Infective Endocarditis Faculty of Medicine University of Brawijaya Malang

Infective EndocarditisInfective Endocarditis

Faculty of Medicine Faculty of Medicine

University of BrawijayaUniversity of Brawijaya

MalangMalang

INTRODUCTIONINTRODUCTION

The term ‘bacterial endocarditis’ has been The term ‘bacterial endocarditis’ has been replaced by ‘Infective endocarditis’ (IE) since fungi replaced by ‘Infective endocarditis’ (IE) since fungi are also involved as causative pathogens are also involved as causative pathogens

IE is an uncommon but lifethreatening infection.IE is an uncommon but lifethreatening infection.

If the diagnosis is delayed or appropriate If the diagnosis is delayed or appropriate therapeutic measures postpone, mortality is still therapeutic measures postpone, mortality is still highhigh

JADA, Vol. 138, 2007JADA, Vol. 138, 2007European Heart Journal (2004) 00, 1-37European Heart Journal (2004) 00, 1-37

Guidelines AHA, Circulation. 2007;115:&NA;-.Guidelines AHA, Circulation. 2007;115:&NA;-.

If untreated Infective Endocarditis (IE) is a fatal If untreated Infective Endocarditis (IE) is a fatal disease. disease. Major diagnosticMajor diagnostic (first of all (first of all echocardiography) and echocardiography) and therapeutic progresstherapeutic progress (mainly surgery during active IE) have (mainly surgery during active IE) have contributed to some prognostic improvement.contributed to some prognostic improvement.In this respect, it is of utmost importance that:In this respect, it is of utmost importance that:– IE is considered early in every patients with fever or IE is considered early in every patients with fever or

septicaemia and cardiac murmurs.septicaemia and cardiac murmurs.– Echocardiography is applied without delay in Echocardiography is applied without delay in

suspected IE.suspected IE.– Cardiologist, microbiologists and cardiac surgeons Cardiologist, microbiologists and cardiac surgeons

cooperate closely if IE is suspected or definite.cooperate closely if IE is suspected or definite.



Cardiol Clin 21 (2003) 159–166Cardiol Clin 21 (2003) 159–166

Recent data suggest it may be increasing,Recent data suggest it may be increasing,1.1. In industrialized nations, patients are living longerIn industrialized nations, patients are living longer2.2. There is an increase in nosocomial infectionsThere is an increase in nosocomial infections3.3. Intravenous drug use has increased in industrialized Intravenous drug use has increased in industrialized

societiessocieties4.4. Increasing application of cardiac surgery has provided Increasing application of cardiac surgery has provided

new substrates for endocardial infectionnew substrates for endocardial infection5.5. The increased use of indwelling intravascular lines and The increased use of indwelling intravascular lines and

implantable devices implantable devices 6.6. the increased application of echocardiographythe increased application of echocardiography

IE is an IE is an endovascularendovascular, , microbial microbial infectioninfection of of intracardiac intracardiac structures facing structures facing the blood including infections of the large the blood including infections of the large intrathoracic vesseisintrathoracic vesseis and of and of intracardiac intracardiac foreign bodies.foreign bodies.The early characteristic lesion is a variably The early characteristic lesion is a variably sized vegetation, although destruction, sized vegetation, although destruction, ulceration or abscess formation may be ulceration or abscess formation may be seen earlier by echocardiography. seen earlier by echocardiography.

DEFINITIONDEFINITION

DefinitionDefinition

Infectious Endocarditis (IE):Infectious Endocarditis (IE): an infection of an infection of the heart’s endocardial surfacethe heart’s endocardial surface

Classified into Classified into fourfour groups: groups: – Native Valve IENative Valve IE– Prosthetic Valve IEProsthetic Valve IE– Intravenous drug abuse (IVDA) IEIntravenous drug abuse (IVDA) IE– Nosocomial IENosocomial IE

Characterized byCharacterized by inflammation inflammation or or infectioninfection

two major predisposing factors:two major predisposing factors:– susceptible susceptible cardiac cardiac or or vascular vascular substratesubstrate

lesions associated with high-velocity flow, jet impact and lesions associated with high-velocity flow, jet impact and focal increases in the rate of shearfocal increases in the rate of shear

