Infective endocarditis
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INFECTIVE ENDOCARDITI
S
ByLIKHILA ABRAHAM
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Definition Infective endocarditis (IE) is defined as an infection of the endocardial surface of the heart, which may include one or more heart valves, the mural endocardium, or a septal defect. Its intracardiac effects include severe valvular insufficiency, which may lead to intractable congestive heart failure and myocardial abscesses. If left untreated, IE is generally fatal.(medscape)
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Infective endocarditis (IE) is a microbial infection of the endothelial surface of the heart or iatrogenic foreign bodies like prosthetic valves or other intracardiac devices
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Types Native valve endocarditis (NVE), acute and subacuteProsthetic valve endocarditis (PVE),[10] early and lateIntravenous drug abuse (IVDA) endocarditis
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•Risk factors •Structural heart disease–Rheumatic, congenital, aging–Prosthetic heart valves•Injected drug use•Invasive procedures (Intracardiac pacemaker, ICD , AV Fistula)•Indwelling vascular devices•Other infection with bacteremia (e.g. pneumonia, meningitis)•Immunocompromised states•History of infective endocarditis
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BacterialStaphylococcus aureus followed by Streptococci of the viridans group and Coagulase negativ Staphylococci are the three most common organisms responsible for infective endocarditis. Other Streptococci and Enterococci are also a frequent cause of infective endocarditis.
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Fungal and Viral
Candida albicans, a yeast, is associated with endocarditis in IV drug users and immunocompromised patients. Other fungi demonstrated to cause endocarditis are Histoplasma capsulatum and Aspergillus
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HACEK organismsHemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella
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Nonbacterial Thrombotic Endocarditis
Endothelial injuryHypercoagulable state
Lesions seen at coaptation points of valves
Atrial surface mitral/tricuspidVentricular surface aortic/pulmonic
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Clinical features
•Symptoms–Fever, sweats, chills–Anorexia, malaise, weight loss•Signs–Anemia (normochromic, normocytic)–Splenomegaly–Microscopic hematuria, proteinuria–New or changing heart murmur, CHF–Embolic or immunologic dermatologic signs–Hypergammaglobulinemia, elevated ESR, CRP, RF
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Cardiac Pathologic Changes Vegetations on valve closure lines Destruction and perforation of valve leaflet Rupture of chordae tendinae,
intraventricular septum, papillary muscles Valve ring abscess Myocardial abscess Conduction abnormalities
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S. Aureus mitral valve vegetation, anterior leaflet
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Pathologic Changes
Kidney◦ Immune complex glomerulonephritis◦ Emboli with infarction, abscess
Aortic mycotic aneurysms
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Pathologic Changes
Splenic enlargement, infarction Septic or bland pulmonary embolism Skin
◦ Petechiae◦ Osler nodes: diffuse infiltrate of neutrophils,
and monocytes in the dermal vessels with immune complex deposition. Tender and erythematous
◦ Janeway lesions: septic emboli with bacteria, neutrophils and S/C hemorrhage and necrosis. Blanching and non-tender. Palms and soles
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Splinter Hemorrhages
1. Nonspecific2. Nonblanching3. Linear reddish-brown lesions found under the nail bed4. Usually do NOT extend the entire length of the nail
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Osler’s Nodes
1. More specific2. Painful and erythematous nodules3. Located on pulp of fingers and toes4. More common in subacute IE
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Janeway Lesions
1. More specific2. Erythematous, blanching macules 3. Nonpainful4. Located on palms and soles
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Roth spots
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Modified Duke Criteria
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Two major criteria, OR One major and three minor criteria, ORFive minor criteria allows a clinicaldiagnosis of definite endocarditis.
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Other tests
Electrocardiogram◦ Conduction delays◦ Ischemia or infarction
Chest X-ray◦ Septic emboli in right-sided IE◦ Valve calcification◦ CHF
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Antimicrobial Therapy
Blood culture become sterile within 2 days Fever resolves in 4 to 7 days If fever persists despite 7 days of antibiotics
evaluate for paravalvular or extracardiac abscess
Combination therapy most important for◦ Shorter course regimens◦ Enterococcal endocarditis◦ Prosthetic valve infections
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Streptococci susceptible to pencillin
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NVE
Fungal◦ Amphotericin◦ Fluconazole◦ Caspofungin, little data◦ Surgery usually necessary 1-2 weeks into
treatment