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Cardiac Infections (Boards and Beyond: Pericarditis/Endocarditis) +…
Cardiac Infections (Boards and Beyond: Pericarditis/Endocarditis) + lecture:Myocarditis
Endocarditis
Pathophysiology
Colonization of damaged valvular endothelium
Thrombus + Organisms= vegetations
enlarging vegetation > fragments spread
CVA
metastatic infections
Clinical Manifestations
Constitutional
Fever
chills
Night sweats
Anorexia
Consequences of destruction of heart valves
New Murmur
Heart Failure
AV Block (prolonged PR)
Embolic Phenomena
L- sided endocarditis
CVA
brain abscess
Splenic or renal infarct (abn/flank pain)
emboli: splinter hemorrhages
Janeway Lesions
Retinal Hemorrhages
Conjunctival Hemorrhages
R-sided endocarditis
splenic pulmonary emboli
cough
SOB
chest pain
hemoptysis
Antigen-Ab deposition from uncontrolled infx
Osler's Nodes
Roth's spots
glomerulonephritis
arthritis
Pathgens
Native valve
Community Onset
Viridans group
streptococci
S. Aureus
S. Bovis
Enterococcus spp
Nocosomial
S. Aureus
Enterococcus spp
S. epidermidis
IV drug user
S. aureus
gram - rods
Pseudomonas
,
Candida spp
Prosthetic Valve
Early Life
S. epidermidis
S. Aureus
Late
S. Aureus
viridians group
streptococci
Enterococcus spp
S. epidermidis
Pacemaker or Defibrillator
S. epidermidis
S. Aureus
Culture Negative
Prior Abx
Bartonella spp
Coxiella b.
Brucella spp
T. whipplei
Diagnosis
Modified Duke Criteria for Infective Endocarditis
Definite Infective Endocarditis (either)
Pathologic Criteria
Microorganism seen in histology/culture/vegetation, or vegetation emboli zed or in intracardiac abscess
Pathological Lesions, vegetation or intracardiac abscess confirmed by historical showing active endocarditis
Clinical criteria
Major (2 needed) or (1 maj + 3 minor)
(+) blood cultures of typical organism from 2 sep blood cultures
single (+) culture for culture or serology consistent with
Coxiella burnetii
infection
(+) echo for infective endocarditis
Minor
Predisposing heart condition or intravenous drug use
Fever
Vascular phenomena (arterial emboli, septic pulmonary infarcts, mycotic aneurysm, etc.)
Immunologic phenomena (Osler’s nodes, Roth’s spots, glomerulonephritis, etc.)
Microbiologic evidence not meeting major criteria
Treatment
Empiric
Vancomycin
plus either Ceftriaxone or Gentamicin
Prophylaxis
Amoxicillin
Diagnostic Testing
ECG
Echocardiogram
Transthoracic Echo TTE
Transesophageal Echo TEE
Myocarditis
Definition: Infx of heart muscle
Pathophysiology
Infection most frequently occurs following hematogenous spread of virus or other pathogen to the heart muscle
Cardiac Dysfunction
Heart Failure
Clinical Manifestations
signs of heart failure (days - weeks depending on infection
systemic infection signs
fever + constitutional symptoms
pericarditis
chest pain
Pathogens
Viral
#1 cause: Coxsackie Virus
CMV
EBV
Parvo virus B19
influenza
T. cruzi
T. spiralis
Idiopathic
Diagnosis
cardiac muscle biopsy
necrosis
myocardial inflamm
cardiac failure (global)
cardiac dysfunction on echo
elevated cardiac enzymes
abnormal ECG
ST changes
mimicking acute MI
Treatment
none (maybe heart transplant)
Prevention
none
Pericarditis
#
Definition: inflammation of the pericardium
Pathophysiology
hematogenous spread
Pericardial effusion
Direct cardiac
tamponade
Diabetic nephropathy
low oncotic pressure moves fluid into pleura
Constrictive physilogy
concomitant myocarditis
direct spread from adj intrathoracic structures
rarely: directly from infected myocardium
non-infectious causes
uremia
Post-MI
Fibrinous (days)
Dresslers(weeks)
Autoimmune
RA
SLE
Tx
NSAIDs
steroids
colchicine
Clinical Manifestations
#1 common: Chest pain worsening w/ inspiration or cough
sitting up improves pain
fever and constitutional symptoms
Friction rub on exam (pathognomonic)
patients who present w/ acute or subacute onset of HF symptoms
Pathogens
Viruses
Coxsackie and echoviruses
HIV
CMV
bacteria
S. Aureus
S. Pneumoniae
fungi
#1 cause worldwide: M. tuberculosis
subacute presentation
in US, restrictive Pericarditis is usually due to radiation therapy
Histoplasma c.
Coccidiodes immitis
Diagnosis
Pericardial fluid culture/ pericardial tissue culture
ECG changes
significant pericardial effusion
PR and ST changes
Diffuse(every lead) Concave ST segment elevation : acute pericarditis
PR segment depression: Acute pericarditis
atrial involvement
reduced amplitude in all leads
Later: T wave inversions
normal progression
cardiac MRI
pericardial effusion or pericardial thickening
CXR
enlarged cardiac silhouette:
Water bottle sign
Pericardial effusion: Meniscus line
labs: elevated cardiac enzymes
pericardiocentesis or pericardial biopsy
recovery of pathogen
Treatment (untreated is fatal)
Viral
symptom management
self limiting if viral or idiopathic
fungi, bacteria,mycobacteria
antimicrobial
tamponade symptoms
pericardiocentesis (lifesaving)
