Download Mr. CC and Infective Endocarditis GUYZ WE NEED A WITTY TITLE!!!

“The Heart of the Problem”
A Case of Acute Renal Failure,
Infective Endocarditis and
Poor Nutrition
Professor Oliveira’s firm:
Jane Miller, Kristina Antonova,
Lav Joshi, Madeline Butcher
and Mark Bowers
The Plan
1) Present the case of Mr. CC
2) Discuss the topic of infective endocarditis
The case of Mr. CC
History
•
PC
– protracted vomiting
– renal failure (incidental)
•
DH
– nil, NKDA
•
SH
– Council house living with 3
siblings
– retired motor mechanic
– non-smoker, no alcohol
HPC
– 2-3/52 vomiting,  appetite ?cause
– GP organised OGD mild
gastritis , H. pylori, contd vomiting
 hospital
•
•
•
FH
– nil of note
PMH
– Hx of learning difficulties
– Vitiligo, Seborrhoeic keratosis,
Fibromyalgia
•
SE
–
–
–
–
Resp - chest infection
CVS - nil
ABDO - constipation BWO
Neuro - nil else
Examination
•
•
Unkempt, Cachectic, °JACCOL
HS I + II + 0
HR 80 reg
JVP 
No oedema
Resp
– Good air entry L=R
– good expansion
– RR =14
Abdo
– Soft, non-tender
– Faecal loading LIF
– dark urine
CVS
–
–
–
–
•
•
•
Neuro
– CN I - XII normal
– Tone, power, reflexes,
coordination and sensation
– plantars - down-going
Plan and Investigations
•
1) Bloods - recheck Ca, needs
•
•
•
•
•
•
•
PTH
2) Fluids
3) Antiemetics
4) Urine dipstick MSU
5) Fluid balance
6) Keep catheter in
7) Abdo USS
8) CXR
Na 145
K 3.9
Cl 109
HCO3 23
Ur 50.7
Cr 563
CRP 105.2
Bili 21
ALT 17
Alk P 70
Alb 21
Ca 2.26
P04 1.64
Adj Ca 2.64
Hb 9.0
Plts 157
WCC 9.3
Management and Progress
• Transfuse - 2 units blood
• USS Kidney (22/4)
• large 13.5
•  corticomedullary differentiation in keeping with acute tubular
necrosis (ATN).
• CXR and subsequent clinical signs indicated chest
infection.Rx Antibiotics: Augmentin and Erythromycin
• Haemodialysis started
• Renal biopsy (1/5)
• ATN, some crescents. Some form of immune complex disease 
?endocarditis
• not a small vessel disease
• IgG & C3 complexes seen - prednisolone started
Management and Progress 2
• Blood cultures (1/5)
• taken - but pt on AB. Advice from microbiology stop AB and
repeat BC
• Echo (1/5)
• marked thickening of leaflet tip with small mobile lesion
• AR Murmur heard (10/5)
• Normal PR interval on ECG
• IV gentamicin and benzylpenicillin started
• Splinter Haemorrhage right toe (13/5)
• Bilateral small pleural effusions (13/5)
Management and Progress 3
• Rash over both shins- non blanching (16/5)
• Intermittently pyrexial, referred to cardiologist (22/5)
• TOE- broad jet of severe AR arising from the left
coronary cusp (23/5)
• Plan: Replace aortic valve
• MaxFax review (23/5)
• Oral hygiene very poor
• pre-op oral scale and polish and antibiotic cover
• AV replacement carried out (24/5)
Progress to Date
• Pt has had 23% wt loss since admission
• Pt refusing oral nutrition, and unable tolerate NG
tube
• PEG tube inserted (17/7)
Topic of interest:
Infective Endocarditis
Definition
• Infection of the endocardium, vascular
endothelium of the heart or intracardiac foreign
bodies.
• May occur as acute infection (e.g. <24hrs after
surgery)
• More commonly runs an insidious course :
Subacute Bacterial Endocarditis (SBE)
Incidence
• Approx. annual incidence in UK is 6-7 per
100,000.
• Differing ages, mainly middle-age/elderly.
• More common in men.
• St. George’s: range of between 6-17 cases seen per
year (between 1991-1999)
Diagnosis
• New regurgitant murmur
+
• Continuous/remitting fever
=
• Endocarditis until proven otherwise
Diagnosis
• Duke clinical criteria.
2 major criteria
or
1 major & 3 minor criteria
or
5 minor criteria
Dukes Criteria
Major
• Typical organism in 2 separate cultures or
persistently +ve blood cultures (>3, >12 hrs apart)
• +ve echocardiogram (vegetation, abscess) or new
valvular regurgitation
Minor
• Predisposition
• Fever >38˚C
• Vascular/ immunological phenomena (splinter
haemorrhages, Osler’s nodes)
• +ve blood cultures (not meet major criteria)
• +ve echocardiogram (not meet major criteria)
Aetiology
Agent
Prevalance
Streptococci .
