infective endocarditis & r.f
TRANSCRIPT
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Acute bacterial endocarditis caused by Staphylococcus aureus with aortic valve ring abscess
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HADI'S PART
Carditis:
-Most serious manifestation that can lead to death
within 1-2 weeks.
Acute valvular dysfunction → acute heart failure → DEATH.
-Any cardiac tissue may be affected (endocardium + myocardium + pericardium)
---valvular lesions are the most common specially mitral and aortic valves.
---Seldom see isolated pericarditis or myocarditis alone without valves lesions.
THE CLINICAL SIGNS:
-High pulse rate: in the past the drs were diagnose RF by watching the pt
while he is sleep to check for tachycardia
-Murmurs: we check for new murmurs; we consider mitral regurgitation so
we hear a systolic murmur in the apex of the heart.
-Cardiomegaly: by chest x-ray.-Rhythm disturbances (prolonged PR interval)
Q: in spite of tachycardia there is prolonged PR interval. Whyyyyyyyy?A: because of block (first degree) in the AV node and this is because the
rheumatoid fever is an inflammatory process affect the endocardium and
the valves; and the aortic valve is very close to the AV node so when the
valve become inflamed and enlarged it will affect the AV node.
-Pericardial friction rubs: when there is pericarditis.
-Cardiac failure: that cause pulmonary edema and lower limb edema as a
manifestations.
-Mitral and aortic regurgitation most common you can hear apical systolic (relatedto the apex) and basal diastolic murmurs (related to the base of the heart where
the great vessels orginates).
-Pericarditis usually asymptomatic and occasionally causes chest pain, friction
rubs or distant heart sounds (distant because of the pericardial effusion the
sounds are muffled).
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NOTE: if the pt has pericardial effusion on the echo and you can't hear the heart
sounds this indicates that the amount of the effusion is significant.
This chest X-ray for a pt with RF and you can see Cardiomegaly ( the cardio-thoracic
ratio more than 50%).
Sydenham’s Chorea:
Extrapyramidal disorder characterized by fast, clonic, involuntary
movements (especially face and limbs) and the pt looks like dancing.
Muscular hypotonus
Emotional liability: crying then smiling……etc.
The First sign starts with difficulty in walking, talking, writing
Usually Sydenham's Chorea is a late manifestation occure months after
the infection.
rarely the only manifestation of ARF.
Occurs in 30% of patients with ARF and can return back after the pt recovered
from the ARF.
1/2 of these (30%) also have carditis (more common with sydenham's chorea) or
arthritis.
Usually benign and resolves in 2 - 3 months and can last for more than 2 years.
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Subcutaneous Nodules:
Usually 0.5 - 2 cm long, Firm, non-tender, isolated or in clusters.Most common: along extensor surfaces of joint (Knees, elbows, wrists); just
move your hand over the skin and you will feel the nodules. Also you find it on
bony prominences, tendons, dorsi of feet, occiput or cervical spine.
Last a few days only and Occur in 9 - 20% of cases.
Often associated with carditis (always if you found subcutaneous nodules then
the pt 100% has carditis). Erythema Marginatum: (begin as small dot then increase in size)
• Present in 7% of patients
• Highly specific to ARF
•
Cutaneous lesion: Reddish pink border, Pale center, Round or irregular shape.
• Often on trunk, abdomen, inner arms, or thighs.
• Highly suggestive of carditis
Erythema marginatum : notice the pink border and the pale in the center.
Other Clinical Features: Less frequent or less specific to ARF
-fever -Arthralgia instead of arthritis -Epistaxis
-Abdominal pain (5%) due to peritonitis (because of serositis Inflammation of theserous tissues of the body. The serous tissues line the lungs (pleura), heart (pericardium), and the
inner lining of the abdomen (peritoneum) and organs within).
-Hematuria (5%) because of renal involvement and when we do routine biopsy in
pts with ARF we find 40% of them have renal involvement.
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-Pneumonitis
-Mild pleuritis (5 - 10%)
-Encephalitis (extremely rare).
