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Infectious Disease: Endocarditis Serious Viral Infections

Infectious Disease: Endocarditis Serious Viral Infections. Thomas Vu Resident Weekly Conference 10/022019. Recent Case. 41yoM recently traveled from Nigeria 8 days ago p/w fever, headache, nausea, body aches Afebrile in ed, other vs wnl , non specific exam

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Infectious Disease: Endocarditis Serious Viral Infections

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  1. Infectious Disease:EndocarditisSerious Viral Infections Thomas Vu Resident Weekly Conference 10/022019

  2. Recent Case • 41yoM recently traveled from Nigeria 8 days ago p/w fever, headache, nausea, body aches • Afebrile in ed, other vs wnl, non specific exam • Wbc 1.2, Hgb 11.0, platelets 102

  3. Recent Case • 41yoM recently traveled from Nigeria 8 days ago p/w fever, headache, nausea, body aches • Afebrile in ed, other vs wnl, non specific exam • Wbc 1.2, Hgb 11.0, platelets 102 • Parasite smear: Plasmodium +

  4. Recent Case Malaria • Plasmodium – ovale, viax, malaria, knowlesi, falciparum • Fever + exposure to endemic country – cyclic fever, headache cough, GI symptoms • Severe – AMS, anemia hgb <7, renal failure, ARDS, hypotension, DIC, bleeding, acidosis, hemoglobinuria, jaundice, hepatomegaly, splenomegaly, seizures, parasitemia >5% • Normocytic anemia, thrombocytopenia, elev ESR/LDH/LFTs/Cr, HypoNa/Gluc • Management: supportive, Antimalarials (Artesunate, Qunidine), Exchange Transfusion for life-threatening complications / P. falciparum

  5. Recent Case Speaking of Nigeria

  6. Endocarditis • Intro • Pathophysiology • Clinical Features • Diagnostic Criteria & Tests • Treatment • Prophylaxis

  7. Why do I care and when should I care?

  8. Endocarditis – Intro • Potential to affect nearly all organ systems • Majority case = infective • Unrecognized IE has high mortality, complications • Developed countries – 2-11.6 cases per 100,000; urban (IVDU) > rural

  9. Quiz 1

  10. Endocarditis – Intro • Predisposing Identifiable • Pediatric: structural CHD, Rheumatic HD (#1 developing), Nosocomial, Catheter-related Bacteremia • Structural: Prosthetic Valve, AS, MVP (#1 developed world • Risk Factor: IVDU, poor dental hygiene, chronic HD, HIV, indwelling vascular devices • Valves – Mitral #1; IVDU = Tricuspid • Prosthetic • 1-4% during 1st year, 1% per year thereafter • No difference between mechanical and bioprosthetic

  11. Endocarditis – Pathophysiology • Normal endothelium can be injured by high pressure gradient, turbulent flow state • Valvular, congenital, IVDU particles • Hypercoagulable states – Malignancy (MaranaticEndocarditis), SLE (Libman-Sacks Endocarditis) • Non-Infective Vegetations made of platelets, fibrin • Transient bacteremia may result in colonization of vegetations, conversion to infective • Transient bacteremia from trauma to skin or mucosal surfaces (oropharynx, GI, GU) • Nontraumatic – poor hygiene, S. aureus (highly invasive)

  12. Quiz 2

  13. Endocarditis – Pathophysiology Microbio • Bacteria #1 >> fungal • Type of organism based on condition (native vs prosthetic, IVDU, intracardiac devices) • Staph #1 followed by strep, enteroccici • Staph – increased healthcare associated, increasing IVDU; increased in-hospital death • Enterococcal – valvular + DM + GI/GU manipulation • Also – HACEK group (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella), Bartonella, Coxiella

  14. Quiz 3

  15. Endocarditis – Clinical Features • Fever • >90% patients overall, >98% IVDU • Can be absent in elderly or history abx/antipyretic use • Assoc other ssx of sepsis • Cardiac • CHF70% - valvular leaflet, rupture chordae tendinae/papillary/chambers • Murmurs 50-85% (less for R-sided) • Other – blocks, dysrhythmias • Neurologic • 20-40% • Multifocal cerebral ischemia, CNS abscess, ICH, aneurysm, meningitis, seizures

