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Infective endocarditis

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  • 1. Infective Endocarditis in Children: an overview Dr.B.BALAGOBI
  • 2. Points to ponder...• IE is infection of the cardiac tissue/related structures - valves• Is a complication of congenital and acquired heart disease → can change the outcome of the heart disease• Lesion associated with a high velocity jet of blood or an intra cardiac prosthesis• Predisposing factors - dental or surgical procedure, following cardiac surgery• Relatively rare in children• Pre-antibiotic era: mortality was nearly 100%
  • 3. Infective Endocarditis• Febrile illness• Persistent bacteremia• Characteristic lesion of microbial infection of the endothelial surface of the heart The vegetation – Variable in size – Amorphous mass of fibrin & platelets – Abundant organisms – Few inflammatory cells
  • 4. Distinction between Acute and Subacute Bacterial Endocarditis Feature Acute SubacuteUnderlying Heart Heart may be normal RHD,CHD, etc.DiseaseOrganism S. aureus, Pneumococcus viridans S. pyogenes, Streptococci, Enterococcus EntercoccusTherapy Prompt, vigorous and initiated Can often be delayed on empirical ground until culture reports and susceptibilities available
  • 5. Prevention – the underlying lesion• High risk lesions • Intermediate risk – Prosthetic valves – MVP with murmur – Prior IE – Pure MS – Cyanotic congenital heart disease – Tricuspid disease – PDA – Pulmonary stenosis – AR, AS, MR,MS with MR – ASH – VSD – Bicuspid Ao valve with no – Coarctation hemodynamic significance – Surgical systemic-pulmonary shunts Lesions at highest risk
  • 6. Prevention – the underlying lesion • Low/no risk – MVP without murmur – Trivial valvular regurg. – Isolated ASD – Implanted device (pacer, ICD) – CAD – CABG
  • 7. Culprits...• Viridans group of streptococci (α haemolyti strep) - flora of mouth• Enterococci - gastrointestinal tract• Staphylococcus aureus• Fungi
  • 8. Pathophysiology• Embolization • Clinically evident 11 – 43% of patients • Pathologically present 45 – 65% • High risk for embolization » Large > 10 mm vegetation » Hypermobile vegetation » Mitral vegetations (esp. anterior leaflet) • Pulmonary (septic) – 65 – 75% of i.v. drug abusers with tricuspid IE
  • 9. When to suspect…?• Congenital/acquired • Murmur - failure, heart lesion changing murmurs• Continued fever • Splenomegaly• Anorexia, weight loss, • Embolic phenomena malaise to lungs/kidneys/brain• Pallor - demonstrate a limbs (rare since use drop in Hb% of antibiotics)• Clubbing, petechiae • Urine - microscopic• Splinter haematuria (immune haemorrhages etc - complex) not usually found
  • 10. The echocardiogram in IE
  • 11. Splinter Hemorrhage
  • 12. Roth’s Spots
  • 13. Sequelae• Neurologic manifestations, 20% – Cerebral emboli, mycotic aneurysms, cerebritis, brain abscess, hemorrhage, etc.• Peripheral embolization – Ischemia, infarction, mycotic aneurysms, etc• Pulmonary infarction• Renal insufficiency• Congestive heart failure
  • 14. Prophylaxis...• Any procedure likely to cause bacteriaemia • Dental procedures - • dental treatment Amoxycillin/Erythromycin • abdominal surgery • GU/GI procedures, • surgery or previous endocarditis, instrumentation of intracardiac prostheses - upper respiratory or Ampicillin and Gentamicin genitourinary tract • Vancomycin and Gentamicin following burns • IV alimentation
  • 15. T/F Infective endocarditis?A. Diagnosis is based on Duckett Jone’s criteriaB. ASD is a common causeC. Cause firm splenomegalyD. Associated with Streptococcus Viridans infectionE. Vegetations are sterileF. Never cause embolisation
  • 16. T/F features of Infective endocarditis?A. ClubbingB. HaematuriaC. FeverD. ArthralgiaE. Chorea
  • 17. T/F Regarding Infective endocarditis?A. Normal WBC count exclude the diagnosisB. 2D echocardiography is not useful in diagnosisC. Blood for culture is taken at the peak of the feverD. Macroscopic haematuria is commonE. Clubbing is an early feature.
  • 18. T/F Diastolic murmur in 7 year old?A. Mitral stenosisB. AnaemiaC. Infective endocarditisD. Tetralogy of fallotE. Acute Rheumatic carditis
  • 19. T/F Infective endocarditis in children?A. Is often caused by Streptococcal pneumoniaB. Is seen in child with PDAC. Cause haematuriaD. Cause clubbing during first week of the illnessE. IV antibiotics is given for 2 weeks