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CASE PRESENTATION

. 47 YR old female ptCRF for the last 4 yrs on regular HDNo DM , HTN NO previous heart disease. . C/O ; fever for the last 3 w. chills

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CASE PRESENTATION

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    1. CASE PRESENTATION

    2. 47 YR old female pt CRF for the last 4 yrs on regular HD No DM , HTN NO previous heart disease

    3. C/O ; fever for the last 3 w. chills & rigors poor appetite , wt loss , fatigue upper abdominal pain lt ankle pain & swelling

    4. ROS ; no cough , no sputum , no chest ...pain no vomiting , no diarrhea no urinary symp. no skin rash

    5. PMH ; cholecystictomy Drug H. ; oscal , neurobion , lanzoprazol motilium

    6. PE BP 110/70 , PR 100 bpm , Tem 38 H&N ; pale , no LN enlargement Chest ; clear Heart ; reg. s1 s2 , ESM & EDM at LSB , LSM at apex Abd. ; LUQ tenderness Extrem. ; lt ankle swelling , no skin leasions

    7. CXR ; slight cardiomegally EKG ; s.tachycardia Lab ; Hb 9.3 , WBC 12.9 , PLT 341 CR 5.6 , Na 129 , K 4.0 , RBS 135 CRP 341 ,ESR 120 LFT ; normal urine ; +1 protein , +2 blood , 10-12 WBC , 20-24 RBC

    8. U/S abd. ; normal TTE ; +2 MR , +2 AI , mild AS with PG 25 EF 65 % , NO vegitations TEE ; vegitation over the rt coronary cusp of the AV Blood C&S ; enterococcus sensitive to ampicillin & vancomycine

    9. Rx ; ampicillin 2 gm I.V BID & gentamicin 120 mg after each dialysis

    10. Next day ; she developed p.edemaintubated & put on mechanical ventilator for ~ 24 hr. After extubation , she continued to c/o abdominal pain & LUQ tenderness . CT abdomen , large hypodense splenic lesion . She is planned for splenectomy today.

    11. Infective Endocarditis Vegetation is the characteristic lesion ( a mass of plt & fibrin in which abundant microorganisms & inflammatory cells are engorged ) Valves are most commonly involved , however , infection may occur at sites of septal defect, on chordae tendineae , mural endocardium ,PDA , coarctation of aorta

    12. DIAGNOSIS BUGS + ECHO + CLINICAL = IE Duke criteria ; 2 major ( or ) 5 minors ( or ) 1 major + 3 minors

    13. Major criteria ; 1) Echo ; new vegetation , new valve regurg. , abscess , new partial dehiscence of prosthetic valve 2) Bugs ; positive blood culture ( X 2) for typical organisms viridans , bovis , s.aureus , enterococcus , HACEK

    14. Minor criteria ; 1) predisposing heart condition or IV drug user 2) fever > 38 3) embolic phenomena 4) immunological phenomena 5) lesser echo or clinical data

    15. Embolic phenomena ; 1) major arterial emboli 2) septic pulmonary or splenic emboli 3) mycotic aneurism ( cerebral ) 4) janeway lesions (small nontender macular lesions on the palms & soles ) 5) subungual ( splinter ) hemorrhages

    16. Immunological phenomena ; 1) GN 2) arthritis 3) oslers nodes ( painful nodular lesions in the pulp of the digits ) 4) roths spots ( retinal hemorrhage ) 5) RF

    17. Mortality 4-16 % viridans strep 15-25 % enterococcus 25- 47 % s.aureus 50 % p.auroginosa & enterobacteriaceae

    18. BLOOD CULTURE 3 blood cultures in 1st 24 hr If bacteremia is present positive blood culture in 90 % after 2 sets HACEK 4 w to grow Serology for Q fever , brucella ,legionella

    19. Culture negative endocarditis ; < 5 % of cases of IE recent antibiotics fastidious bugs ( HACEK ) fungal endocarditis intracellular parasite ( chlamydia , brucella )

    20. Strep viridans pen./ceftriaxone/vanco + gentamicin Enterococci ampicillin + gentamicin S.aureus vanco + genta

    21. Rule of surgery Definite indication ; 1) acute valvular dysfunction with hemodynamic instability 2) intractable CHF 3) persistent infection ( antibiotic-resistant 4) myocardial invasion

    22. Other indications ; 1) recurrent endocarditis 2) recurrent embolization 3) abscess formation 4) fungal endocarditis 5) prosthetic valve endocarditis

    23. Splenic abscess 5 % of pts with IE Most commonly with s.aureus , strep , gram negatives U/S & CT cannot discriminate between abscess & infarct Percutaneous needle aspiration confirm dx Rx; percut. drainage , if unsuccessful or multiple abscesses splenictomy It should be treated before valve replacement to avoid recurrence of the infection in the prosthetic valve

    24. Prophylaxis for endocarditis Cardiac lesion + risk of bacteremia Cardiac lesions ; high risk ; 1) prosthetic valves (mechan./biopros.) 2) previous IE 3) complex cyanotic CHD 4) surgical systemic- pulmonary shunt

    25. Intermediate risk lesions ; 1)HCM 2) non-cyanotic CHD 3) VHD 4) ASD 5) MVP + regurgitation or valve thickening

    26. Negligible risk condition ; 1) secundum ASD 2) beyond 6 months of VSD or PDA repair 3) MVP without regurg. or valve thickening 4) CABG 5) ICD / PM

    27. Procedures requiring IE prophylaxis Almost all dental procedures Esophageal dilatation Sclerotherapy of esophageal varices ERCP Rigid bronchoscopy Prostate or bladder surgery Cystoscopy , urethral dilatation Tonsillectomy / adenoidectomy GB surgery

    28. Optional prophylaxis High risk pts ( prosthetic valve , previous IE,) 1) endoscopy 2) TEE 3) Delivery ( vaginal or C/S )

    29. Prosthetic valve endocarditis 10 % of prosthetic valves will develop endocarditis Mechanical = bioprosthesis Mitral = aortic Early < 60 days s.epidermidis Late > 60 daysusual bacteria

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