Lívia Jánoskuti · •Marfan sy, 2 years ago luxatio lentis( Her mother had Marfan sy) •On the...
Transcript of Lívia Jánoskuti · •Marfan sy, 2 years ago luxatio lentis( Her mother had Marfan sy) •On the...
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Infective endocarditis
Lívia Jánoskuti
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Definition
• Bacterial or fungal
– (chlamydial, rickettsial also occur)
• Infection
• Within the heart
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Classification • Infective organism
– (Gram pos., Gram neg, fungal, hemoculture negative IE)
• Native valve , prosthetic valve
– (early:within 12 month after operation, > 12 month after operation)
• Population
– (iv drug abusers, children, old patients)
• Nosocomial
– IE developing > 48 h prior to the onset of signs and symptoms consistent with IE
• Active at operation
– (fever, positive hemoculture)
• Recidive: 1 year after recovery
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Epidemiology
• 60/1 million inhabitants/year
• Hungary:24/ 1 M / year
Predisposing lesions:
• Prostetic valve and mitral valve prolapse sclerosis,degenerative valve increasing incidence
• Rheumatic valve disease decreasing incidence in association with IE
• Iv drug abusers have an unique propensity to develope IE of the tricuspid valve
Mortality: 16-33%, early prosthetic valve IE 80%
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Pathogenesis
• Bacteria enters the blood stream
– (oral or other source)
• Lodge in the heart valves, that already may
bear platelet-fibrin thrombi
• Bacteria proliferate freely-vegetation
develops
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Complications of the disease
• Emboli: brain, spleen, kidney,right sided-pulmonary
• Valve destruction: regurgitation, obstruction
• Extension: septum-AV block, fistulas-pericardium (sinus Valsalva aneurysm rupture into the pericardium)
• IC vasculitis: arthritis, glom. nephritis, Osler nodes, Roth spots, Latex positivity
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Peripheral manifestations of IE
Physical finding Pathogenesis Most common
organism
Petechiae(20-40%)red,
nonblanching lesions in crops on
conjuctivae, buccal mucosa, palate,
extremities
Vasculitis or
emboli
Streptococcus
Staphylococcus
Splinter hemorrhages(15%) linear
red streaks proximal in nailbed
Vasculitis or
emboli
Staphylococcus
Streptococcus
Osler s nodes(10-25%) 2-5mm
painful nodules on pads of fingers
or toes
Vasculitis Streptococcus
Janeway lesions (<10%) macular
red or hemorrhagic painless patches
on palm or soles)
Emboli Staphylococcus
Roth s spots (<5%) oval pale retinal
lesions surrounded by hemorrhage
Vasculitis Streptococcus
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Janeway lesion
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Osler nodul and Janeway lesion
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Splinter hemorrhage
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Clinical features
Symptoms of IE starts within 2 weeks of
precipitating bacteremia
• Malaise, night sweats, weight loss with
organism of low pathogenicity (viridans
streptococci)
• Explosive onset with organims of high
pathogenicity ( Staphylococcus aureus)
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Symptoms Fever In almost all patients
Heart murmurs (new) Up 99%
Splenomegaly 30 %
Petechiae, (Osler nodes, Janeway
etc.)
20-40%
Musculoskeletal complaints Arthralgias, arthitis
Pulmonary emboli In tricuspid valve IE
Clubbing Duration longer than 6 weeks
Neurological( headache) Brain abscesses,meningitis,arteritis
Congestive heart failure
Renal disease Nephritis 80%,infarction-50%,absc.