– source of source of bacteremiabacteremia

INFECTIVE ENDOCARDITISINFECTIVE ENDOCARDITIS

Further ClassificationFurther Classification

AcuteAcute– Affects normal heart Affects normal heart

valvesvalves– Rapidly destructiveRapidly destructive– Metastatic fociMetastatic foci– Commonly Staph.Commonly Staph.– If not treated, usually If not treated, usually

fatal within 6 weeksfatal within 6 weeks

SubacuteSubacute– Often affects damaged Often affects damaged

heart valvesheart valves– Indolent natureIndolent nature– If not treated, usually If not treated, usually

fatal by one yearfatal by one year

PathophysiologyPathophysiology

1.1. Turbulent blood flow Turbulent blood flow disrupts the disrupts the endocardium making it “sticky”endocardium making it “sticky”

2.2. Bacteremia Bacteremia delivers the organisms to delivers the organisms to the endocardial surface the endocardial surface

3.3. AdherenceAdherence of the organisms to the of the organisms to the endocardial surfaceendocardial surface

4.4. Eventual invasionEventual invasion of the valvular of the valvular leafletsleaflets

Mandell, Bennett, & Dolin:

Principles and Practice of Infectious Diseases, 6th ed

Proposed scheme for the pathogenesis of infective endocarditis

EpidemiologyEpidemiology

Incidence difficult to ascertain and varies Incidence difficult to ascertain and varies according to locationaccording to location

Much more common in males than in Much more common in males than in femalesfemales

May occur in persons of any age and May occur in persons of any age and increasingly common in elderlyincreasingly common in elderly

Mortality ranges from 20-30%Mortality ranges from 20-30%

Risk FactorsRisk Factors

Intravenous drug abuseIntravenous drug abuse

Artificial heart valves and pacemakers Artificial heart valves and pacemakers

Acquired heart defectsAcquired heart defects– Calcific aortic stenosisCalcific aortic stenosis– Mitral valve prolapse with regurgitationMitral valve prolapse with regurgitation

Congenital heart defectsCongenital heart defects

Intravascular cathetersIntravascular catheters

Infecting OrganismsInfecting Organisms

Common bacteriaCommon bacteria– S. aureusS. aureus– Streptococci Streptococci – EnterococciEnterococci

Not so common bacteriaNot so common bacteria– FungiFungi– PseudomonasPseudomonas– HACEKHACEK

HACEK organismsHACEK organisms

• Hemophilus, Actinobacillus, Hemophilus, Actinobacillus, Cardiobacterium, Eikenella, KingellaCardiobacterium, Eikenella, Kingella

• Gram negative inhabitants of the upper Gram negative inhabitants of the upper airways.airways.

• Large vegetations, high likelihood of Large vegetations, high likelihood of embolization.embolization.

• Slow growing: hold cultures for 3 weeks.Slow growing: hold cultures for 3 weeks.• Traditionally sensitive to beta lactams, now Traditionally sensitive to beta lactams, now

some produce beta lactamase.some produce beta lactamase.

SymptomsSymptoms

AcuteAcute– High grade fever and High grade fever and

chillschills– SOBSOB (shortness of (shortness of

breath)breath)– Arthralgias/ myalgiasArthralgias/ myalgias– Abdominal painAbdominal pain– Pleuritic chest painPleuritic chest pain– Back painBack pain

SubacuteSubacute– Low grade feverLow grade fever– AnorexiaAnorexia– Weight lossWeight loss– FatigueFatigue– Arthralgias/ myalgiasArthralgias/ myalgias– Abdominal painAbdominal pain

The onset of symptoms is usually ~2 weeks or less from the initiating bacteremia

SignsSignsFever Fever

Heart murmurHeart murmur

Nonspecific signs – petechiae, subungal Nonspecific signs – petechiae, subungal or “splinter” hemorrhages, clubbing, or “splinter” hemorrhages, clubbing, splenomegaly, neurologic changessplenomegaly, neurologic changes

More specific signs - Osler’s Nodes, More specific signs - Osler’s Nodes, Janeway lesions, and Roth SpotsJaneway lesions, and Roth Spots

PetechiaePetechiae

Photo credit, Josh Fierer, M.D. medicine.ucsd.edu/clinicalimg/ Eye-Petechiae.html

Harden Library for the Health Scienceswww.lib.uiowa.edu/ hardin/md/cdc/3184.html

1. Nonspecific2. Often located on extremities

or mucous membranesdermatology.about.com/.../ blpetechiaephoto.htm

Splinter HemorrhagesSplinter Hemorrhages

1. Nonspecific2. Nonblanching3. Linear reddish-brown lesions found under the nail bed4. Usually do NOT extend the entire length of the nail

