West Medical Ward

Bio dataName Usman S/O Zulfiqar Ali Khan

Age 24 years

Sex Male,

Religion Muslim,

Resident of Allama Iqbal Town, Lahore.

M.O.A= Out Patient Dept., Mayo Hospital, Lahore

D.O.A= 29/3/14

Presenting complaintsFever- 15 days

Malaise 15 days

Shortness Of Breath- 7 days

History of presenting illnessPatient is , normotensive, normoglycemic known I.V drug abuser for 7 years presented with complains of fever from last 15 days. Fever was sudden in onset, high grade, associated with rigors and chills that relieved by taking medication, along with fever patient also complains of malaise generalized body weakness .

For last 7 days patient also complaining of shortness of breath there is no history of orthopnea and PND.

Cough was associated with sputum that was white in color and small in quantity.

Past historyHistory of visits to hospital OPD

No history of hospital admissions for any other disease

No history of any surgery in the past

Treatment historyNot significant

Family historyHe is married male

Divorced his wife

No family history of diabetes hypertension IHD asthma or TB.

Personal historyI/V Drug abuser- 7 years

Unemployed

Smoker

Drug history

Opioids (self medication)- 7 years

Socio-economic history

Low income group

General physical examinationAn ill looking young man lying 0n bed, well oriented in time, place and person, i/v line passed in left arm.

Vitals are:

Pulse: 88/min,

B.P: 100/60

Temp: 100 F

Respiratory rate: 22/min

GPE ….. Pallor +ve Cyanosis -ve Clubbing -ve Koilonychia -ve S /hemorrhage -ve Osler nodes absent Heberden nodes absent Boucard nodes absent Palmer erythema -ve Dupuytren contrature -ve Skin rash -ve Axillary nodes not palpable JVP not raised Thyroid normal Ankle edema absent Sign of dehyration +ve

CVSOn inspection; Shape of chest is normal.

On palpation; Apex beat in 5th intercostal space just medial to mid clavicular line,no other sound is palpable,no thrill,no murmur.

On auscultation; On Auscultation S1, S2 of normal intensity, A grade III,pan-systolic murmur with maximum intensity at left lower sternal border, high pitched, blowing in character and loud during inspiration best audible with diaphragm not radiating to any side.

RespiratoryOn inspection; Rate 22/m abdomino thoracic

shape of chest is normal with no striea no scar mark no pulsation.

On palpation; Trachea is central,apex beat in 5th in midclavicular line,chest movement and expansion within normal range,no vocal fremitus.

On purcussion; upper border of liver is in 5th

intercostal space.

On auscultation; Breath sounds are normal,noronchi,bi-basilar fine crepitations are there.

Gastro-intestinal systemOn inspection; Oral hygiene is poor , shape of

abdomen is normal,umblicus normal,no pulsation and no scar mark.

On palpation; Abdomen is mildly tender, no ascites,no visceromegaly.

On purcusion; Normal

On auscultation; B/S are audible,no bruit is present.

Hernial orifices and genitalia are normal.

PR not done.

CNS GCS 15/15

Cranial nerves intact

Motor and Sensory system intact

SOMI –ve

Recap A 24 years male who is I/V drug abuser presented with

history of high grade fever,associated with rigors, complaining of shortness of breath for last 7 days, pallor on general physical examination and a murmur.

Differential diagnosis Infective endocarditis

HIV

Enteric fever

Malaria

LRTI??

Assessment planAll baseline investigations (CBC, LFTs, RFTs, BSL,

Viral Markers)