DIAGNOSIS
In the diagnosis we follow jone's criteria which is:-
- Criteria developed to prevent overdiagnosis
- Some criticism regarding validity
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Still important as guidelines
Probability of ARF high with:
Evidence of previous infection with streptococcal upper airway infection we do athroat swap then culture and look for group A streptococci.
2 major criteria
1 major criteria and 2 minor criteria
Evidence of Previous Infection:
o Culture: the gold role to isolate the group A
streptococci.
o
Antistreptolysin antibody: less sensitive forRF; often elevated in healthy children or
with Rheumatoid Arthritis, Henoch-Schonlein Purpura, Takayasu’s Arteritis.
o Antibodies to other strep antigens like Anti-DNAase B, anti-hyaluronidase, anti-
streptokinase, anti-nicotinamide.
the dr here begin to skip a lot of
slides so I will put them and add
some notes.
The Differential Diagnosis of ARF:Juvenile rheumatoid arthritis
Systemic lupus erythematosusOther connective tissue diseases, including vasculitidies
Bacterial endocarditis
Reactive arthritis
Seronegative spondyloarthropathies
Infections (Hansen’s Disease, Lyme, Yersinia)
Familial Mediterranean Fever
Antiphospholipid SyndromeLeukemiasSickle cell anemia and other hemoglobin disorders
Sarcoidosis
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Laboratory Studies- None capable of diagnosing ARF: clinical
diagnosis
- Can help eliminate other diseases
- Aids in diagnosis- Monitor inflammatory process- Evaluate extent of cardiac involvement
- CBC: not very helpful we can see leukocytosis
- increase CRP, increase ESR: non-specific indicators of inflammation
- Tests for anti-streptococcal antibody
- CXR for cardiomegaly
- EKG: prolonged PR interval in 1/3 patients
not specific to ARF
not associated with later cardiac sequelae
TREATMENT
The treatment of ARF depends mainly on the Eradication of the group A strep,
and the best treatment is a sigle dose of IM benzathine penicillin G acts for
month. We give the dose for pts >27 kg 1,200,000 units and for pts
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For arthritis:
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Salicylates we use them in high dose 600mg/kg or NSAIDs x 3 weeks
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Usually excellent response
- If poor response: diagnosis in question
For Carditis:
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Pts with Carditis its recommended to take steroids beside aspirin.
- Prednisone 1 -2 mg/kg/d (max 60 mg) x 10 - 15 days.
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If simultaneous arthritis and carditis: steroids alone sufficient but most
cardiologist starts with aspirin.
For Sydenham's chorea:
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Haloperidol (anti psychotic) 0.5 - 1 mg/kg
- Alternate: Sodium valproate (anti epileptic) 15 -20 mg/kg/d
- No proven benefit of steroids (steroids just with arthritis and carditis).
primary prophylaxis:
we mean by primary prophylaxis is to give the treatment before having the
disease, but the secondary prophylaxis is to prevent the complications and the
recurrence of the disease.
We use antibiotics (penicillin) as we said, and in Jordan we apply roles to
- Improving living conditions و (for more info. Watch 8:00 pm
news 3la jordan tv)
-
Hygiene
... ی
ی
و
وآ
- Overcrowding
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Access to medical care - Education رو ی و آ یي آر
Secondary prophylaxis
Benzathine PCN given to prevent recurrences of ARF and to prevent any chronic valve
disease, studies shows that pts with ARF when they treated they get what we call it
chronic smoldering (it means that there is a disease but progress very slowly).
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Pts with valvular disease (mitral regurge or stenosis or aortic regurge) we give them
lifelong penicillin treatment.
Conclusions:
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Acute Rheumatic Fever leading to Rheumatic Heart Disease is a majorproblem world wide.
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Appropriate treatment of group A strep pharyngitis necessary to prevent
disease.
- Preventing recurrences causing chronic heart disease is simple, universally
available, and cost effective.
THE END THE END THE END THE ENDBest regard to all group A9 every one of them except sheikh el group Saleh Abu
Lebdeh☺( from Omar )
Done by: Hadi Al Radaideh & Omar Abu Farsakh
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