilling to stay in the hospital for 4-6 weeks
cant d/c to home with central line
high risk of recurrence
higher mortality rate with HIV co-infection
Risk for HCV co-infection as well
Poorer long-term prognosis after surgery

27
Q

how can endocarditis be prevented

A

indicated for select group of patients to have prophylaxis prior to dental work, invasive respiratory tract procedures, procedures involving skin or MSK infection

Amoxicillin 2g PO 1 hr prior to procedure
ampicillin or ceftriaxone 2g IV
if PCN allergy, cephalexin, clindamycin, azithromycin

28
Q

What is the population that we see rheumatic heart disease in

A

higher in developing countries
endemic in some areas
peak incidence 5-15 yo
sequelae of strep pharyngitis

29
Q

how long after pharyngitis do rheumatic heart disease symptoms occur

A

2-3 weeks s/p symptom development

30
Q

what is the JONES criteria

A

Joints
O- heart
Nodules
Erythema marginatum
Sydenham chorea

2 Major OR 1 major and 1 minor

31
Q

what is the diagnostic criteria for acute rheumatic fever

A

JONES criteria

32
Q

What are the Major JONES criteria

A

erythema marginatum
carditis
skin nodules
sydenham chorea
migratory polyarthritis

33
Q

what are the Minor JONES criteria

A

fever
arthralgia
raised ESR
Raised CRP
prolonged PR-interval
Hx rheumatic fever or rheumatic heart disease

34
Q

What is erythema marginatum

A

rapidly enlarging ring or crescent shaped macules with central clearing

35
Q

what are subcutaneous nodules

A

small, firm, non-tender nodules that adherent to underlying structures

36
Q

what is sydenham chorea

A

random, continuous, involuntary movements

37
Q

what occurs with rheumatic heart disease

A

valvular damage secondary to rheumatic fever: valvular damage - stenosis, regurgitation or both
manifests as new or changing murmur
50-70% involve mitral valve
30% involves the aortic valve

38
Q

what is the treatment for rheumatic heart disease

A

early appropriate treatment of streph pharyngitis
treatment of acute rheumatic fever: NSAIDs, PCN, +/- prednisone for symptomatic treatment

prevention of recurrent episodes of rheumatic fever
(PCN prophylaxis IM every 4 weeks)

39
Q

What is myocarditis

A

inflammation of the myocardium

40
Q

who usually presents with myocarditis

A

primarily young, healthy patients
kids
pregnant females
immunosuppressed

41
Q

what are the types of myocarditis

A

infectious (viral is m/c, bacteria, fungi, spirochetes etc) and non-infectious myocarditis (autoimmune, meds, venoms, hypothermia, radiation injury)

42
Q

What is the presentation of myocarditis

A

flu-like illness that persists for 7-14 days (fever, malaise, myalgias, n/v/d)
dyspnea, chest pain, arrhythmias, tachycardia, hypotension
kids compensate until they cant - hypoxia, respiratory distress, cyanosis, cardiac arrest
may see S3, S4, Rales, Tachycardia

43
Q

How do you work up myocarditis

A

most lab findings will be non-specific
abnormal EKG, elevated troponins, elevated WBC, ESR, CRP
+ viral antibody titers
abnormal echo
Nuclear imaging (MRI) or cardiac muscle biopsy

44
Q

what is the gold standard diagnostic study for myocarditis

A

Cardiac muscle biopsy

45
Q

How do you treat acute myocarditis

A

IV,O2, monitor
treatment of arrhythmias
treatment of HF

46
Q

how do you treat sub-acute to chronic

A

avoid cardiotoxic agents
avoid NSAIDs
serial echos to monitor
if mild, spontaneous recovery over several months
if severe, referral to advanaced care

47
Q

What is pericarditis

A

inflammation of the pericardium
epidemiology poorly defined
infectious vs non-infectious

48
Q

what is desslers syndrome

A

post MI pericarditis

49
Q

what is the classic presentation of pericarditis

A

sharp, stabbing retrosternal chest pain
fever
pain that is pleuritic and postural (worse with inspiration, better sitting up and leaning forward)
pain may radiate to shoulder
Kussmaul’s sign
hours to days

50
Q

what is Kussmaul’s sign

A

elevated JVP with inspiration (should decrease)

51
Q

How is pericarditis worked up

A

no specific lab testing - elevated ESR, CRPand troponins
classiv EKG findings
echo to rule out pericardial effusion/tamponade

52
Q

what is the treatment of pericarditis

A

treat underlying cause
activity restriction until asymptomatic or CRP normalizes

53
Q

what is the prognosis of pericarditis

A

most patients recover completely
those who do not improve should get further work-up
complications include pericardial effusions or tamponade

54
Q

What is pericardial effusion

A

build up of fluid in the pericardial space
between pericardium and heart

55
Q

What is pericardial tamponade

A

when pressure gets high enough (>15 mmHg)

56
Q

what is the leading cause of pericardial effusion and tamponade

A

viral
secondary to viral pericarditis

57
Q

what is the presentation of pericardial effusion and tamponade

A

acute effusions
chronic effusions
first, non-specific symptoms
-dyspnea, cought, edema, fatigue, +/- pain, +/- symptoms consistent with pericarditis

58
Q

what is the presentation of later stages pericardial effusion and tamponade

A

venous congestions - tachycardia, increased CO, hypotension and reduced CO

59
Q

what is found on PE for a patient with Pericardial effusion and tamponae

A

pericardial friction rub
other PE findings in tamponade
Becks Triad
pulsus paradoxus
trachycardia, tachypena
cool, clammy extremties,cyanosis

60
Q

What is Becks Triad

A

hypotension
JVD
muffled heart sounds

61
Q

how do you work up pericardial effusion and tamponade

A

depends on urgency of situation
if theres time, Chest XR, EKG
Endocardiogram is the best test for diagnosis
pericardiocentesis (diagnostic AND therapeutic

62
Q

what is the treatment or pericardial effusion/tamponade

A

if small without tamponade- observation and treatment of underlying cause
if tamponade present - urgent pericardiocentesis
if present, recurrent, or very large, consider pericardial window

Clin Med 2 - CARDS (11 decks)

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