Osler’s NodesOsler’s Nodes

1. More specific2. Painful and erythematous nodules3. Located on pulp of fingers and toes4. More common in subacute IE

American College of Rheumatologywebrheum.bham.ac.uk/.../ default/pages/3b5.htm www.meddean.luc.edu/.../

Hand10/Hand10dx.html

Janeway LesionsJaneway Lesions

1. More specific2. Erythematous, blanching macules 3. Nonpainful4. Located on palms and soles

TheThe EssentialEssential Blood TestBlood Test

Blood CulturesBlood Cultures– Minimum of three blood culturesMinimum of three blood cultures11

– Three separate venipuncture sitesThree separate venipuncture sites– Obtain 10-20mL in adults and 0.5-5mL in childrenObtain 10-20mL in adults and 0.5-5mL in children22

Positive ResultPositive Result– Typical organisms present in at least Typical organisms present in at least 22 separate samples separate samples– Persistently positive blood culture (atypical organisms)Persistently positive blood culture (atypical organisms)

Two positive blood cultures obtained at least 12 hours apartTwo positive blood cultures obtained at least 12 hours apartThree or a more positive blood cultures in which the first and Three or a more positive blood cultures in which the first and last samples were collected at least one hour apartlast samples were collected at least one hour apart

Additional LabsAdditional Labs

CBCCBC (complete blood count) (complete blood count)

ESRESR (erythrocyte sedimentation rate) and (erythrocyte sedimentation rate) and CRPCRP (C reactive protein) (C reactive protein)

Complement levels (C3, C4, CH50)Complement levels (C3, C4, CH50)

RFRF (rheumatoid factors) (rheumatoid factors)

UrinalysisUrinalysis

Baseline chemistries and coagBaseline chemistries and coagulationulationss

ImagingImaging

Chest x-ray Chest x-ray – Look for multiple focal infiltrates and Look for multiple focal infiltrates and

calcification of heart valvescalcification of heart valves

EKGEKG– Rarely diagnosticRarely diagnostic– Look for evidence of ischemia, conduction Look for evidence of ischemia, conduction

delay, and arrhythmiasdelay, and arrhythmias

EchocardiographyEchocardiography

Indications for EchocardiographyIndications for Echocardiography

Transthoracic echocardiography (TTE)Transthoracic echocardiography (TTE)– First line if suspected IEFirst line if suspected IE– Native valvesNative valves

Transesophageal echocardiography (TEE)Transesophageal echocardiography (TEE)– Prosthetic valvesProsthetic valves– Intracardiac complicationsIntracardiac complications– Inadequate TTE Inadequate TTE – Fungal or S. aureus or bacteremiaFungal or S. aureus or bacteremia

Making the DiagnosisMaking the Diagnosis

Pelletier and Petersdorf criteriaPelletier and Petersdorf criteria (1977) (1977)– Classification scheme of definite, probable, and possible IEClassification scheme of definite, probable, and possible IE

– Reasonably specific but lacked sensitivityReasonably specific but lacked sensitivity

Von Reyn criteriaVon Reyn criteria (1981) (1981)– Added “rejected” as a categoryAdded “rejected” as a category

– Added more clinical criteriaAdded more clinical criteria

– Improved specificity and clinical utilityImproved specificity and clinical utility

Duke criteriaDuke criteria (1994) (1994)– Included the role of echocardiography in diagnosisIncluded the role of echocardiography in diagnosis

– Added IVDA as a “predisposing heart condition”Added IVDA as a “predisposing heart condition”

Modified Duke CriteriaModified Duke Criteria

Definite IEDefinite IE– Microorganism (via culture or histology) in a valvular vegetation, Microorganism (via culture or histology) in a valvular vegetation,

embolized vegetation, or intracardiac abscessembolized vegetation, or intracardiac abscess– Histologic evidence of vegetation or intracardiac abscessHistologic evidence of vegetation or intracardiac abscess

Possible IEPossible IE– 2 major2 major– 1 major and 3 minor1 major and 3 minor– 5 minor5 minor

Rejected IERejected IE– Resolution of illness with four days or less of antibioticsResolution of illness with four days or less of antibiotics

High clinical suspicion (urgent indication for echocardiographic High clinical suspicion (urgent indication for echocardiographic screening and possibly hospital admission)screening and possibly hospital admission)– New valve lesion/(regurgitant) murmurNew valve lesion/(regurgitant) murmur– Embolic events of unknown origin (esp. cerebral and renal infarction)Embolic events of unknown origin (esp. cerebral and renal infarction)– Sepsis of unknown origin Sepsis of unknown origin – Haematuria, glomerulonephritis, and suspected renal infarctionHaematuria, glomerulonephritis, and suspected renal infarction– ““Fever “ plusFever “ plus

