2. Case History 35 yr old female KHAIRUNNISA was admitted thru ER on 19oct 2010 with; Fever 6 months Generalized weakness According to patient; she was in her usual state of health 6 months back that she started having low grade, on and off fever; associated with generalized weakness that patient’s routine activities were disturbed. For that she visited many general practitioners but got no ultimate relief. Besides that, from last 1 week she started having high grade fever that was associated with rigors, chills, headache and nausea. There is no h/o of joint pain, sore throat, palpitation, sweating, shortness of breath, skin rash, dysuria, hematuria, diarrhea and vomiting.
3. Case History PM Hx: Not significant PS Hx: Not significant Personal Hx: Appetite---Good Bowel Habits---Regular Micturition ---- Normal Thirst---- Normal Weight loss--- No Family Hx: No history of T.B, D.M, HTN, Asthma Parents: Healthy Siblings: Healthy 4 Children: Healthy Socio-economic Hx: Fair
4. Physical examination 35 year old female of average height& built, lying comfortably on bed; oriented to time place and person Pulse: 98/min B.P: 130/80 Resp: 16/min Temp:103F Gen: Anxious and worried, Anemia+ve, Jaundice –ve, Dehydration –ve, Cyanosis –ve, Clubbing –ve, osler nodes -ve, splintterhemmorhage-ve, janeway lesion -ve . Neck: No JVD or hepatojugular reflux & no lymph nodes palpable Cardiovascular: S1 and S2 audible, murmurs audible Pulmonary: B/L NVB, No wheeze, crepts Abd: Soft, non tender, hepato-spleenomegaly
5. Physical examination CNS: GCS 15/15 and neck stiffness-ve, other signs of meningeal irritation -ve At time of presentation CNS was fully intact; unfortunately on 3rd day of admission here in hospital she developed left sided weakness with dysarthria Bulk --- B/L Normal Power ---1/5 Lt side & 5/5 Rt side Tone ---Dec Lt side Reflexs--- Diminished Lt side Plantars--- Rt ↓ ----- Lt- ↑
11. Definition Infective Endocarditis (IE): A bacterial or fungal infection of the valvular or endocardial surface of heart Microbial infection of the endothelial lining of the heart
12. Classification Classified into four groups: Native Valve IE Prosthetic Valve IE Intravenous drug abuse (IVDA) IE Nosocomial IE
13. Further Classification Acute Affects normal heart valves Rapidly destructive Metastatic foci Commonly Staph. If not treated, usually fatal within 6 weeks Subacute Often affects damaged heart valves Indolent nature If not treated, usually fatal by one year
14. Pathophysiology Turbulent blood flow disrupts the endocardium making it “sticky” Bacteremia delivers the organisms to the endocardial surface Adherence of the organisms to the endocardial surface Eventual invasion of the valvular leaflets
15. Epidemiology Incidence difficult to ascertain and varies according to location, Estimated incidence: 1.6 to 6.0 / 100,000 person-per year. Much more common in males than in females, Male:female ratio is 1.7:1. May occur in persons of any age and increasingly common in elderly; 50% of cases are over 60yrs of age. Mortality ranges from 20-30%
16. Risk Factors Intravenous drug abuse Artificial heart valves and pacemakers Acquired heart defects Calcific aortic stenosis Mitral valve prolapse with regurgitation Congenital heart defects Intravascular catheters
17. Infecting Organisms Common bacteria S. aureus Streptococci Enterococci Not so common Fungi Pseudomonas HACEK
18. Symptoms Acute High grade fever and chills SOB Arthralgias/ myalgias Abdominal pain Pleuritic chest pain Back pain Subacute Low grade fever Anorexia Weight loss Fatigue Arthralgias/ myalgias Abdominal pain
19. Signs Fever Heart murmur Nonspecific signs – petechiae, subungal or “splinter” hemorrhages, clubbing, splenomegaly, neurologic changes More specific signs - Osler’s Nodes, Janeway lesions, and Roth Spots
21. Splinter Hemorrhages Nonspecific Nonblanching Linear reddish-brown lesions found under the nail bed Usually do NOT extend the entire length of the nail
28. Immunologic originMore specific Painful and erythematous nodules Located on pulp of fingers and toes More common in subacute IE
29. Janeway Lesions More specific Erythematous, blanching macules Nonpainful Located on palms and soles Septic emboli
30.
31. Lab findings Serology Rheumatoid factor (40-50%) Circulating immune complexes Antinuclear antibodies Complement Blood culture Most important lab test Positive cultures in 97% of cases
32. Imaging Chest x-ray Look for multiple focal infiltrates and calcification of heart valves EKG Rarely diagnostic Look for evidence of ischemia, conduction delay, and arrhythmias Echocardiography
33. Indications for Echocardiography Transthoracic echocardiography (TTE) First line if suspected IE Native valves is rapid, noninvasive specificity: 98% sensitivity: <60% Transesophageal echocardiography (TEE) Prosthetic valves Intracardiac complications higher ultrasonic frequencies, improve spatial resolution specificity: 94% (prosthetic valve: 88-100%) sensitivity: 76-100% (prosthetic valve: 86-94%)
34. Making the Diagnosis Pelletier and Petersdorf criteria (1977) Classification scheme of definite, probable, and possible IE Reasonably specific but lacked sensitivity Von Reyn criteria (1981) Added “rejected” as a category Added more clinical criteria Improved specificity and clinical utility Duke criteria (1994) Included the role of echocardiography in diagnosis Added IVDA as a “predisposing heart condition”
37. Modified Duke Criteria Definite IE Microorganism (via culture or histology) in a valvular vegetation, embolized vegetation, or intracardiac abscess Histologic evidence of vegetation or intracardiac abscess Possible IE 2 major 1 major and 3 minor 5 minor Rejected IE Resolution of illness with four days or less of antibiotics
60. Embolic Complications Occur in up to 40% of patients with IE Predictors of embolization Size of vegetation Left-sided vegetations Fungal pathogens, S. aureus, and Strep. Bovis Incidence decreases significantly after initiation of effective antibiotics
61. Embolic Complications Stroke Myocardial Infarction Fragments of valvular vegetation or vegetation-induced stenosis of coronary ostia Ischemic limbs Hypoxia from pulmonary emboli Abdominal pain (splenic or renal infarction)
64. Local Spread of Infection Heart failure Extensive valvular damage Paravalvular abscess (30-40%) Most common in aortic valve, IVDA, and S. aureus May extend into adjacent conduction tissue causing arrythmias Higher rates of embolization and mortality Pericarditis Fistulous intracardiac connections
65. Local Spread of Infection Acute S. aureus IE with perforation of the aortic valve and aortic valve vegetations. Acute S. aureus IE with mitral valve ring abscess extending into myocardium.
67. Summary IVDA and the elderly are at greatest risk of developing IE. The signs and symptoms of IE are nonspecific and varied. A thorough but timely evaluation (including serial blood cultures, adjunct labs, and an echo) is crucial to accurately diagnose and treat IE. Beware of life-threatening complications.
