This document describes four cases of infective endocarditis. The first case involves a 57-year-old man admitted to the hospital with symptoms including fatigue, fever, night sweats, and weight loss. He has a history of mitral valve prolapse and recent dental work. Physical exam reveals fever, rashes, and murmurs. Blood tests show anemia and elevated inflammatory markers. Cultures grow streptococci. The second case involves a 65-year-old man with a history of heart valve replacement who presents with fever, chills, and weight loss. Staphylococci are suspected as the cause due to their prevalence in early prosthetic valve infections. The third case describes

1. Infective
Endocarditis Cases
Dr. Sameh Ahmad Muhamad abdelghany
Lecturer Of Clinical Pharmacology
Mansura Faculty of medicine

2. Infective
Endocarditis

3. CAS(1)

4. Present History
4
A.G., a 57-year-old, 60-kg man with chief complaints
of fatigue, a persistent low-grade fever, night sweats,
arthralgias, and a 7-kg weight loss, is admitted to the
hospital for evaluation. Visual inspection reveals a
cachectic, ill-appearing man in no acute distress.

5. PAST HISTORY
5
A.G.’s medical history is significant for mitral valve
prolapse and, more recently, a dental procedure involving
the extraction of four wisdom teeth. The history of his
present illness is noteworthy for the development of
symptoms 2 weeks after the dental procedure (about 2
months before admission).

6. PHYSICAL EXAMINATION
6
a temperature of 38.0◦C
Petechial skin lesions, subungual splinter
hemorrhages, and Janeway lesions on the soles of
both feet.
 Roth spots,or Osler’s nodes are not evident.

7. PHYSICAL EXAMINATION
7

8. PHYSICAL EXAMINATION
8
Cardiac examination is significant for a grade III/IV
diastolic murmur with mitral regurgitation
(insufficiency) increased from pre-existing murmur
The remainder of his physical examination is
unremarkable.

9. LABORATORY
9
 Hemoglobin (Hgb), 11.4 g/dL
White blood cell (WBC) count, 85,000/μL with 65%
polys
The erythrocyte sedimentation rate (ESR) is elevated at
66 mm/hour, and the rheumatoid factor (RF) is positive.

10. LABORATORY
10
 Results from a transthoracic echocardiogram were
unrevealing.
Three blood cultures were obtained during 24 hours,and
all cultures obtained on day 1 are growing α -hemolytic
streptococci. Antimicrobial susceptibility results are
pending.

11. 11
 While confirmation and speciation of the organism is
being performed, A.G. is started on penicillin G, 2
million units IV every 4 hours (12 million units/day),
and gentamicin, 120 mg (loading dose) followed by 60
mg every 12 hours.

12. Questions
12
Q1. What clinical manifestations and laboratory
abnormalities in A.G. are consistent with IE?
Q2: How was the diagnosis of IE established in
A.G.?
Q3: Which regimen should be used for A.G.?

13. Answer of Question 1
13
 Fever, most common symptom (but may be absent)
 weight-loss, malaise, night sweats, arthralgias(non specific)
 Increased heart murmurs
 Petechial skin lesions, subungual splinter hemorrhages, and
Janeway lesions on the soles of both feet.
 Three blood cultures were obtained during 24 hours,and all
cultures obtained on day 1 are growing α -hemolytic streptococci
 Anemia , leukocytosis, increased ESR and positive Rheumatoid
factor (non specific)
Back

14. Answer of Question 2
14
 A.G. possesses one major criterion (positive blood
cultures) and three minor criteria (fever, predisposing
heart condition, vascular and immunologic phenomena)
So meats DUKE’s criteria
Back

15. Answer of Question 3
15
As culture reveals Viridans Streptococci so
 Benzyl penicillin (1.2g 4 hourly) 4-6 weeks alone
 OR Benzyl penicillin (1.2g 4 hourly) 4-6 weeks combined
with Gentamicin (1mg/kg 8-12 hourly) 4-6 weeks
Back

16. CAS(2)

17. Scenario
17
 F.T., a 65-year-old man, presents with chief complaints
of anorexia, fever, chills, and weight loss. His medical
history is significant for replacement of his mitral and
aortic heart valves (both porcine) 1 year ago for aortic
stenosis, mitral regurgitation, and mitral stenosis
secondary to rheumatic heart disease.

18. Scenario
18
 One month later he was readmitted with fever, a right
pleural effusion, a pericardial friction rub, and pericarditis.
The impression at that time was either postpericardiotomy
or Dressler syndrome. F.T. was sent home on anti-
inflammatory agents but failed to improve. After
continued complaints of anorexia, nausea, chills, and
fever to 38.3◦C, he returned to the hospital.

