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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 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

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