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

Infections of the Heart Flashcards

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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
what are complications of endocarditis
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
how are IVDU endocarditis treated differently
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
how can endocarditis be prevented
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
What is the population that we see rheumatic heart disease in
higher in developing countries endemic in some areas peak incidence 5-15 yo sequelae of strep pharyngitis
29
how long after pharyngitis do rheumatic heart disease symptoms occur
2-3 weeks s/p symptom development
30
what is the JONES criteria
Joints O- heart Nodules Erythema marginatum Sydenham chorea 2 Major OR 1 major and 1 minor
31
what is the diagnostic criteria for acute rheumatic fever
JONES criteria
32
What are the Major JONES criteria
erythema marginatum carditis skin nodules sydenham chorea migratory polyarthritis
33
what are the Minor JONES criteria
fever arthralgia raised ESR Raised CRP prolonged PR-interval Hx rheumatic fever or rheumatic heart disease
34
What is erythema marginatum
rapidly enlarging ring or crescent shaped macules with central clearing
35
what are subcutaneous nodules
small, firm, non-tender nodules that adherent to underlying structures
36
what is sydenham chorea
random, continuous, involuntary movements
37
what occurs with rheumatic heart disease
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
what is the treatment for rheumatic heart disease
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
What is myocarditis
inflammation of the myocardium
40
who usually presents with myocarditis
primarily young, healthy patients kids pregnant females immunosuppressed
41
what are the types of myocarditis
infectious (viral is m/c, bacteria, fungi, spirochetes etc) and non-infectious myocarditis (autoimmune, meds, venoms, hypothermia, radiation injury)
42
What is the presentation of myocarditis
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
How do you work up myocarditis
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
what is the gold standard diagnostic study for myocarditis
Cardiac muscle biopsy
45
How do you treat acute myocarditis
IV,O2, monitor treatment of arrhythmias treatment of HF
46
how do you treat sub-acute to chronic
avoid cardiotoxic agents avoid NSAIDs serial echos to monitor if mild, spontaneous recovery over several months if severe, referral to advanaced care
47
What is pericarditis
inflammation of the pericardium epidemiology poorly defined infectious vs non-infectious
48
what is desslers syndrome
post MI pericarditis
49
what is the classic presentation of pericarditis
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
what is Kussmaul's sign
elevated JVP with inspiration (should decrease)
51
How is pericarditis worked up
no specific lab testing - elevated ESR, CRPand troponins classiv EKG findings echo to rule out pericardial effusion/tamponade
52
what is the treatment of pericarditis
treat underlying cause activity restriction until asymptomatic or CRP normalizes
53
what is the prognosis of pericarditis
most patients recover completely those who do not improve should get further work-up complications include pericardial effusions or tamponade
54
What is pericardial effusion
build up of fluid in the pericardial space between pericardium and heart
55
What is pericardial tamponade
when pressure gets high enough (>15 mmHg)
56
what is the leading cause of pericardial effusion and tamponade
viral secondary to viral pericarditis
57
what is the presentation of pericardial effusion and tamponade
acute effusions chronic effusions first, non-specific symptoms -dyspnea, cought, edema, fatigue, +/- pain, +/- symptoms consistent with pericarditis
58
what is the presentation of later stages pericardial effusion and tamponade
venous congestions - tachycardia, increased CO, hypotension and reduced CO
59
what is found on PE for a patient with Pericardial effusion and tamponae
pericardial friction rub other PE findings in tamponade Becks Triad pulsus paradoxus trachycardia, tachypena cool, clammy extremties,cyanosis
60
What is Becks Triad
hypotension JVD muffled heart sounds
61
how do you work up pericardial effusion and tamponade
depends on urgency of situation if theres time, Chest XR, EKG Endocardiogram is the best test for diagnosis pericardiocentesis (diagnostic AND therapeutic
62
what is the treatment or pericardial effusion/tamponade
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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