Infective Endocarditis & R.F

8/18/2019 Infective Endocarditis & R.F

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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).


12/17

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.


13/17

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.


14/17

-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

-

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


15/17

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


16/17

For arthritis:

-

Salicylates we use them in high dose 600mg/kg or NSAIDs x 3 weeks

-

Usually excellent response

- If poor response: diagnosis in question

For Carditis:

-

Pts with Carditis its recommended to take steroids beside aspirin.

- Prednisone 1 -2 mg/kg/d (max 60 mg) x 10 - 15 days.

-

If simultaneous arthritis and carditis: steroids alone sufficient but most

cardiologist starts with aspirin.

For Sydenham's chorea:

-

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

-

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).


17/17

Pts with valvular disease (mitral regurge or stenosis or aortic regurge) we give them

lifelong penicillin treatment.

Conclusions:

-

Acute Rheumatic Fever leading to Rheumatic Heart Disease is a majorproblem world wide.

-

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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Infective Endocarditis & R.F