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Diagnostic criteria (Duke)
• Certain:
– pathological criteria: surgical or autopsy findings,
– clinical criteria: 2 major, 1 major+3 minor, 5 minor criteria
• Possible: hemoculture positivity+ new heart murmur, or known valve disease+vasculitis
• Not possible: recovery in 4 days, negative surgical, or autopsy findings
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Diagnostic criteria (Duke)
Major:
1. positive hemoculture ( typical agent and 2 tests positivity)
2. positive echocardiography (vegetation, abscess)
3. new regurgitation murmur
Minor:
1. predisposing heart disease
2. fever
3. vascular symptoms
4. immune phenomenons
5. echocardiographically possible, but not certain
6. microbiologically possible, but not certain
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Differential diagnosis
Missleading clinical presentations:
• Young adult with stroke
• Adult with confusion( but fever, murmur)
Blood cultures are negative:
Acute rheumatic fever
Multiple pulm. embolism
Atrial myxoma
SLE-Libman Sacks endocarditis
malignancy
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Indications of TEE in IE
• 1.Suspected prosthetic valve IE
• 2.Suspected native valve IE, but TTE is
uncertain, or certain, but patient has high
risk (large vegetation)
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Syndromes suggesting specific
bacteria causing IE
• Indolent course: – viridans streptococci, streptococcus bovis (colon cc),
Streptococcus faecalis
• Aggressive course: – staphylococcus aureus, str. pneumoniae, str.pyogenes,
neisseria gonorrhoea
• Drug users: – staphylo.aureus, pseudomonas, candida
• Frequent major emboli: – haemophilus sp., bacterioides sp, Candida sp.
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Native valve endocarditis
Most people (60-80%) have an identifiable predisposing cardiac lesion
• Rheumatic heart disease
• Congenital heart disease (bicuspic aortic valve, M valve prolapse with regurg., HOCM, Marfane with AI)
• Aortic sclerosis, calcified mitral anulus, ventricular aneurysms
• Diabetes mell-accel.artscler+infections
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Native valve endocarditis/
Microbiology
• Streptococci (50-70%) cure rate 90%
• Enterococci (10%) cure rate 75-90%
• Staphylococci (25%) cure rate 60-70%
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Native valve endocarditis/mortality
30%
Poorer prognosis
• Old or very young
• Aortic, versus mitral valve
• Left sided versus right sided
• Large vegetations (more than 10mm)
• Delay of diagnosis
• Staphylococcus
• Enterococci (10%) cure rate 75-90%
• Staphylococci (25%) cure rate 60-70%
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Prostetic valve endocarditis/5-15%
of all IE cases
Cardiac valve
replacement
Early-<12month Late->12month
Bacteria Staph.epiderm.
Staph.aureus
diphteroids
Strept.viridans
Mortality 75% 40%
Therapy Vancomycin+
gentamycin(Ripha
mpicin)
Surgical treatment
Penicillin+
gentamycin
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Endocarditis in iv drug abusers
• Male/female ratio 3:1
• Right sided predilection
• Staphylococcal 60%, polymicroorganism 5%
• Migratory pneumonia
– (multiple septic pulm. emboli)
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IE in children
• Rare 34/1 million inhab./year
• Rheumatic heart disease, congenital heart
disease
• Str viridans
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Therapy
• Early antibiotic treatment with bactericid
AB
• Duration of iv treatment 4-6 weeks
• No anticoagulation (but in prosthetic valve
cases it is necessary)
• No steroid
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Empiric therapy
Native valve endocarditis
• 4x3gr Ampicillin/sulbactam or
A/clavulanate
with 3mg/kg/die Gentamycin
Ampicillin intolerance:
• 30mg/kg/die Vancomycin+ Gentamycin +
Ciprofloxacine (800mg/die iv)
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Empiric therapy
Early prostetic valve IE (< 12 month)
• Vancomycin 6 weeks+Gentamycin (2
weeks) iv+ Rifampícin 1200mg/die pos(2
weeks)
Late prostetic valve IE (>12 month)
• As in native IE
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Treatment
• Streptococcus viridans-10-20 ME penicillin or
Ceftriaxon 2 gr/day
• Enterococcal-Ampicillin 4x3gr/die +Gentamycin
1,5mg/kg/die
• Staphylococcal-Oxacillin 12g/die+Gentamycin
Methicillin resistant species or at penicillin allergie
2x1gr Vancomycin+ Gentamycin/die
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Surgery
Absolute indications:
• Refractory heart failure
• Myocardial, paravalvular abscess
• Ineffective therapy
• Repeated relapses
Relative indications:multiple embolic
episodes
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Endocarditis profilaxis
recommended
• Prosthetic cardiac valves
• Previous IE
• Congenital malformations
A. Cyanotic CHD without surgical correction, or
with residual defects, or palliative shunts
B.For 6 month after complete surgical repaire
C.After surgical correction with residual defects
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IE profilaxis is not recommended
• Isolated sec. atrial septal defect
• Surgical repair without residua beyond 6 month of ASD-II,VSD, or patent duct.art.
