Clinical Pathological Correlation

Question 1

• 24 year old man presents with fever and exertional shortness of breath
• Previously well
• • smoker, daily marijuana, occasional IVDU
• General malaise with subjective fevers and chills for 2-3 weeks • Lack of appetite, night sweats • One week of shortness of breath with exertion • Progressed to dyspnea with one flight of stairs • 2 pillow orthopnea, no paroxysmal nocturnal dyspnea • Mild cough with no sputum or hemoptysis • No recent travel, no sick contacts, no COVID exposure • No chest pain, occasional fast heartbeats with lightheadedness but no frank syncope

What is this clinical picture consistent with?

Answer 1

splinter hemorrhage, dyspnea, fever, murmur = endocarditis!!

Classical symptoms include: fevers chills nightsweats, anorexia/weight loss, congestive heart failure, NEW murmur

Question 2

Risk factors for endocarditis

Answer 2

1. pathological valve; rheumatic valve, degenerative valve, mtral valve prolapse, congenital heart disease
2. patient factors: >30, IVDU, immunosuppression, poor dentition
3. implanted devices ; prosthetic valve, pacemaker ICD, indwelling catheter.

Question 3

5 characteristic physical exam findings of infective endocarditis (SOJOS)

Answer 3

1. splinter hemorrhages
2. osler nodes
3. janeway lesions
4. ocular findings
5. splenomegaly

Question 4

“2 options” for a new systolic murmur

Answer 4

1. obstruction to systolic flow = STENOSIS of a semilunar valve (aortic or pulmonary)
2. Turbulent flow in the wrong direction = regurgitation of an AV valve (mitral or tricuspid)

Question 5

investigations for you suspecting infectious endocarditis

Answer 5

CXR and ECG fo sho

TEE ECHO

Question 6

most common organism for infectious endocarditis

Answer 6

staph aureus

Question 7

major criteria for infectious endocarditis

Answer 7

1. typical microorganism for infective endo from 2 separate blood cultures
2. evidence of endocardial involvement; oscillating intracardiac mass, on valve or supporting structures, or in the path or regurgitant jets.
3. new valvular regurgitation/murmur

Question 8

minor criteria for IE

Answer 8

• predisposing heart condition or IVDU
• fever
• vascular phenomena; emboli, septic pulmonary infarcts, mycotic aneurism, intracranial hemorhage, conjunctival hemorhage, janeway lesions
• immunologic phenomena; glomulonephrtisi, osler nodes, roth spots, rheumatoid factor

Question 9

complications of IE

Answer 9

• sepsis
• thromboembolic events: stroke, mycotic aneurysm
• valvular destruction; heart failure
• abscess formation: heart block in aortic valve IE

Question 10

management of IE

Answer 10

• consultation
• antibiotics
• surgery

Question 11

which bacteris is the most common cause ofinfective endocarditis today?

a) Enterococcus faecalis b) Pseudomonas aeruginosa c) Staphylococcus auerus d) Escherichia coli

Answer 11

c. staphylococcus auerus

Question 13

virulence factors of IE organisms include

1. adhesion
2. vegetation maturation
3. tissue destruction
4. chronicity

give examples of each virulence factor.

Answer 13

Question 14

most of the IEagents are gram positive- staph A, streptococcus viridans, enterococcus etc. What are the gram negatives?

Answer 14

HACEK and non-HACEK

HACEK = H. influenzae, actinobacillus, cardiobacterum, eikenalla corroden, kingella.

non hacek = e. coli, klebsiella, pseudomonas.

Question 15

Question 16

examples of targeted gram positive agents

Answer 16

penicillin, amplicillin, cloxacillin, cefazolin, vancomyin

Question 17

should you choose bactericidal or bacteriostatic antibiotics for IE

Answer 17

bactericidal– Beta lactams

Question 18

Note: there’s a role of adjuvant antibiotic agents.

• aminoglycosides for enterococcus and streptococcus
• rigampin- prostehtic vavle.

Question 19

route of administration for endocarditis

Answer 19

IV generally preferred

Question 20

what is the duration of therapy when treating IE and what is the “start date of effective therapy” definition

Answer 20

4-6 week.

start date of effective therapy: date of first negative blood culture.