1 / 80

CARDIAC INFECTIONS

CARDIAC INFECTIONS. Assoc Prof Dr . Meral SÖNMEZOĞLU Yeditepe University Hospital. Learning Objectives. Recognize the risk factors, signs, and symptoms of cardiac infections Understand the many approaches to diagnosing endocarditis , myocarditis and pericarditis .

philipo
Download Presentation

CARDIAC INFECTIONS

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. CARDIAC INFECTIONS Assoc Prof Dr.Meral SÖNMEZOĞLU Yeditepe UniversityHospital

  2. LearningObjectives • Recognize the risk factors, signs, and symptoms of cardiacinfections • Understand the many approaches to diagnosing endocarditis, myocarditisandpericarditis. • Appreciate the necessity of rapid treatment. • Anticipate possible complications.

  3. CardiacInfections • Endocarditis • Myocarditis • Pericarditis

  4. INFECTIVE ENDOCARDITIS

  5. Definition • Infectious Endocarditis (IE): an infection of the heart’s endocardial surface • Classified into four groups: • Native Valve IE • Prosthetic Valve IE • Intravenous drug abuse (IVDA) IE • Nosocomial IE

  6. Sites of lesions • Mitral Valve: 85% (Left atrium/ventricle) • Common site for Strep viridans group • Aortic valve: 55% (Left ventricle) • Emboli would effect systemic organs brain, kidneys, spleen • Tricuspid valve: 20% (Right atrium/ventricle) • Common site for IV drug users (Staph. spp) • Emboli to lung • Pulmonary valve: 1% (Right ventricle)

  7. 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 Further Classification

  8. Acute Rapid progression of symptoms Less than 6 weeks duration Significant systemic signs/symptoms Fever Elevated systemic WBC/ left shift Subacute Slower, more chronic progression of symptoms Low grade fevers Vague clinical signs/symptoms weakness, anorexia, malaise,etc. Further Classification

  9. Acute NVE • Frequently involves normal valves and usually has an aggressive course. • Rapidly progressive illness in persons who are healthy or debilitated • Virulentorganisms, S aureus and group B streptococciare typically the causative agents

  10. Subacute NVE • Typically affects only abnormal valves. • Its course, even in untreated patients, is usually more indolent than that of the acute form and may extend over many months. • Alpha-hemolytic streptococci or enterococci, usually in the setting of underlying structural valve disease

  11. Early PVE • Early PVE occurs within 60 days of valve implantation. • Traditionally, • coagulase-negative staphylococci, • gram-negative bacilli, and • Candida species have been the common infecting organisms.

  12. Late PVE • Late PVE occurs 60 days or more after valve implantation. • Staphylococci, • alpha-hemolytic streptococci, and • enterococci are the common causative organisms. • Recent data suggest that S aureusmay now be the most common infecting organism in both early and late PVE

  13. 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

  14. Pathogenesis • Multiple independent pathophysiological processes • “Trauma” of the heart surfaces • Platelet/fibrin deposition over traumatized tissue (non-bacterial thrombotic endocarditis) • “Bacteremia” subsequent infection of the platelet/fibrin deposition (Bacterial endocarditis) • Bacterial multiplication (10 9,10cfu/gram of tissue)

  15. Epidemiology • Incidence difficult to ascertain and varies according to location • Much more common in males than in females • May occur in persons of any age and increasingly common in elderly • 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 • Permanent central venous access lines • Prior valve surgery • Recent dental surgery • Weakened valves

  17. Predisposingfactors • rheumaticheartdisease (25-30%) • congenitalheartdisease (10-20%) • mitral valvedisease (10-30%) • IV drugabuse (15-35%) • no predisposition (25-45%)

  18. Infecting Organisms • Common bacteria • S. aureus • Streptococci • Enterococci • Not so common bacteria • Fungi • Pseudomonas • HACEK

  19. Infecting Organisms • Overall, S aureusinfection is the most common cause of IE, including PVE, acute IE, and IVDA IE. • Approximately 35-60.5% of staphylococcal bacteremias are complicated by IE. • More than half the cases are not associated with underlying valvular disease.

  20. Infecting Organisms • HACEK - slow growing, fastidious organisms that may need 3 weeks to grow out of culture • Haemophilus sp. • Actinobacillus • Cardiobacterium • Eikenella • Kingella

  21. Nativevalveendocarditis • Viridansstreptococci (30-60%) • Staphylococcusaureus (30-40%) usuallycausesacuteendocarditis • Gram negativebacteria (e..g.Haemophilus) (5-10%) • Coagulasenegativestaphylococci (e.g. S.epidermidis) (5%) • Streptococcuspneumoniae (1-3%)Fungi (1-2%)

  22. Prostheticvalveendocarditis • Coagulasenegativestaphylococi (10-33%) • Streptococci (1-31%,theproportion of cases of endocarditisduetostreptococciincreases progressively in the first 12months post valvereplacement) • S. aureus (20%) • Gram negativebacteria (10%) • Fungi (1%)

  23. Symptoms  • Chills • Fatigue • Fever • Heart murmur • Joint pain • Muscle aches and pains • Night sweats • Nail abnormalities (splinter hemorrhages under the nails) • Paleness • Red, painless skin spots on the palms and soles (Janeway lesions)

  24. Symptoms  • Red, painful nodes in the pads of the fingers and toes (Osler's nodes) • Shortness of breath with activity • Swelling of feet, legs, abdomen • Weakness • Weight loss Note:Endocarditis symptoms can develop slowly (subacute) or suddenly (acute).