19. Scenario
19
 On readmission, his physical examination was
noteworthy for a systolic ejection murmur at the left
sternal border and 3+ pedal edema. Blood cultures were
obtained, and routine laboratory studies were performed.
His history and clinical presentation were strongly
suggestive of prosthetic valve endocarditis (PVE).

20. Questions
20
Q1. What are the most likely organisms responsible
for PVE in F.T.?
Q2: What measures can be taken to prevent early
PVE?
Q3: What are the treatment options for F.T.?

21. Answer of Question 1
21
 The most common organisms cultured from patients such
as F.T. with early PVE are coagulase-negative
staphylococci (primarily S. epidermidis ), followed by S.
aureus, and gram-negative bacilli.
Back

22. Answer of Question 2
22
 Following are the antibiotic regimens recommended by the American Heart
Association for antibiotic prophylaxis:
 Oral Amoxicillin 1 hour before the procedure
 Intravenous or intramuscular ampicillin 1 hour before the procedure
 In patients allergic to penicillins:
o Azithromycin or clarithromycin orally 1 hour before the procedure
o Cephalexin orally 1 hour before the procedure
o Clindamycin orally 1 hour before the procedure
Back

23. Answer of Question 3
23
As organism suggested for Prosthetic valve is
coagulase staph. epidermidis then staph. aureus so
use
Flucloxacillin + aminoglycoside + rifampicin OR
Vancomycin + aminoglycoside + rifampicin
 Back

24. CAS(3)

25. Scenario
25
 T.J., a 36-year-old human immunodeficiency virus
(HIV)-seropositive man with a long history of IV drug
abuse, was admitted to the hospital 4 months after being
released from the state prison. His chief complaints
included fever, night sweats, pleuritic chest pain,
shortness of breath, dyspnea on exertion, and fatigue.

26. Scenario
26
 Physical examination was remarkable for a temperature
of 38.5◦C, splenomegaly, and a pansystolic ejection
murmur at the left sternal border, best heard during
inspiration. The chest radiograph revealed diffuse nodular
infiltrates. TTE(Transthoracic Echo) was positive for a
small vegetation on the tricuspid valve leaflet.

27. Scenario
27
 Significant laboratory results included the following:
 WBC count, 14,000/μL with 65% polys
 Hgb, 13.1 g/dL
 ESR, 55 mm/hour
 IE was suspected. Blood cultures were obtained, and all six samples
were positive for coagulase-positive, gram-positive cocci, later
identified as methicillin-sensitive S. aureus (MSSA).

28. Questions
28
Q1. What clinical manifestations and laboratory
abnormalities in A.G. are consistent with IE?
Q2: What are the therapeutic options for treating S.
aureus endocarditis in T.J.?
Q3: How would T.J.’s therapy differ if he were
infected with MRSA?

29. Answer of Question 1
29
 fever, night sweats, and fatigue.
 splenomegaly, and a pansystolic ejection murmur
 TTE was positive for a small vegetation on the tricuspid
valve leaflet
 Leukocytosis, elevated ESR, 55 mm/hour
 Blood cultures were positive for coagulase-positive, gram-
positive cocci, later identified as methicillin-sensitive S.
aureus (MSSA).
Back

30. Answer of Question 2
30
 Penicillin resistant but methicillin sensitive treated by
Flucloxacillin I.V (2g 4 hourly )
Back

31. Answer of Question 3
31
 If Both penicillin and methicillin resistant give:
Vancomycin I.V (1g 12 hourly) and Gentamicin
Back

32. CAS(4)

33. Case
33
 B.B., a 74-year-old man with poor dentition, is
scheduled to have all of his remaining teeth
extracted for subsequent fitting of dentures. His
medical history is significant for numerous
infections of the oral cavity and prosthetic valve
replacement 2 years ago.

34. Questions
34
Q1. What is the rationale for antibiotic
prophylaxis?
Q2: Is prophylactic antibiotic therapy indicated
for B.B.? If so, which antibiotic(s) should be
used?

35. Answer of Question 1
35
Following are the antibiotic regimens recommended by the American
Heart Association for antibiotic prophylaxis:
 Oral Amoxicillin 1 hour before the procedure
 Intravenous or intramuscular ampicillin 1 hour before the procedure
 In patients allergic to penicillins:
 Azithromycin or clarithromycin orally 1 hour before the procedure
 Cephalexin orally 1 hour before the procedure
 Clindamycin orally 1 hour before the procedure
Back

36. Answer of Question 2
36
 Based on the current recommendations, B.B. is a
candidate for antibiotic prophylaxis.
 Presence of a prosthetic aortic valve while undergoing
multiple tooth extractions places him at risk for
experiencing endocarditis.
Back

37. T H A N K Y O U !
A N Y Q U E S T I O N S ?