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Student Grand Rounds. Dr Vermani Firm Ekta, Kavina, Jessica, Rachel, Richard, Siwaporn . Case history. 73 year old retired male PC : presented 1 week ago with fatigue, blackouts and a persistent dry cough that had been present for almost a year

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Student grand rounds

Student Grand Rounds

Dr Vermani Firm

Ekta, Kavina, Jessica, Rachel, Richard, Siwaporn


Case history

Case history

  • 73 year old retired male

  • PC: presented 1 week ago with fatigue, blackouts and a persistent dry cough that had been present for almost a year

  • HPC: 4-month history of increasing fatigue, chest pain, dizziness, generalised weakness, low-grade on and off fever. No history of palpitation, SOB, haematuria.

  • PMH: Ross procedure (pulmonary autograft), type 1 diabetes

  • DH: Insulin (Novorapid and Glargine)

  • SH: no recreational drugs, ex-smoker, drank 35-40 units of alcohol since the age of 16, no history of foreign travel

  • FM: No relevant family history


Physical examination

Physicalexamination

  • BP 105/61 mmHg

  • HR 80/min

  • RR 18/min

  • Temp 38.4˚C

  • Both heart sounds were audible with an additional ejection systolic murmur and a soft early diastolic murmur at the left sternal edge.

  • Abdomen soft, non-tender

  • Splenomegaly


Laboratory findings

Laboratory findings

  • Renal profile and LFTs were normal

  • ECG and CXR normal

  • Echocardiography: moderate aortic AS, mild to moderate AR, large aortic vegetation seen

  • Blood culture: gram positive cocci

  • WBC 11.3

  • Hb10.5

  • Na 134

  • K 4.6

  • Cl 100

  • CRP 120

  • ESR 64


Infective endocarditis

Infective Endocarditis


Infective endocarditis definition

Infective Endocarditis:Definition

A microbial infection of the endocardial

lining of the heart or heart valve, usually

associated with an underlying cardiac

defect.


Infective endocarditis aetiology

Infective Endocarditis:Aetiology

  • Bacteria

    • Staphylococcus aureus

    • Streptococcus viridans

    • Staphylococcus epidermidis

    • Diphtheroids

    • Streptococcus microaerophilic

  • Fungi

    • Candida

    • Aspergillus

    • Histoplasma

  • Others

    • SLE

    • Malignancies


Infective endocarditis risk factors

Infective Endocarditis:Risk factors

  • Age

  • Gender

  • Congenital heart defects

  • Cardiac surgery

  • Organ transplant

  • Post-op

  • Pervious endocarditis

  • Presence of prosthetic valves

  • IV drug abuse

  • Valvular dysfunction

  • Poor dental hygiene


Infective endocarditis classification

Infective EndocarditisClassification

  • Acute

  • Subacute

    Disease process for both are similar

    • Bacteraemia

    • Adherence of organisms

    • Invasive of valve leaflets


Infective endocarditis pathophysiology

Infective Endocarditis:Pathophysiology

  • Valves affected:

    Mitral > aortic > (mitral + aortic) > Pulmonary > Tricuspid

  • Mechanical and bioprosthetic valves

    - Equal rates of infection


Infective endocarditis clinical manifestations

Infective Endocarditis:Clinical manifestations

  • Fever

  • Heart murmur

  • Non-specific symptoms (weakness, arthralgias, weight loss, night sweats)

  • Petechiae

  • Osler’s nodes

  • Janeway lesions

  • Splinter haemorrhages

  • Roth spots

  • Finger clubbing

  • Splenomegaly


Infective endocarditis diagnosis duke classification

Infective Endocarditis:Diagnosis – Duke Classification

  • Major criteria

    1. Positive blood culture

    - Typical organism from 2 cultures – Streptococcus Viridans,

    Streptococcus bovis, HACEK, S. aureus, Enterococci

    OR

    - Persistently positive blood culture

    OR

    - Single positive culture for Coxiellaburnetti


Infective endocarditis diagnosis duke classification1

Infective Endocarditis:Diagnosis – Duke Classification

2. Evidence of endocardial involvement with positive

echocardiogram

- Oscillating intracardiac mass

OR

- Abscess

OR

- New valve regurgitation


Infective endocarditis diagnosis duke classification2

Infective Endocarditis:Diagnosis – Duke Classification

  • Minor criteria

    • Predisposing heart condition

    • Fever > 38˚C

    • Vascular: emboli, Janeway lesions

    • Microbiology: positive blood culture but not meeting major

    • Immunological: Osler’s nodes, Roth spots, glomerulonephritis


Infective endocarditis diagnosis duke classification3

Infective Endocarditis:Diagnosis – Duke Classification

  • Definite IE:

    - 2 major

    - 1 major + 3 minor

    - 5 minor

  • Possible IE:

    - 1 major + 1 minor

    - 3 minor


Infective endocarditis management

Infective Endocarditis:Management

  • Specialisedhospitalisation

  • Parenteral antibiotics:

    • Prosthetic valves

      Vancomycin, Gentamycin, Rifampicin

    • Native valves

      Vancomycin, Gentamycin, Ciprofloxacin

  • Normally 2-6 weeks


Infective endocarditis specific treatments for staphylococcal ie

Infective Endocarditis:Specific treatments for Staphylococcal IE

  • 4 weeks IV therapy for native valve endocarditis (NVE), or 6 weeks for prosthetic valve endocarditis (PVE)

  • NVE:

    Non-MRSA – Flucloxacillin

    MRSA – Vancomycin + Rifampicin

  • PVE:

    Non-MRSA – Flucloxacillin, Rifampicin + Gentamycin

    MRSA – Vancomycin, Rifampicin + Gentamycin


Infective endocarditis specific treatments for streptococcal ie

Infective Endocarditis:Specific treatments for Streptococcal IE

  • Standard:

    Ceftriaxone + Gentamycin

  • Penicillin allergy:

    Vancomycin + Gentamycin


Thank you

Thank you


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