Prosthetic material inside the heart Prosthetic material inside the heart Other high predispositions of IEOther high predispositions of IENewly developed ventricular arrhythmias or conduction disturbancesNewly developed ventricular arrhythmias or conduction disturbancesFirst manifestation of chronic heart failureFirst manifestation of chronic heart failurePositive blood cultures (if the organism identified is typical for NVE/PVE)Positive blood cultures (if the organism identified is typical for NVE/PVE)Cutaneous (Osler, janeway) or ophthalmic (roth) manifestationsCutaneous (Osler, janeway) or ophthalmic (roth) manifestationsMultifocal/rapid changing pulmonary infiltrations (right heart IE)Multifocal/rapid changing pulmonary infiltrations (right heart IE)Peripheral abscesses (renal, spienic, spine) of unknown originPeripheral abscesses (renal, spienic, spine) of unknown originPredisposition and recent diagnostic/therapeutic interventions known to Predisposition and recent diagnostic/therapeutic interventions known to result in significant bacteraemia result in significant bacteraemia

Low Clinical Suspicion Low Clinical Suspicion – Fever plus none of the aboveFever plus none of the above

CRITERIA THAT SHOULD RAISE CRITERIA THAT SHOULD RAISE SUSPICION OF IESUSPICION OF IE

Any patient suspected of having Native Valve Endocarditis (NVE) by Any patient suspected of having Native Valve Endocarditis (NVE) by clinical criteria clinical criteria should be screened by Transthoracic should be screened by Transthoracic Echocardiography (TTE).Echocardiography (TTE).

When images are of When images are of good qualitygood quality and and prove to be negativeprove to be negative and and there is only a low clinical suspicion of IE, endocarditis is unlikely there is only a low clinical suspicion of IE, endocarditis is unlikely and other diagnosis are to be considered.and other diagnosis are to be considered.

If suspicion of IE is high, TransEsophageal Echocardiography (TEE) If suspicion of IE is high, TransEsophageal Echocardiography (TEE) should be performed in all should be performed in all TTE-negative casesTTE-negative cases, in , in suspected suspected Prosthetic Valve Endocarditis (PVE),Prosthetic Valve Endocarditis (PVE), and if and if TTE is positive but TTE is positive but complications are suspectedcomplications are suspected or likely and or likely and before cardiac before cardiac surgery during active IE.surgery during active IE.

If TEE remains negative and there is still suspicion, it should be If TEE remains negative and there is still suspicion, it should be repeated within repeated within one weekone week. A repeatedly negative study should . A repeatedly negative study should virtually exclude the diagnosis.virtually exclude the diagnosis.

ECHOCARDIOGRAPHYECHOCARDIOGRAPHY

Three echocardiographic findingsThree echocardiographic findings are are considered to be major critetria in the considered to be major critetria in the diagnosis of IE:diagnosis of IE:– A mobile, echodense mass attached to the A mobile, echodense mass attached to the

valvular or the mural endocardium or to valvular or the mural endocardium or to implanted prosthetic materialimplanted prosthetic material

– Demonstration of abscesses or fistulasDemonstration of abscesses or fistulas– A new dehiscence of a valve prosthesis, A new dehiscence of a valve prosthesis,

especially when occurring late after especially when occurring late after implantationimplantation

TreatmentTreatment

Parenteral antibioticsParenteral antibiotics– High serum concentrations to penetrate High serum concentrations to penetrate

vegetationsvegetations– Prolonged treatment to kill dormant bacteria Prolonged treatment to kill dormant bacteria

clustered in vegetationsclustered in vegetations

SurgerySurgery– Intracardiac complicationsIntracardiac complications

Surveillance blood culturesSurveillance blood cultures

If initiation of antimicrobial therapy is urgent,If initiation of antimicrobial therapy is urgent, empiric antibiotic treatmentempiric antibiotic treatment can be started can be started thereafter (blood culture) thereafter (blood culture) In all other cases it is recommended to post-In all other cases it is recommended to post-pone therapy until blood cultures become pone therapy until blood cultures become positive.positive.

Previous short term antibiotic Previous short term antibiotic discontinue for discontinue for at least 3 day before taking blood cultures.at least 3 day before taking blood cultures.

Previous long term antibiotic treatment Previous long term antibiotic treatment discontinue for 6 - 7 days.discontinue for 6 - 7 days.

