endocarditis and myocarditis

1. Endocarditis andMyocarditis Laura Wexler, M.D. 558-5575 wexlerl@ucmail.uc.edu

2. Case A 45-year-old stockbroker comes to your office complaining of generalized fatigue and dyspnea. His symptoms began approximately three months ago and have slowly progressed. Two months ago, he saw another physician who told him he had the flu and mild anemia and prescribed iron pills. His appetite has decreased and he has lost 10 lbs. He denies chest pain and he has no prior history of heart disease or cardiac abnormality other than a heart murmur that was first noted in childhood.

3. He has no history of hypertension or diabetes, he does not smoke and his lipid profile was normal when it was checked a year ago. He has no family history of heart disease. He denies drug abuse and takes no medications other than an occasional aspirin. Six months he underwent extraction of an abscessed tooth: other than that, he has had no medical procedures.

4. Physical Examination BP 155/45, P 78 reg, RR 14, T 99.8? JVP is estimated at 5 cm. Carotid upstrokes are very brisk There are rales at both lung bases. The PMI is diffuse, heaving and displaced laterally to the anterior axillary line . The first and second heart sounds are normal. There is an S3 at the apex. At the lower left sternal border there is a mid- peaking, 3/6 systolic ejection murmur and a 4/6 diastolic decrescendo blowing murmur. Examination of the abdomen and extremities is unremarkable.

5. Infective Endocarditis Infection of the endocardial surface of the heart: ? Usually valvular Classifications: ? Course: acute vs. subacute ? Substrate: native vs. prosthetic valve ? Valve: Aortic, mitral, tricuspid ? Organism: staphylococcal, fungal, etc.

6. Pathogenesis Endocardial surface injury - High velocity jet of blood, usually across abnormal valve (70%) - Intravascular hardware: intravenous catheters, prosthetic valves Platelet adherence and thrombus formation at the site of injury Bacterial entry into the circulation Bacterial adherence to the injured endothelial surface

7. Sites of endocarditis

8. Determinants of Infectivity of an Organism in Endocarditis Access to the blood stream Survival in the circulation Adherence to the endocardial surface Size of the inoculum (number of organisms)

9. Common Causes of Infective Endocarditis Organism Incidence (%) Streptococci 70 - Viridans 35 - Enterococci 10 - Other 25 Staphylococci 20 - S. aureus 18 - Coagulase negative 2 Other organisms 10 (e.g. gram neg., haemophilus, fungi)

10. Clinical Presentations of Infective Endocarditis Fever Fatigue, anorexia, myalgias, night sweats, weakness Heart failure Stroke, abdominal pain Arthralgias

11. Physical Findings Skin: splinter hemorrhages, Osler�s nodes, Janeway lesions Mucosal surfaces: petechiae Funduscopic exam: Roth spots Heart: Murmurs, especially new or increasing regurgitant murmur Abdomen: Enlarged, tender spleen

12. Splinter hemorrhages

13. Osler�s nodes

14. Janeway Lesions

15. Conjunctival petechiae

16. Diagnosis Blood cultures (at least 3 sets): 95% likely to be positive Culture negative endocarditis - �Fastidious� organisms - Recent exposure to antibiotics

17. Adjunctive Diagnostic Tests in Infective Endocarditis ECG: New AV block (first, second or third degree), PVCs Chest X-ray: septic pulmonary emboli (TV endocarditis) Echocardiogram: valvular vegetation

18. Septic pulmonary emboli

19. Aortic valve vegetations

20. Complications of Infective Endocarditis Embolization of infected vegetation: skin, brain, kidney, spleen, lungs Metastatic infection (e.g. osteomyelitis) Valve destruction and regurgitation Local extension of infection: - Valve ring abscess, - Myocardial or conduction system abscess, - Pericarditis Immune complex injury: deposition of antigen-antibody complex: arthritis, glomerulonephritis

21. Laboratory Tests in Infective Endocarditis Evidence of infection/inflammation Elevated erythrocyte sedimentation rate (ESR) Leukocytosis Anemia Evidence of immune complex formation Elevated serum globulins Rheumatoid factor Antinuclear antibody (ANA) Hypocomplementemia Evidence of renal involvement: Hematuria Proteinuria RBC casts

22. Management of Infective Endocarditis Targeted antibiotics: 4-6 weeks of IV therapy Close surveillance for evidence of continued infection Close surveillance for evidence of valve destruction Valve replacement indications: Heart failure Uncontrolled infection Massive vegetation Valve ring abscess Mechanical valve endocarditis

23. Prevention of Bacterial Endocarditis Identify patient at risk Prompt, aggressive treatment of any infection Rigorous attention to dental care Prophylactic antibiotics during procedures likely to cause bacteremia

24. Cardiac Lesions that Predispose to Infective Endocarditis Aortic, mitral valve disease, pulmonic stenosis HOCM (IHSS) Some congenital lesions (high velocity jets, e.g. ventricular septal defect, coarctation of the aorta) Intravascular hardware Intravenous catheters Prosthetic heart valves

25. Procedures Warranting Antibiotic Prophylaxis Dental work with gingival bleeding Upper respiratory procedures: bronchoscopy, surgery Genitourinary procedures: Indwelling bladder catheter Cystoscopy Prostatectomy Vaginal delivery if infection present Gastrointestinal surgery

26. Antibiotic Prophylaxis:AHA Recommendations Dental, upper respiratory procedures - Oral antibiotic 1-2 hours before procedure GI, genitourinary procedures - IV/Oral antibiotics before procedure

31. Myocarditis: Infectious causes Viral: Coxsackie A, B, polio, influenza, adeno, echo, rubeola, rubella, hepatitis, HIV Bacterial: Rare Other: Toxoplasmosis: toxoplasma gondii Aspergillus Chagas� Disease: Trypanosoma cruzi

32. Myocarditis: Non-infectious causes Radiation Toxic or hypersensitivity reaction to drug: Adriamycin (chemotherapy) Cocaine �Collagen vascular� (rheumatoid arthritis, lupus) Cardiac transplant rejection

33. Natural History of Acute (Viral) Myocarditis Subclinical, no sequelae Fulminant; cardiac dilation, heart failure, arrhythmias, death Self limited cardiac dysfunction with resolution in weeks/months Chronic cardiomyopathy

34. Diagnosis of Acute Myocarditis Clinical Setting: Acute onset heart failure without underlying cause Physical Exam: Cardiac dilation, heart failure ECG: Sinus tachycardia, diffuse T wave inversions Viral titers/cultures RV endomyocardial biopsy via R jugular vein

35. Treatment of Acute Myocarditis Supportive Care: Drugs for congestive heart failure Mechanical support Intra-aortic balloon counterpulsation Ventricular assist device Cardiac transplantation