  25. 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 Nausea/Vomiting Symptoms The onset of symptoms is usually ~2 weeks or less from the initiating bacteremia

  26. 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

  27. Duke’sCriteria • MAJOR • Positive blood culture for appropriate organism • Evidence of endocardialinvolvement • MINOR • Predisposition • Fever • Vascularphenomena • Immunologicalphenomena • Microbiological evidence not meeting major criteria • Echo finding not meeting major criteria • Raisedinflammatorymarkers • DIAGNOSIS • Twomajor • Onemajor + Threeminor • Fiveminor

  28. Janeway Lesions • More specific • Erythematous, blanching macules • Nonpainful • Located on palms and soles

  29. Janewaylesion

  30. IE:Janeway Lesions

  31. Splinter Hemorrhages • Nonspecific • Nonblanching • Linear reddish-brown lesions found under the nail bed • Usually do NOT extend the entire length of the nail

  32. IE: Splinter hemorrhages

  33. Osler’s Nodes American College of Rheumatology webrheum.bham.ac.uk/.../ default/pages/3b5.htm www.meddean.luc.edu/.../ Hand10/Hand10dx.html • More specific • Painful and erythematous nodules • Located on pulp of fingers and toes • More common in subacute IE

  34. IE: Osler Nodes

  35. Petechiae • Nonspecific • Often located on extremities • or mucous membranes dermatology.about.com/.../ blpetechiaephoto.htm Harden Library for the Health Sciences www.lib.uiowa.edu/ hardin/ md/cdc/3184.html Photo credit, Josh Fierer, M.D. medicine.ucsd.edu/clinicalimg/ Eye-Petechiae.html

  36. Roth spot Roth’sspots Retinalhaemorrhages Alsoseen in leukaemia, Diabetes, perniciousanaemia

  37. Exams and Tests • CBC -anemia • Chest x-ray • Echocardiogram • ECG • Erythrocyte sedimentation rate (ESR) • Repeated blood cultureand sensitivity

  38. Investigations • Bloodtests • FBC • U&E • CRP to monitor disease activity • LFT • Blood cultures are essential, with a minimum of three samplestaken from different sites at least an hour apart (preferably more)sent for analysis, before initiation of antibiotics. • Serological tests for exotic organisms are usually done forculturenegative IE if splenicabsceses are suspected

  39. Investigations • Chestradiograph - thismaydetectsepticlunginfarcts(commoner in IE secondary to drug abuse), signs ofcardiac failure, and evidence of pulmonary infection • Urinedipstick/ MSU todetecthaematuria • Electrocardiogramtoprovide a "baseline“ prolongationof the PR interval may mean the development of anaorticrootabscess) • Abdominal ultrasound or CT Abdomen may beindicated

  40. Possible Complications • Arrhythmias, such as atrial fibrillation • Blood clots or an infected clot from the endocarditis that travels to the brain, kidneys, lungs, or abdomen, causing severe damage to, and infection of, these organs • Brain abscess • Brain or nervous system changes • Congestive heart failure • Glomerulonephritis • Jaundice • Severe heart valve damage • Stroke

  41. Prevention • People with certain heart conditions often take preventive antibiotics before dental procedures or surgeries involving the respiratory, urinary, or intestinal tract. • Those with a history of endocarditis should have continued medical follow-up.

  42. Treatment • Ifpatientstabledeferuntiladequatebloodcultures done • liaisewithmicrobiology re appropriateantibiotics • Internationalguidelinesexist • Reviewwithcultureresults • Usually six weeks treatment, at least four on iv

  43. Treatment • Long-term antibiotic therapy is needed to get the bacteria out of the heart chambers and valves. • usually have therapy for 6 weeks • must be specific for the organism • blood culture and the sensitivity tests

  44. Treatment • Parenteral antibiotics • High serum concentrations to penetrate vegetations • Prolonged treatment to kill dormant bacteria clustered in vegetations • Surgery • Intracardiac complications • Surveillance blood cultures

  45. Complications requiring surgery • Infected prosthetic material: less than 1 year out from original heart surgery • Refractory congestive heart failure (Leading cause of death) • Unresponsive infection/ continued infection despite appropriate antibiotics • Pt. experiences more than 1 major emboli

  46. MYOCARDITIS

  47. Myocarditis • an inflammation of the heart muscle • an uncommon disorder that is usually caused by viral infections such as coxsackie virus, adenovirus, and echovirus

  48. Myocarditis • may also occur during or after various viral, bacterial, or parasitic infections (such as polio, influenza, or rubella). • exposure to chemicals or allergic reactions to certain medications • associated with autoimmune diseases. • muscle becomes inflamed and weakened

More Related