Infective endocarditis. Infections in cardiology. Guidelines jerri points.

1. Defferentiation between Rheumatic
fever and Endocarditis
Shirjeel

2. • A young girl was admitted in A & E
department with high grade fever for 4 days
and joint pains. She had a soft diastolic
murmur at the apex.

3. • A known patient having mitral regurgitation
presented to A & E after having sore throat
follwed by breathlessness for 5 days and high
grade fever for 6 days

4. Some Random DIFFERENCES
RHEUMATIC FEVER INFECTIVE ENDOCARDITIS
AGE 5-15 for ARF ; 25-40 RHD Any AGE
INCIDENCE 100 / lac 5-15/ lac / year
CAUSE Immune Mediated Infectious (24 % e RHD )
INVOLVEMENT Endo , Myo , Peri carditis Endocarditis
PROPHYLAXIS YES NO ( NICE ); YES ( AHA)
JOINTS Arthritis 75 % Arthralgia 30 %
HISTOLOGY Aschoff Nodules Active inflammation
SKIN LESION TIME EM 3 weeks afterwards With SBE
NEUROLOGICAL Chorea 3 months afterward ICH ( Mycotic Aneurysms)

5. Rheumatic Fever and Rheumatic heart
disease

6. 2002-2003 WHO Criteria for Diagnosis
of RHEUMATIC FEVER AND RHD
DIAGNOSIS REQUIREMENT
Primary Episode of Rheumatic Fever
2M
1M + 2m
EVIDENCE of preceeding
GROUP A streptococcal
infection
Recurrent RF without RHD
2M
1M + 2m
3m (2015 revised)
Recurrent RF with RHD ( Infective
Endocarditis ruled out )
2m
Rheumatic Chorea
Insiduos onset of Rheumatic Carditis ( rule
out Infective Endocarditis )
Not Required Not required
RHD ( presenting 1st time with MS; MS/MR ±
Aortic disease ) ( rule out congential Heart
Disease )
Not Required Not required

7. ORIGINAL ( JONES ) 1992
MAJOR CRITERIA
Carditis
Poly Arthritits
Chorea
Subcutaneous Nodules
Erythema Marginatum
MINOR CRITERA
CLINICAL: Fever , Poly arthralgia
LAB: ESR , TLC
ECG: Prolonged PR Interval
EVIDENCE : streptococal infection within last 45 days
ASO titre ( >200 u adults ; >300 u children );
Antibodies ( anti DNAse ) ;
Throat swab Culture ;
Rapid antigen test ;
Scarlet Fever ( 2002 WHO ) not in 2015

8. WHF Criteria for ECHO diagnosis of RHD in < 20 y age
Definite RHD
Either of
• Pathological MR + 2 features of
RHD of MV
• Pathological AR + 2 features of
RHD of AV
• MS mean gradient > 4 mmHg
• Borderline disease of both MV
and AV
• Pathological AR + 2 features of
RHD of MV ( for adults >20 )
Borderline RHD
Either of
• 2 features of RHD of MV w/o MR/
AR
• Pathological MR
• Pathological AR

9. WHF Criteria for ECHO diagnosis of RHD in < 20 y age
NORMAL
• MR ( not pathological )
• AR ( not pathological )
• 1 feature of RHD of MV w/o MS/MR
• 1 feature of RHD of AV w/o AS/AR

10. Pathological MR
1. Pansystolic jet
2. Visible at 2 views
3. Jet > 2 cm
4. Velocity > 3 m/s
Pathological AR
1. Pandiastolic jet
2. Visible at 2 views
3. Jet > 1 cm
4. Velocity > 3 m/s
WHF Criteria for ECHO diagnosis of RHD in < 20 y age

11. MV features of RHD
• Anterior leaflet thickening >3mm
• Chordal thickening
• Restricted leaflet motion
• Excessive tip motion during systole
AV features of RHD
• Focal thickening
• Coaptation defect
• Restrited motion
• Prolapse
WHF Criteria for ECHO diagnosis of RHD in < 20 y age

12. WHF Criteria for ECHO diagnosis of RHD in < 20 y age
Definite RHD
Either of
• Pathological MR + 2 features of
RHD of MV
• Pathological AR + 2 features of
RHD of AV
• MS mean gradient > 4 mmHg
• Borderline disease of both MV
and AV
• Pathological AR + 2 features of
RHD of MV ( for adults >20 )
Borderline RHD
Either of
• 2 features of RHD of MV w/o MR/
AR
• Pathological MR
• Pathological AR

13. Diagnosis of Infective Endocarditis
Modified Duke Criteria
DEFINITE ENDOCARDITIS
• PATHOLOGICAL CRITERIA OR
• CLINICAL CRITERIA
• 2 M
• 1 M + 3m
• 5 m
POSSIBLE ENDOCARDITIS
• 1M + 1m
• 3m
REJCETED
• Alterante diagnosis
• Sustained resolution of symptoms
after < 4 days of antibiotics
• No evidence on autopsy after < 4 days
antibiotics

14. Diagnosis of Infective Endocarditis
Modified Duke Criteria
• Microrganism in
– Culture or Hstology of
• Vegetation
• Embolic vegetation
• Abcess
• Demonstration of Pathologic Lesion
– Vegetation or abcess
• Confirmed by histology showing active inflammation
PATHOLOGICAL CRITERIA

15. Diagnosis of Infective Endocarditis
Modified Duke Criteria
• MAJOR CRITERIA
1. Positive blood culture
• Typical organism from 2 separate cultures in the absence of primary focus
• Persistant +ve blood cultures
• 2 cultures taken > 12 hours apart
• 3 or more +ve cultures taken over > 1 hour
• Single +ve culture of Coxeilla burnetti or antibody titre > 1 : 800
2. Endocardial involvment
• Positive echocardiographic findings of vegetations
• Oscillating mass ( no anatomical explanation )
• Abscess
• New partial dehiecnece of PV
• New valvular regurgitation
• ESC guidelines include CT, FDG/PET aslo
CLINICAL CRITERIA
• Its recommended to
take ..
..
..
2 hourly
• If negative for 48-72
hours, take 2 or 3
additional sets;
consult the lab
• If patient is stable
then antibiotic can be
withheld
• In acute cases start
treatment after 3 sets
of cultures

16. • MINOR CRITERIA
1. Predisposition
• IV drug abuse
• Heart condition except ASD ; repaired VSD ; repaired PDA
2. Fever > 38 0C ( 100.4 0F )
3. Vascular Phenomena
• Emboli
• Infarcts
• Aneurysms
• ICH
• Conjuntival hemorrhages
• Janeway lesions
4. Imunologic Phenomena
• GN
• Roth spots
• Osler nodes
• Rheumatoid Factor
5. Microbiological
• Culture +ve ( not fullfilling major criteria; except staph epidermidis and those
which do not cause endocarditis )
• Serological evidence of typical microbes