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CR - infective endocarditis (clinical features (peripheral manifestations…
CR - infective endocarditis
intro
febrile illness with persistent bacteraemia (even if pyrexial)
microbial infection of endothelial surface of heart
can be community-acquired, acquired post-op, hospital-acquired, right-sided, or culture -ve (bad prognosis, patient often on anti-tnf drugs e.g. rituximab, infliximab)
up to 50% mortality depending on pathogen
vegetations
characteristic lesions
variable in size
amorphous mass of fibrin + platelets
abundant with microorganisms, few inflamm cells
pathogens
strep
strep viridians most common causative organism in native valves (alpha haemolytic)
beta-haemolytic uncommon
pneumococci rare (alpha-hemolytic under aerobic conditions, beta-hemolytic under anaerobic conditions)
enterococci (group D rare)
Staph
S Aureus
2nd most common
MSSA has a worse prognosis
coag -ve staph uncommon but increasing
gram -ves
enterics
pseudomonas
Neisseria
HACEK
haemophilus
actinobacillus
cardiobacterium
Eikenella
Kingella
rare
fungi (candida) uncommon
types
acute bacterial (ABE)
fulminant
severe
uncommon
death not uncommon
often S aureus or S pyogenes
subacute bacterial (SBE)
more common
indolent (little/no pain)
slower course over months
less severe
S viridans
native valve (NVE)
55-75% of cases have underlying valve abnormalities
congenital
10% of cases in young adults
8% of cases in older adults
VSD
bicuspid aortic valve
patent ductus arteriosus
rheumatic
prevalence decreasing
mitral nearly always affected
mitral valve prolapse
prevalence = 2%
accounts for 7-30% of cases not related to IVDU or nosocomial infection
risk factor = IVDU
usually right-sided
most common tricuspid, then mitral, then aortic
valve normal in 75-93%
usually S aureus
prosthetic valve (PVE)
10-30% of all cases in developed nations
timing NB - guides Tx
early if within 60 days of getting new valve (nosocomial, usually S epidermidis)
late if after 60 days (community-acquired - same organisms as NVE)
Tx = replacement usually (poor drug delivery as prosthetic valve has no blood supply)
pathophysiology
CK release -typical infection symptoms
local destruction
hypercoaguable state - embolisation (septic or bland)
ICD
complement
clinical features
onset of symptoms usually 2+ wks after infection
fever most common sign
murmur in 80-85% (often changes)
lung manifestation if tricuspid
peripheral manifestations uncommon nowadays
Osler's nodes (painful erythematous nodular lesions)
Janeway lesions (non-tender, small, erythematous, haemorrhagic macule/nodules on palms/soles)
splinter haemorrhages
subconjunctival haemorrhages
roth spots (retinal haemorrhages seen on fundoscpy)
systemic emboli common (incidence decreases with effective microbial tx)
neurological sequelae: embolic stroke, mycotic aneurysm, cerebritis)
CHF due to mechanical disruption (high mortality without surgical intervention
acute kidney injury
ICD
impaired haemodynamics -> drug toxicity
Dx
Hx + physical exam
sustained +ve blood cultures (before tx unless ABE)
haematology, rheumatologic, renal studies
TOE
if not transthoracic (but negation must be > 2/3 mm to see it)
duke criteria (2 major OR 1 major + 3 minor OR 5 minor)
Tx
prolonged bactericidal antibiotics
aim for 3-4 wks - sterile valve for as long as possible before surgery
combos for synergy
prophylaxis
only for @ risk patients (prosthetic valve, previous infective endocarditis, congenital heart disease, heart transplant) in resp or dental procedures
prognosis
high in hosp + 6 month mortality
longterm risk of heart failure + stroke