• ACBG
• Mitral valve prolapse without regurg.
• Previous rheumatic fever without valvular dysfunction
• Cardiac pacemakers and impl. defibrillators
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IE profilaxis for patients undergoing dental or
upper resp. procedures
• 1 hour before the procedure 2 gr Amoxicillin
orally
• Penicillin allergic patients: Clindamycin
600mg, or 500mg Claritromycin, or
Azitromycin orally
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B.A. 34 year old man
Case report 1.
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Past history
• Patient 6 years old - tonsillectomie
• Patient 8 years old - rheumatic fever ( migratory ankle and knee arthritis, AST ) – Penicillin therapy for years
• Patient 34 years old, when recurrent dentological interventions were done
• Two month after this intervention, 3 weeks before admission, he got
– weekness,
– afternoons fever,
– arthralgias,
– recurrent transient visual loss.
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Physical examination
• Pale, maculopapular rash on the chest
• No lymph node enlargement
• No pulmonary abnormalities
• Diastolic murmur in the II.III. right intercostal
space
• Pulse 96/min ,RR 130/60
• Negative abdomen
• Fever: 38,5
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Lab values
• Urin sediment: 40-50 rbc, 4-5wbc
• Sediment rate 90mm/h Ht 0,34 HB 9,5 wbc
10000 Se 83% Se protein 73 ELFO
gammaglob 21% IC, RF negative
• ECG: Sinus tachycardia QRS left deviation.
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Imagine methods
• Chest X-ray:neg
• Abd. US: cystae renis.l.u.
• Fundus: neg.
• Cardiac US: bicusp. aortic valve with
vegetation, AI-III.
• TEE: large, moblie vegetation, with cusp
fenestration
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TTE
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Therapy
• Hemocultures (nutritionally varinat Streptococcus, sensitive to Penicillin, gentamycin)
• Penicillin 4x5M unit/day + Tobramycin 160mg/day
• Constant fever.
• Cardiac surgery: arteficial aortic valve implantation.
• After 12 years patient has no complaines, he is a dancer, can work without problems.
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D.T-59 year old man
Case report 2.
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Past history • Tonsillectomie in his childhood.
• In 1994, in his age 59, in March 3 days fever without any concomittant symptoms
• In April: transient dizziness and double-vision. Neurological, ophtalmological and rheumatological examinations were performed. Dg. Spondylosos cerv.
• In May: sudden left leg spasm-pain
Phys. examination:out of soft aortic systolic murmur, normal.
Lab values: normal sed. rate, urin, blood smear
Imagine methods: chest Xray, arterial and venous Doppler, carotis Doppler negative
Dg.Myalgia cruris
He travelled to the USA, where he got fever and cough
• In June: admission to our hospital because of 3 weeks fever and weakness
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Results and history
• Physical: pale, pulmonary rales, loud diastolic murmur above the aorta.
2cm liver enlargement. Temp: 37,1
• Lab: Sed.rate 60mm/h Ht 0,36 wbc 9,9 IC positive
• Chest X ray: pulmonary congestion
• TTE: vegetation on the aortic valve, AI-II-III
• TEE: bicuspid aotic valve, 9mm large veg on it.
• Hemoculture (was negative)
• Therapy 20Me penicillin-160mg Tobramycine
• After 2 weeks of therapy recurrent fever-TTE control: vegetation
became larger
• Surgery: artefic. valve implanation.
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J.L. 82 year old man
Case report 3.
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History
• Treated because of NHL in Central Institute
of Oncology.
• For 4 weeks he has had fever. No
explanation of it was found. Weekness,
dyspnoe at 20 m walk.
• TTE was requested.
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TTE
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Results and history
• Physical: pale, no lymph nodes, Loud systolic murmur at the apex, radiated to the axillary line. Palpable spleen.