Blood cultures from three different sites

ECG

Echocardiography

Urine complete

Chest X-ray

Sputum for AFB

ESR

HIV serology

Investigations

CBC HB: 8.5mg/dl

WBCs: 7.3

Plt: 132

Neutrophil: 72.2%

ESR 34

HCT 33

LFTs ALP: 177

AST: 30.7

ALT: 23.5

Total protien 7.1

Albumin 3.5

Bilirubin 0.8

RFTs Urea 20.8

S/Creatinine: 0.6

Viral markers Anti-HCV +ve

HbSAg -ve

Anti-HIV (screening) +ve

ABGs PH 7.52

pO2 84.6 mmHg

pCO2 25.5mmHg

HCO3- 20.7 mmol/L

Base excess - 1.7

O2 92 %

CHEST-XRAY

ECG

USG Report Enlarged liver 18cm

Enlarged spleen 15cm

Kidneys: normal

Minimum abdomino-pelvic ascites

Sputum examination

ZN staining - No AFB

Urine Complete COLOUR Deep yellow

PH 6

Specific gravity 1.030

Protein: +ve

Sugar: nil

Blood: +++

Pus cell : 3-5 cells

Blood culture

Awaited

Final Diagnosis

Right sided native valve Endocarditis

summary A 24 years old patient who is I/V drug abuser (Anti-

HCV,Anti- HIV +VE)presented with history of fever, that is high grade associated with rigors and chills,alsohaving history of malaise for up to a similar period,forlast 7 days he was complaining of shortness of breath ,pallor on general physical examination,anemia on FBC, tricuspid valve vegetation on echo and proteinurea and +++ red cell on urine complete

Modified Duke criteria1 A) Positive blood culture with typical IE microorganismTypical microorganism consistent with IE from 2 separate blood

culutre Viridans-group streptococci Streptococcus bovis, orHACEK group, orStaphylococcus aureus, orCommunity-acquired Enterococci,

B)Microorganisms consistent with IE from persistently positive blood cultures defined as: Two positive cultures of blood samples drawn >12 hours apart, or

All of 3 or a majority of 4 separate cultures of blood (with first and last sample drawn 1 hour apart)

Coxiella burnetii detected by at least one positive blood culture or antiphase I IgG antibody titer >1:800

2) Evidence of endocardial involvement with

positive echocardiogram

Oscillating intracardiac mass on valve

Abscess, or

New partial dehiscence of prosthetic valve or

New valvular regurgitation

Minor criteriaPredisposing factor: known cardiac lesion,

recreational drug injection

Fever >38°C

Evidence of embolism: arterial emboli, pulmonary infarcts, Janeway lesions, conjunctival hemorrhage.

Immunological problems: glomerulonephritis, Osler's nodes

Positive blood culture (that doesn't meet a major criterion) or serologic evidence

Positive echocardiogram (that doesn't meet a major criterion) (this criterion has been removed from the modified Duke criteria)

Clinical criteria

a) 2 major

b) 1 major 3 minor

c) 5 minor

Possible IE

a) 1 major 1 minor

b) 3 minor

Rejected

a) Fewer criteria

b) Alternative explaination identified

c) Fever resolved within 4 days

IE in Addicts Staph aureus 60%

80-90% involve tricuspid valve

Enterococci streptococci 20- 30%

Remainder 10%

Gram –ve aerobic bacilli and fungi

complicationsCongestive heart failure

Most common complication

Main indication to surgical treatment

60% of IE patients

Uncontrolled infection

Persisting infection

Peri-valvular extension in infective endocarditis

Systemic embolism

Brain, spleen and lungs

Complication…. Neurologic events

Acute kidney injury

Rheumatic problems

Myocarditis

Treatment Inj. Vancomycin 1g I/V B.D

Inj. ceftriaxone 2g I/V B.D

Cap. omeprazole 40mg 1 P.O B.D

Inf. Normal Saline 1000cc I/V O.D

Tab. Panadol 2 PO TDS

Drug therapy

Role of surgeryIndication Acute heart failure unresponsive to medical treatment

Infection (unresponsive to medical treatment) 10 days

Fungal endocarditis

Septal abscess

Fragile vegetation on echo

Role of AnticoagulationNative valveContra indicated(intracerebral hemorrhage)

Prosthetic valveControversial(because reversal leads to thrombosis)

Discontinue anticoagulation during septic phase of staph aureus

Staph Aureus prosthetic valve IE+CNS embolism (discontinue anticoagulation for first 2 week therapy)

Role of TherapyDefervescence occur in 3-4 days in case of

viridans,enterococci

Fever commonly persists 9-12 days

Blood culture should be taken for sterilization

Relapse occur 1-2 month after completion of therapy

ProphylaxisCardiac condition Prosthetic cardiac valve

Previous infective endocarditis

Conginital heart diseases

Non cardiac condition All dental procedure

Respiratory tract procedure that involve incision

Procedure of infected skin

Musculoskeletal tissue

Prophylaxis…Oral Amoxicillin 2 g 1 hr before procedure

Clindamycin 600 mg

Penicillin allergy clarithromycin azithromycin 500mg

Parenteral

Ampicillin 2g I/V,I/M 30 min before procedure

Clindamycin 600 mg

Cefazolin 1g

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