ESC guideline; European Heart J 2004

ANTIMICROBIAL THERAPYANTIMICROBIAL THERAPY

2 weeks regimen (combination) has similar 2 weeks regimen (combination) has similar cure rates to 4 week regimencure rates to 4 week regimen4 week regimen (monotherapy) preferred in 4 week regimen (monotherapy) preferred in – patients >65 yo patients >65 yo – with 8with 8thth cranial nerve impairment cranial nerve impairment– renal dysfunction renal dysfunction – Cardiac/extracardiac abscessCardiac/extracardiac abscess

Vancomycin only for patients not tolerate to Vancomycin only for patients not tolerate to penicillin / ceftriaxonepenicillin / ceftriaxoneFor combination antibiotics For combination antibiotics given at given at same time or close together to increase same time or close together to increase synergistic effectsynergistic effect

Most common: Most common: S aureus *, **S aureus *, **

MRSA had been emerging (60-70% in MRSA had been emerging (60-70% in Europe)**Europe)**

Other organisms: Other organisms: P aeruginosaP aeruginosa, , CandidaCandida, , enterococci, streptococci *, **enterococci, streptococci *, **

Polymicrobial infection 5-10% **Polymicrobial infection 5-10% **

* AHA guidelines IE. Circulation 2005;111;e394-e433

** ESC guidelines Infective Endocarditis 2004

IE IN INTRAVENOUS DRUG USER IE IN INTRAVENOUS DRUG USER (IVDU)(IVDU)

Background for prophylaxis:Background for prophylaxis:

– Bacteremia causes endocarditis Bacteremia causes endocarditis

– Viridans group streptococci are part of normal oral flora, Viridans group streptococci are part of normal oral flora, and enterococci are part of normal GI and GU tract and enterococci are part of normal GI and GU tract floraflora

– These microorganisms were usually susceptible to These microorganisms were usually susceptible to

antibiotics recommended for prophylaxis antibiotics recommended for prophylaxis

– Antibiotic prophylaxis prevents viridans group Antibiotic prophylaxis prevents viridans group streptococcal or enterococcal experimental endocarditis streptococcal or enterococcal experimental endocarditis in animalsin animals

AHA guideline: Prevention of Infective Endocarditis. Circulation 2007;115

ANTIBIOTIC PROPHYLAXISANTIBIOTIC PROPHYLAXIS

– Large number of poorly documented case Large number of poorly documented case reports implicated a dental procedure as a reports implicated a dental procedure as a cause of IE cause of IE

– In some cases, there was a temporal In some cases, there was a temporal relationship between a dental procedure and relationship between a dental procedure and the onset of symptoms of IE the onset of symptoms of IE

– The risk of significant adverse reactions to an The risk of significant adverse reactions to an antibiotic is low in an individual patientantibiotic is low in an individual patient

– Morbidity and mortality from IE are high.Morbidity and mortality from IE are high.

High RiskHigh Risk– Prosthetic heart valvesProsthetic heart valves– Complex congenital cyanotic heart diseasesComplex congenital cyanotic heart diseases– Previous infective endocarditisPrevious infective endocarditis– Surgically constructed systemic or pulmonary Surgically constructed systemic or pulmonary

conduitsconduits

Moderate RiskModerate Risk– Acquired valvular heart diseaseAcquired valvular heart disease– Mitral valve prolapse with valvular regurgitation or Mitral valve prolapse with valvular regurgitation or

severe valve thickeningsevere valve thickening– Non-cyanotic congenital heart diseases (except for Non-cyanotic congenital heart diseases (except for

secundum type Atrial Septal Defect) including secundum type Atrial Septal Defect) including bicuspid aortic valves bicuspid aortic valves

– Hypertrophic cardiomyopathy Hypertrophic cardiomyopathy

Cardiac condition in Which Antimicrobial Prophylaxis is Indicated

Procedure which may cause bacteraemia and for which Procedure which may cause bacteraemia and for which antimicrobial prophylaxis is recommendedantimicrobial prophylaxis is recommendedDiagnostic and therapeutic interventions likely to produce Diagnostic and therapeutic interventions likely to produce bacteraemiabacteraemia– Bronchoscopy (rigid instrument)Bronchoscopy (rigid instrument)– Cystoscopy during urinary tract infectionCystoscopy during urinary tract infection– Biopsy of urinary tract/prostateBiopsy of urinary tract/prostate– Dental procedures with the risk of gingival/mucosal traumaDental procedures with the risk of gingival/mucosal trauma– Tonsillectomy and adenoidectomyTonsillectomy and adenoidectomy– Oesophageal dilatation/ sclerotherapyOesophageal dilatation/ sclerotherapy– Instrumentation of obstructed biliary tractsInstrumentation of obstructed biliary tracts– Transurethral resection of prostateTransurethral resection of prostate– Urethral instrumentation/ dilationUrethral instrumentation/ dilation– LithotripsyLithotripsy– Gynaecologic procedures in the presence of infection Gynaecologic procedures in the presence of infection