  16. Quiz 4

  17. Endocarditis – Clinical Features • Arterial Embolization • Can embolize to any artery – results in infarction/abscess in remote tissue • Multiple brain/liver abscesses • Pulmonary – infarct, pna, empyema, effusion • Renal – flank pain, hematuria • Mesenteric – abdominal pain, rectal bleed, bowel ischemia • Acute Limb Ischemia • Cerebral, Retinal (Roth Spots) • Cutaneous Findings • Classic but rare - 5-10% • Petechiae/Splinter/Subungal Hemorrhages of fingers/toes • Osler Nodes, Janeway Lesions, clubbing • Can be seen in other vasculitis

  18. Quiz

  19. Endocarditis – Diagnostic Criteria & Tests • Admit patients with high suspicion for endocarditis • Consider in • Unexplained Fever + Risk Factors (i.e. IVDU) • Prolonged unexplained fever, malaise, other constitutional symptoms without another cause • Fever + Prosthetic Valve (signs of vasculitis, new murmur) = high mortality • Discharged stable patients with + blood culture

  20. Endocarditis – Diagnostic Criteria & Tests • Blood Cultures • 3 separate sets from separate sites • At least 10ml for each bottle • Additional sets if already on Abx • 1 hour between 1st and last blood culture draw • Do not delay treatment for blood cultures if systemic complications or septic • Echo • Part of major criteria, helps in management • TTEsn 88%, sp 94-98% • TEE better sn/sp; use for prosthetic valves/intracardiac devices, intermediate to high clinical prob of endocarditis • Helps i.d. complications like abscesses • Other • Anemia – 70-90%, ESR – >90% • Nonspecific – hematuria, CRP, Procalcitonin • EKG – nonspecific; prolonged PR, LBBB, RBBB + LAFB, Heart block

  21. Quiz 5

  22. Endocarditis – Treatment • Resuscitation • ABCs as usual • Balloon pump for unstable MV rupture, contraindicated AoV rupture • Team approach – ID, cardiology, cardiac surgery • Lytics/AC - controversial • Antibiotics • Target toward isolated organism; presume Staph or Strep until results • Native Valves – Ceph + Aminoglycos • + Vanc if complicated (IVDU, CHD, nosocomial, suspected MRSA) • Artificial Valve – Vanc + Aminoglycoside + Rifampin • Surgery • Severe valvular dysfunction • CHF • Relapsing Valve Endocarditis • Major Embolic Complications • Fungal • New conduction defect/dysrhythmias • Persistent bacteremia after appropriate antibiotic therapy

  23. Endocarditis – Prophylaxis

  24. Quiz 6

  25. Endocarditis – Prophylaxis • Provide for dental procedures that involve • Manipulation of gingival tissue • Periapical region of teeth • Perforation of oral mucosa • Not needed • Local injections • Laceration suturing • IV line placement, draws • Intubation, endoscopy, vaginal delivery, oral trauma, bleeding, uretheralcahterization • Indeterminant • Manipulation of infect skin structures or msk tissue • Oral Procedure – Amox or Amp or Cefazloin • Vanc or Clinda or Azithro if pen allergic • Skin/MSK Procedure – Dicloxacillin or Cephalexin • Vanc or Clinda if b-lactam allergic

  26. Why do I care and when should I care? • High morbidity and mortality • Need to obtain appropriate testing • Need optimal management

  27. When should it cross my mind? • Acutely ill patient with multiple organ dysfunctions, multiple ischemic organs like ischemic leg, stroke like symptoms, pulmonary effusions, associated fever…Endocarditis? • Sepsis without a source (especially with predisposing risk factors)…Endocarditis? • IVDU fever without a source….Endocarditis? (Also spinal abscess?) • Sepsis with new onset congestive heart failure…Endocarditis?