• Lab: CRP 58 Ht 0,28 wbc 2,8 Se 78% Urin sed. Neg.
• Hemoculture neg
• Augmentin, later Imipenem therapy for 5 weeks- no fever, no dyspnoe.
• TEE controll: no vegetation on mitral valve.
MI-III. Good left ventricular function.
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P.A. 44 year old woman
Case report 4.
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History
• No previous illness
• In 2008.Aug. she got fever and chills.
• Because of cough and dyspnoe she was admitted
to the Institute of Pulmonolgy.
• Physical examination : systolic murmur at the
apex, diastolic murmur above the aorta was heard
• Chest X ray showed pneumonia
• TTE: showed aortic and mitral valve vegetations
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TEE
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49
Results and history
• Hemoculture was positive
– (staphylococcus aureus)
• Vancomycin therapy started
• Because hemodinamic insufficiency aortic
and mitral arteficial valve was implanted.
• 5 weeks post op. antibiotic therapy.
• CRP normal, patient is well.
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SZ-M 65 year old man
Case report 5.
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Past history
• 5 years ago working in Cyprus has had a severe pneumonia. Since he has been weak, and has had dyspnoe at exertion.He has been treated with bronchodilatators on Pulmonology, with the diagnosis of COPD.
• In Dec. 2006. CLL and AIHA was diagnosed. Medrol and Cytoxan therapy have induced complet remission.
• Present therapy: Symbicort, Spiriva, Berodual, Verospiron, Lokren, Medrol, Cytoxan
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Complaines
• On 15. January 2007. he got chest pain,
radiating to the right shoulder, the pain
increased with breathing. He got fever 40 C,
with cough and dyspnoe.
• Physical examination showed diffuse
pulmonary wheezels. Diminished heart
sounds. Blood pressure 150/70 , pulse rate
100/min. Palpable spleen.
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Examinations
• Labor: Ht 0,31 wbc 13,950 thrcyta 80 000 Ly 78% DDimer 2,2 SGOT 76 GPT 90 LDH 340 SAP 58 CRP 135
• pO2 68 pCO2 27 O2 sat 96% with oxygen
• Pulmonary scintigraphy: Multiple segmental, bilateral perfusion defects.
• Chest X ray: negative
• TTE: for the detection of acute right heart enlargement and pulmonary hypertension
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Echocardiography/ the surprise
• TTE:10mm vegetation on the noncoron
cusp of the aortic valve. A vegetation on the
septal cusp of the mitral valve. AI-I. MI-II.
Pulm systolic pressure 36HGmm
• TEE: Aortic, and mitral valve vegetation.
Normal pulmonary and tricuspid valves.
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History
• Hemoculture: Enterococcus sp.
• Therapy:4x3gr Ampicillin 3x80mg
gentamycin.
• No fever after 2 weeks , CRP 25,9
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V.Cs. 27 year old women
Case report 6.
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Anamnesis.
• Marfan sy, 2 years ago luxatio lentis( Her
mother had Marfan sy)
• On the 18.07.2006. Mitral valve and aortic
valve and aorta asc. conduit,biological was
performed.
• Since 2 days, chills and fever 38-40 C. No
cough, no dyspnoe, no dysuria.
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Physical examination:
• Tall stature, arachnodactyly, joint
hyperflexibility, ectopia lentis. 1/6 systolic
murmur p.max at the aortic region. Blood
pressure100/70 P 88/min
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Labor
• We: 14 CRP 37 -26-28 Ht 0,33 thrcyta 96 wbc
4004 SGOT 103 GPT 121 Urine sediment:15-20
wbc
• Next day: CRP 43 SGOT 94 GPT 137
• Hemoculture
• Chest Xray: neg.
• Abdominal US: negative
• TTE: aortic non coron cusp is thicker. Small AI.
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History
• Every day chills and fever
• TEE no vegetation was found.
• One week later procalcitonin 20,3
• wbc 11 000 CRP 132
• TEE :vegetation on the aortic valve and on
the septal cusp of the mitral valve, the
suspition of a paravalvular abscess.
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V.Cs. 29 years old female
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History
• Early prosthetic valve endocarditis?