Predisposing diagnostic and therapeutic interventions

Bacteremia from daily activities (chewing food, Bacteremia from daily activities (chewing food, tooth brushing and flossing, use of wooden tooth brushing and flossing, use of wooden toothpicks, use of water irrigation devices) is toothpicks, use of water irrigation devices) is much more likely to cause IE than a dental much more likely to cause IE than a dental procedureprocedure

Extremely small number of IE might be Extremely small number of IE might be prevented by antibiotic prophylaxis, even if prevented by antibiotic prophylaxis, even if prophylaxis is 100% effectiveprophylaxis is 100% effective


New from AHA for IE prophylaxis

Limit prophylaxis Limit prophylaxis only to conditions with only to conditions with high adverse outcome from endocarditishigh adverse outcome from endocarditis

Maintenance of optimal Maintenance of optimal oral health and oral health and hygienehygiene may reduce the incidence of may reduce the incidence of bacteremia from daily activities and is bacteremia from daily activities and is mmore importantore important than prophylactic than prophylactic antibioticsantibiotics


ComplicationsComplications

Four etiologiesFour etiologies– EmbolicEmbolic– Local spread of infectionLocal spread of infection– Metastatic spread of infectionMetastatic spread of infection– Formation of immune complexes – Formation of immune complexes –

glomerulonephritis and arthritisglomerulonephritis and arthritis

Embolic ComplicationsEmbolic Complications

Occur in up to 40% of patients with IEOccur in up to 40% of patients with IE

Predictors of embolizationPredictors of embolization– Size of vegetationSize of vegetation– Left-sided vegetationsLeft-sided vegetations– Fungal pathogens, S. aureus, and Strep. Fungal pathogens, S. aureus, and Strep.

BovisBovis

Incidence decreases significantly after Incidence decreases significantly after initiation of effective antibioticsinitiation of effective antibiotics

Embolic ComplicationsEmbolic Complications

StrokeStroke

Myocardial InfarctionMyocardial Infarction– Fragments of valvular vegetation or Fragments of valvular vegetation or

vegetation-induced stenosis of coronary ostiavegetation-induced stenosis of coronary ostia

Ischemic limbsIschemic limbs

Hypoxia from pulmonary emboliHypoxia from pulmonary emboli

Abdominal pain (splenic or renal infarction) Abdominal pain (splenic or renal infarction)

Septic Pulmonary EmboliSeptic Pulmonary Emboli

http://www.emedicine.com/emerg/topic164.htm

Septic Retinal EmbolusSeptic Retinal Embolus

Local Spread of InfectionLocal Spread of Infection

Heart failureHeart failure– Extensive valvular damageExtensive valvular damage

Paravalvular abscessParavalvular abscess (30-40%) (30-40%)– Most common in aortic valve, IVDA, and S. aureusMost common in aortic valve, IVDA, and S. aureus– May extend into adjacent conduction tissue causing May extend into adjacent conduction tissue causing

arrythmiasarrythmias– Higher rates of embolization and mortalityHigher rates of embolization and mortality

PericarditisPericarditis

Fistulous intracardiac connectionsFistulous intracardiac connections

Local Spread of InfectionLocal 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.

Metastatic Spread of InfectionMetastatic Spread of Infection

Metastatic abscess Metastatic abscess – Kidneys, spleen, brain, soft tissuesKidneys, spleen, brain, soft tissues

Meningitis and/or encephalitisMeningitis and/or encephalitis

Vertebral osteomyelitisVertebral osteomyelitis

Septic arthritisSeptic arthritis

Poor Prognostic FactorsPoor Prognostic Factors

FemaleFemale

S. aureusS. aureus

Vegetation sizeVegetation size

Aortic valve Aortic valve

Prosthetic valveProsthetic valve

Older ageOlder age

Diabetes mellitusDiabetes mellitus

Low serum albumen Low serum albumen

Apache II scoreApache II score

Heart failureHeart failure

Paravalvular abscessParavalvular abscess

Embolic eventsEmbolic events

SummarySummary

IVDA and the elderly are at greatest risk of IVDA and the elderly are at greatest risk of developing IE.developing IE.The signs and symptoms of IE are The signs and symptoms of IE are nonspecific and varied.nonspecific and varied.A thorough but timely evaluation (including A thorough but timely evaluation (including serial blood cultures, adjunct labs, and an serial blood cultures, adjunct labs, and an echo) is crucial to accurately diagnose and echo) is crucial to accurately diagnose and treat IE.treat IE.Beware of life-threatening complications.Beware of life-threatening complications.