  28. Quiz

  29. Serious Viral Infections • Influenza • HSV • Varicella and Herpes Zoster • Epstein-Barr Virus • Cytomegalovirus • Measles • Arboviral • Ebola, Hemorrhagic Fevers • Zika

  30. Quiz 7

  31. Serious Viral Infections – Influenza Intro • Orthomyxovirus family; Influenza A (typically more serious) and B • 5k-50k deaths annually • Transmitted via resp secretions (cough, sneeze) Features • Fever, respiratory symptoms, myalagias • Can exacerbate chronic conditions • Complications: pneumonia, ARDS, bacterial super-infections Diagnosis • Clinical – F, aches, cough with virus circulating community • Rapid A and B; low sn (10-80%) • PCR – higher sn/sp; for hospitalized to confirm Treatment • Supportive care most time • Severe – IVF, resp support, occasionally vasopressors, ECMO • Super-bacterial/pna – Abx • Debatable benefit Tamiflu – rec for higher risk pts, uncomp w/in 48hrs

  32. Quiz 8

  33. Serious Viral Infections – HSV Intro • HSV 1&2, DS DNA virus • Oral, genital infections; uncommon but can cause devastating CNS Encephalitis (high mortality) • Transmitted via shedding of ulcerative lesions in saliva, semen, cervical fluid Features • Pharyngitis, Gingivostomatitis, Herpetic Whitlow, Keratitis, Eczema, Gladiatorum, Bells Palsy Diagnosis • Clinical, can obtain viral culture • PCR or direct fluorescent ab • Tzanck – not useful • CT/MRI – temporal lobe for enceph • LP – lympocytocpleocytosis+RBCs Treatment • Enceph/Dissem– IV Acyclovir, Valacyclovir (fewer doses); EmpiricAbx if suspect meningitis • Uncomp HSV1 & 2 – Oral Acyclovir, Vala, Famciclovir 7-10d

  34. Quiz 9

  35. Serious Viral Infections – Varicella and Herpes Zoster Intro • Causes chicken pox (varicella) and shingles (zoster) • Vaccines available, neither 100% • Transmitted respiratory, aerosolized Features • V: Febrile, vesicular, crops varying stages; Cx: immunosupp = CNS • Z: dermatomal, doesn’t cross midline; zoster ophtalmicus, zoster oticus; neuralgia can last >30d; old or >3 demeratones…consider immunosupp (i.e. HIV) Diagnosis • Clinical; can get viral ctx, Ag, PCR Treatment • V: supportive, Acyclovir not recommended for routine, consider for high risk complications (adults, older children, immunosupp) • Z: Antivirals can hasten lesion resolution, reduce new, reduce viral shedding, decrease acute pain; does not reduce postherpetic neuralgiaseverity; start w/in 72hrs (>72hrs if new vesicles present) or any time if immunosupp or dissem/CNS; opiates, +/- steroids

  36. Quiz 10

  37. Serious Viral Infections – Epstein Barr Intro • Mononucleosis, B-cell lympohoma, Hodkins, Burkitts lymphoma, nasopharyngeal carcinoma • Transmitted via salivary secretion • Infects B lymphocytes, significant proliferation can lead to neoplastic transformation Features • Mono – F, lymphadenopathy, pharyngitis, splenomegaly, rash when given amp/amoxicillin; most resolve spontaneously 2-3wks • CNS, hematologic, cardiac Diagnosis • Clinical (H&P) • CBC – with lymphocytosis, atypical • Monospot Test – IDs heterophile antibodies agglutination; can be false neg early; test pregnant Treatment • Supportive – rest, analgesias; avoid contact sports 3 weeks (spleen) • Steroids – has complications, reserved for severe cases (airway obstruct’n, neuro, hemolytic anemia) • Acyclovir–only for hairy leukoplakia

  38. Serious Viral Infections – Cytomegalovirus Intro • Most asymptomatic, severe can be life-threatening • Mucosal spread respiratory, genital • Pregnancy, Transplant, Immunosupp Features • Heterophile-neg Mono – fever, myalgias, lymphocytosis; hepatitis, colitis, GBS, enceph, hemol anemia • Congenital/Neonatal – hepatosplen, jaundice, microceph, petechiae, GR • Transplant – PNA, hepatitis, CNS, late GVHD • HIV - Retinitis Diagnosis • Not available in ED • PCR, Ab, Viral Ctx Treatment • Healthy – Symptomatic Treatment • HIV – Antiviral (Ganciclovir, Valganciclovir, Foscarnet, Cidofovir • Transplant – additional hyperimmune globulin

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