.
60-80%
Viridan
.
.
. 30-40%
Enterococci
Other Strep.
.
.
.
.
.
.
Staphlococci .
.
20-35%
Coagulase +ve .
.
. 10-27%
Coagulase -ve .
.
.
Gram -ve aerobic bacilli
Fungi .
.
.
Miscellanous Bacteria
Mixed .
.
.
Culture -ve .
.
5-18%
15-25%
1-3%
. 1.5-3%
. 2-4%
. <5%
. 1-2%
. <24%
Pathogenesis
Damaged endocardium
Adherence of vWF
Adherence of bacteria
Adherence of platelets
Platelets bind fibrin
Vegetation formation
• Vegetations usually form on the edge of valves.
• The organisms destroy the valves.
Conditions Predisposing to IE
Structural cardiac
abnormalities
• AS, AR
• Bicuspid aortic valves
• MS, MR
• Senile mitral ring
calcification
Factors altering
immunity
• Immunosuppression
• Diabetes
• Chronic alcoholism
External factors
• Mechanical valves
• Indwelling vascular
catheters
• Pacing wires (IV)
Factors causing
bacteraemia
• Dental work
• IV drug misuse
• Urogenital/GI
operations
Clinical Features of SBE
General
• Malaise
• Fever
• Night sweats
• Anaemia
• Clubbing
• Weight loss
Eyes
• Roth spots
• Conjunctival splinter
haemorrhages
Arthralgia
Skin
• Osler’s nodes
• Janeway lesions
• Splinter haemorrhages
• Petechiae
Cardiac
• Murmurs
• Cardiac failure
Splenomegaly
Haematuria
Cerebral emboli/abscess
Kidney
• Glomerulonephritis
Stigmata of SBE
•
•
•
•
•
•
•
Clubbing (2%)
Roth spots
Conjunctival splinter haemorrhages
Osler’s nodes
Janeway lesions
Splinter haemorrhages
Petechiae
Janeway Lesions
Janeway lesions appear as flat, painless, red to bluish-red spots on the palms and soles.
Osler’s Nodes
Clubbing
Splinter Haemorrhages
Roth Spots
Investigations
• Non-specific Tests
– FBC: normocytic normochromic anaemia,
neutrophil leucocytosis
– U+E’s (Mg2+), LFT’s
– ESR/CRP: elevated
– Urinalysis: microscopic haematuria
• Blood Cultures: at least 3 set from different sites at
different times (take BEFORE AB administered)
• Echocardiography: TTE or TOE
• ECG: prolonged P-R interval
• CXR: cardiomegaly
Management
• Pathogens embedded in vegetation
– partially protects from cellular & humoral
defence mechanisms
• Prolonged high dose combination of IV
antibiotics (for at least 4wks - less in
uncomplicated Strep. viridans)
Management contd
• Cidal drugs
Usually penicillin & gentamicin, if IVDA/hospital aquired/on
haemodialysis use vancomycin instead of penicillin ( add
rifampicin with coagulase -ve staph. or Staph. aureus, use
ampicillin/amoxycillin instead of penicillin for Enterococci)
[Antibiotic treatment of streptococcal, enterococcal,
and staphlyoccal endocarditis. Heart 1998;79:207-210]
• Tailour AB’s in light of culture results
• Role of Surgery (consider early)
– MR at presentation
– Not controlled by AB’s
Complications
• Cardiac
– Valve incompetence (Ao>M)
– Intracardiac fistulae/abscesses
– Mycotic aneurysm rupture
(pyohaemopericardium, pericardial tamponade, ASD, VSD, aortopulmonary communication)
• Extra cardiac
–
–
–
–
Arterial embolism (CNS, kidney)
Diffuse immune complex mediated nephritis
Focal embolic glomerularnephritis
Drug hypersensitivity
Prognosis
• 30% mortality with Staphylococcus
• 14% mortality with bowel organisms
• 6% mortality with sensitive Streptococcus
• VT/VF/Sudden death < 1%
• Poorer prognosis if develop CCF from acute
severe Ao regurge
• Thromboembolic complications:
– more in mitral than Ao valve disease
– greater risk with mobile &/or large vegetations
Prevention
• Prevent Rheumatic fever
• Pre-existing valve lesions
– Good oral hygiene
– Antibiotic prophylaxis for surgery & dental
procedures
• Pts in hospital
– Care of IV lines/catheters etc
• IVDA
– Education, needle exchange programmes
Thank you
Any Questions ?