THANK YOUTHANK YOU

ACUTE ACUTE PERICARDITISPERICARDITIS

Faculty of MedicineFaculty of Medicine

Universitas BrawijayaUniversitas Brawijaya

MalangMalang

IncidenceIncidence

Exact incidence and prevalence are Exact incidence and prevalence are unknownunknown

Diagnosed in 0.1% of hospitalized Diagnosed in 0.1% of hospitalized patients and 5% of patients admitted for patients and 5% of patients admitted for non-acute MI chest painnon-acute MI chest pain

Observational study: 27.7 cases/100,000 Observational study: 27.7 cases/100,000 population/yearpopulation/year

Etiology: Can be Tricky. . . Etiology: Can be Tricky. . .

Standard diagnostic evaluations are Standard diagnostic evaluations are oftentimes relatively low yieldoftentimes relatively low yield

One series elucidated a cause in only 16% One series elucidated a cause in only 16% of patientsof patients

Leading possibilities: Leading possibilities: – NeoplasiaNeoplasia– TuberculosisTuberculosis– Non-tuberculous infectionNon-tuberculous infection– Rheumatic diseaseRheumatic disease

Initial clinical and echocardiographic Initial clinical and echocardiographic evaluation of patients with suspected acute evaluation of patients with suspected acute

pericarditis pericarditis

Diagnostic CriteriaDiagnostic Criteria

Chest pain: anterior chest, sudden onset, pleuritic; Chest pain: anterior chest, sudden onset, pleuritic; may decrease in intensity when leans forward, may may decrease in intensity when leans forward, may radiate to one or both trapezius ridgesradiate to one or both trapezius ridges

Pericardial friction rub: most specific, heard best at Pericardial friction rub: most specific, heard best at LSB (Left sternal border)LSB (Left sternal border)

EKG changes: new widespread ST elevation or PR EKG changes: new widespread ST elevation or PR depressiondepression

Pericardial effusion: absence of does not exclude Pericardial effusion: absence of does not exclude diagnosis of pericarditisdiagnosis of pericarditis

Supporting signs/symptoms:Supporting signs/symptoms: Elevated ESR (erythrocyte sedimentation rate), CRP (C Elevated ESR (erythrocyte sedimentation rate), CRP (C

reactive protein)reactive protein) FeverFever LeukocytosisLeukocytosis

EKGEKG

Electrocardiogram in acute pericarditis showing diffuse upsloping ST segment elevations seen best here in leads II, III, aVF, and V2 to V6. There is also subtle PR segment deviation (positive in aVR, negative in most other leads). ST segment elevation is due to a ventricular current of injury associated with epicardial inflammation; similarly, the PR segment changes are due to an atrial current of injury which, in pericarditis, typically displaces the PR segment upward in lead aVR and downward in most other leads.

Pericardial EffusionPericardial Effusion

Cardiomegaly due to a massive pericardial effusion. At least 200 mL of pericardial fluid must accumulate before the cardiac silhouette enlarges.

TestsTests

EKGEKG CXRCXR PPDPPD ANAANA HIVHIV Blood culturesBlood cultures Urgent echocardiogram if evidence of pericardial Urgent echocardiogram if evidence of pericardial

effusioneffusion Not necessary: Not necessary:

Viral studies b/c yield is low and management is not Viral studies b/c yield is low and management is not alteredaltered

TreatmentTreatment

NSAIDs + PPINSAIDs + PPI Aspirin (2-5 g/day)Aspirin (2-5 g/day) Ibuprofen (300-800 mg q6-8H)* Ibuprofen (300-800 mg q6-8H)* KetorolacKetorolac

Theoretical concern that anti-platelet agents promote development of Theoretical concern that anti-platelet agents promote development of hemorrhagic pericardial effusion has not been substantiatedhemorrhagic pericardial effusion has not been substantiated