• Therapy: Vancomycin-Gentamycin
• wbc 8,7 procalcitonin 10,3 CRP 63, but fever on every day
• Hemoculture:haemophilus parainfluenzae
• Therapy: 2 gr Ceftriaxone
• Fever on every day: 2x2 gr Ceftriaxone/day
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History
• 01.20-26 . Continous fever during this
therapy.
• Abdominal US: abscess?- negative
• TTE. The mitral vegetation disappeared, but
the aortic valve vegetation is the same.
• Consultation with surgeon-operation is
possible only, if there is no inflammation.
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Present situation
• From 26.01 no fever.
• CRP 11 fvs 7,6
• We are waiting for complete
remission(calcification of the vegetation)
(Operation has a very high risk)
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A patient with migratory
pneumonia
Lívia Jánoskuti
3rd Dept. of Medicine Semmelweis
University
Budapest, Hungary
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History 1 65 year old woman,
with hypertension and diabetes mellitus type 2.
Recurrent urinary tract infections for 3 years
• In February 2005
she got acute renal failure during acute pyelonephritis, hemodialysis was performed
• At the end of March 2005
hemodialysis was stopped because patient’s renal function has normalized
• In summer 2005
recurrent short fevers, due to urinary tract infections, which were treated by antibiotics
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History 2 • In September 2005
fever, right sided pneumonia, hydrothorax (bacteriology negative)
• In November 2005 fever, left sided pneumonia, hydrothorax, later spleen abscess
blood culture positive: Enterococcus faecalis
After splenectomy, and 4 weeks Clindamycin-amoxicillin therapy; patient’s condition stabilized, became free of fever
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Question
• What is the pathomechanism of the
migratory pneumonias and the splenic
abscess?
1. Urosepsis
2. Right sided endocarditis and sepsis
3. Left sided endocarditis and sepsis
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TEE on 22. December 2005. • Aortic , mitral and pulmonary valves are normal
• Tricuspid valve endocarditis was detected
– On the lateral cusp
echodens 1,5 cm large mobile vegetation
– On the septal cusp
echodens 0,5 cm large mobile vegetation
• No PFO
• TI III. Pulmonary systolic pressure 35Hgmm
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TEE dec.22.
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TEE dec.22.
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History 3
After 8 weeks of AB therapy in January 2006
• No change on TEE control
• Calcified vegetations on the tricuspid valves
• No embolic phenomenons
• No inflammatory labor signs
• Consultant heart surgeon suggested observation
Control on April 2006
• No fever
• Because of TI III-IV, diuretic therapy was intensified
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New risk factors of IE
• IV. Drug abusers
• Intensive care settings
• Hemodialysis
• Elderly age
• Degenerative valve diseases
• Cirrhosis hepatis, diabetes mellitus
• Skin infections
• Gastrointestinal tumors
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Endocarditis of tricuspid valve
• Clinical characteristics: migratory pneumonias
• Frequent among iv drug abusers. Incidence 2-5% per year ( tricuspid valve is the most frequently affected (60-70%),followed by the mitral and aortic valves( 20-30%)
• The most common etiological agent is Staphylococcus aureus, being usually sensitive to methicillin
• The prognosis of right side IE is generally good,
Overall mortality is <5%, and with surgery <2%
• Mortality of HIVinfected iv drug abusers is higher
one year survival 65%, 5 year survival 35%.
» Miro J.M. Cardiology Clinics 21 (2) 164-84 2003.
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Infectious tricuspid valve endocarditis in a
chronic hemodialysis patient
• 67-year old male with chr. Renal failure, complained of
fever up to 38 degrees C after hemodialysis.
• Blood culture negative, CRP high
• TEE:13x25 mm large vegetation on the tricuspid valve
• He got a bioprosthetic valve
• Extensive vegetation was found in each cusps of the
tricuspid valve.
• 9 month after surgery; no signs of reccurence were
obsereved
Yoshida Japanese Journal of Thoracic Surgery 59(3):235-7 2006.
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Message
Think of right sided endocarditis in the case of
migratory pneumonia.
By effective and ongoing therapy, further
complications may be prevented and the
illness may be cured.