Download Infective endocarditis: Clinical case

Infective endocarditis:
Clinical case
Nina Ajmone Marsan, MD, PhD
73 year-old man
Known with:
• Hypertension (therapy with amlodipine and doxazosine)
• COPD GOLD II (therapy with prednisone)
• Chronic anemia by myelodysplasia
• 2013: PTA arteria iliaca communis (therapy with ASA)
• Cardiac murmur due to moderate aortic stenosis: asymptomatic
Episode of flu (myalgia, arthralgia, fever, headache)
After 2 weeks no fever anymore but severe back-pain and general
unwellness
Hospitalized in a peripheral hospital:
• No signs of decompensation, Splinter haemorrhage, subfebriel
• Increased inflammatory parameters: CRP 138 mlg/L, ESR 66 mm/h,
Hb 5.4 mmol/L, leukocytes 12.9 10<9/L
• BNP: 50 pmol/L, Creatinine 136 micromol/L, MDRD 45 ml/min/1.73m2
• Two blood culture positive for streptococcus gallolyticus
• Started therapy with benzylpennicilline ev
During hospitalization of 2 weeks:
Persistent increased inflammatory parameters despite
antibiotic therapy,
Bordeline fever with only once 38.4°C
Blood culture still positive for Str. Gallolyticus
CT scan thorax and abdomen:
Pleura-effusion
Small abscess of left ileopsas muscle
Diffuse severe calcification of thoracic aorta
FDG-PET scan:
no clear endocarditis focus
Possible abscess left ileopsoas muscle
Pleura-effusion without FDG accumulation
Thorax CT scan
FDG-PET scan
First contact with the endocarditis team for surgical
options
Patient transferred to our
tertiary Center
Repeated blood culture
negative for S. Gallolyticus
Development of pneumonia
started cefuroxim
stopped because of
progressive renal dysfunction
Endocarditis team decision:
Not operable
Too high risk operation
Euroscore 64%
Development of complete AV block for which reanimation
Afterwards significant neurological damage (coma)
According to neurologist not compatible with the reanimation.
Maybe embolic? Decision not to perform CT scan
Patient deceased after 1 day
What do the guidelines say?
Reasons for update

New algorithms for diagnosing IE

Multimodality imaging

Role of Endocarditis Team

Antibiotic prophylaxis unchanged!

Emphasis on the three “Es”:
Early diagnosis, Early therapy, Early surgery
What do the guidelines say?
Could we have prevented it?
NO!
Cardiac conditions at highest risk of IE for which
prophylaxis should be considered when a high-risk
procedure is performed
Emphasis on advise for dental hygiene!
What do the guidelines say?
Early diagnosis?
Diagnosis of Infective Endocarditis
“The classic Triad”
Signs of Infection
Signs of embolism
(some are immunological)
Signs of cardiac
disorder
Fever (90%)
Pulse loss
Murmur
Night sweats
Stroke
New murmur
Arthralgia
Myocardial infarction
Heart failure
Myalgia
Unilateral blindness
Anaemia
Haematuria
Weight loss
Petechiae
Clubbing
Splinter haemorrhage
Splenomegaly
Osler nodes
Glomerulonephritis
Jeneway lesions
Role of Imaging
Diagnosis of IE
ESC 2015 modified criteria
Definite: 2 Major or 1 Major+3 minor
or 5 minor
Possible:
1 Major + 1 minor
or 3 minor
Rejected: Firm alternative,
symptom resolution, no path evidence
Diagnostic algorithm for IE
ESC 2015 modified criteria
What do the guidelines say?
Early therapy?
Timely referred patient to
Endocarditis Team/Centre?
IIa / B
IIa / B
Predictors of poor outcome
What do the guidelines say?
Early surgery?
24
Indications and timing of surgery in left-sided valve IE
Indications for surgery
Timing
Class
Level
Emergency
I
B
Urgent
I
B
Urgent
I
B
Urgent/elective
I
C
Urgent
IIa
B
Urgent/elective
IIa
C
Aortic or mitral NVE or PVE with persistent vegetations >10 mm
after one or more embolic episode despite appropriate antibiotic
therapy.
Urgent
I
B
Aortic or mitral NVE with vegetations >10 mm, associated with
severe valve stenosis or regurgitation, and low operative risk.
Urgent
IIa
B
Aortic or mitral NVE or PVE with isolated very large vegetations
(>30 mm).
Urgent
IIa
B
IIb
C
1. Heart Failure
Aortic or mitral NVE or PVE with severe acute regurgitation,
obstruction or fistula causing refractory pulmonary oedema or
cardiogenic shock.
Aortic or mitral NVE or PVE with severe regurgitation or obstruction
causing symptoms of HF or echocardiographic signs of poor
haemodynamic tolerance.
2. Uncontrolled infection
Locally uncontrolled infection (abscess, false aneurysm, fistula,
enlarging vegetation).
Infection caused by fungi or multiresistant organisms.
Persisting positive blood cultures despite appropriate antibiotic
therapy and adequate control of septic metastatic foci.
PVE caused by staphylococci or non-HACEK Gram negative bacteria.
3. Prevention of embolism
Aortic or mitral NVE or PVE with isolated large vegetations
Urgent
(>15 mm) and no other indication for European
surgery.Heart Journal (2015) doi:10.1093/eurheartj/ehv319
www.escardio.org
25
Therapeutic strategy for patients with IE and
neurological complications
Neurological complication
• Clinical assessment
• Cerebral CT scan / MRI
• TTE / TOE
•
•
•
•
Yes
•
•
•
•
Intracranial haemorrhage
Coma
Severe comorbilities
Stroke with severe damage
Heart failure
Uncontrolled infection
Abscess
High embolic risk
No
Yes
No
Consider surgery
www.escardio.org
Conservative treatment
and monitoring
European Heart Journal (2015) doi:10.1093/eurheartj/ehv319
What do the guidelines say?
Controversial issues:
• Late development of peri-annular abscess?
• Mobile aortic plaque or vegetation? Embolic
risk?
• Patient inoperable since the beginning?
• Operative risk assessment…new score?