Colchicine (0.5-1 mg/day) : may prevent recurrenceColchicine (0.5-1 mg/day) : may prevent recurrence Glucocorticoids (prednisone 1 mg/kg/day): ? increased rate of Glucocorticoids (prednisone 1 mg/kg/day): ? increased rate of

complications. Should be restricted to:complications. Should be restricted to: Acute pericarditis due to connective tissue diseaseAcute pericarditis due to connective tissue disease Autoreactive (immune-mediated) pericarditisAutoreactive (immune-mediated) pericarditis Uremic pericarditisUremic pericarditis

*NSAID of choice unless associated with acute MI, where all non-ASA NSAIDs should be avoided

Prognosis for acute idiopathic Prognosis for acute idiopathic pericarditispericarditis

Good long-term prognosisGood long-term prognosis

Cardiac tamponade is rare, but up to 70% Cardiac tamponade is rare, but up to 70% in cases with specific etiologies (eg. in cases with specific etiologies (eg. Neoplastic, tuberculous, purulent)Neoplastic, tuberculous, purulent)

Constrictive pericarditis occurs in about 1% Constrictive pericarditis occurs in about 1% of patientsof patients

15-30% of patients not treated with 15-30% of patients not treated with colchicine develop either recurrent or colchicine develop either recurrent or incessant diseaseincessant disease

Recurrent PericarditisRecurrent Pericarditis

Exact recurrence rate unknownExact recurrence rate unknown

Most cases considered to be autoimmuneMost cases considered to be autoimmune

Risk Factors:Risk Factors:– Lack of response to aspirin or other NSAIDLack of response to aspirin or other NSAID– Glucocorticoid therapyGlucocorticoid therapy– Inappropriate pericardiotomyInappropriate pericardiotomy– Creation of a pericardial windowCreation of a pericardial window

For some patients, symptoms can only be For some patients, symptoms can only be controlled with steroidal therapycontrolled with steroidal therapy

Autoreactive Pericarditis:Autoreactive Pericarditis: diagnostic criteria diagnostic criteria

Pericardial fluid revealing >5000/mm3 mononuclear Pericardial fluid revealing >5000/mm3 mononuclear cells or antisarcolemmal antibodiescells or antisarcolemmal antibodies

Inflammation in epicardial/endomyocardial biopsies Inflammation in epicardial/endomyocardial biopsies by >14 cells/mm2by >14 cells/mm2

Exclusion of active viral infection both in pericardial Exclusion of active viral infection both in pericardial effusion and endocardial/epicardial biopsieseffusion and endocardial/epicardial biopsies

Exclusion of tuberculosis, borrelia burgdorferi, Exclusion of tuberculosis, borrelia burgdorferi, chlamydia pneumoniae and other bacterial infection chlamydia pneumoniae and other bacterial infection

Absence of neoplastic infiltration in effusion and Absence of neoplastic infiltration in effusion and biopsy samplesbiopsy samples

Exclusion of systemic, metabolic disordersExclusion of systemic, metabolic disorders and and uremiauremia

Treatment Treatment

AspirinAspirin NSAIDsNSAIDs Colchicine: can reduce or eliminate need for glucocorticoidsColchicine: can reduce or eliminate need for glucocorticoids Glucocorticoids: should be avoided unless required to treat patients Glucocorticoids: should be avoided unless required to treat patients

who fail NSAID and colchicine therapywho fail NSAID and colchicine therapy Many believe that prednisone may perpetuate recurrencesMany believe that prednisone may perpetuate recurrences Intrapericardial glucocorticoid therapy: sx improvement and prevention Intrapericardial glucocorticoid therapy: sx improvement and prevention

of recurrence in 90% of patients at 3 months and 84% at one yearof recurrence in 90% of patients at 3 months and 84% at one year Other immunosuppressionOther immunosuppression

Azothoprine (75-100 mg/day)Azothoprine (75-100 mg/day) CyclophosphamideCyclophosphamide Mycophenolate: anecdotal evidence onlyMycophenolate: anecdotal evidence only Methotrexate: limited dataMethotrexate: limited data IVIG: limited dataIVIG: limited data

Pericardiectomy: To avoid poor wound healing, recommended to be Pericardiectomy: To avoid poor wound healing, recommended to be off prednisone for one year. Reserved for the following cases:off prednisone for one year. Reserved for the following cases: If >1 recurrence is accompanied by tamponadeIf >1 recurrence is accompanied by tamponade If recurrence is principally manifested by persistent pain despite an If recurrence is principally manifested by persistent pain despite an

intensive medical trial and evidence of serious glucocorticoid toxicityintensive medical trial and evidence of serious glucocorticoid toxicity

Documents

Infective Endocarditis Faculty of Medicine University of Brawijaya Malang