MICROORGANISMS RELATED MICROORGANISMS RELATED TO CARDIAC INFECTIONSTO CARDIAC INFECTIONS

Ramlan SadeliRamlan Sadeli

CARDIAC INFECTIONS :CARDIAC INFECTIONS :

Infective endocarditisInfective endocarditis

Myocarditis Myocarditis

Pericarditis Pericarditis

INFECTIVE ENDOCARDITISINFECTIVE ENDOCARDITIS

The proliferation of microorganisms on The proliferation of microorganisms on to endothelium of the heart. The to endothelium of the heart. The prototypic lesion at the site of prototypic lesion at the site of infection : the vegetation; is a mass of infection : the vegetation; is a mass of platelets, fibrins, micro-colonies of platelets, fibrins, micro-colonies of microorganisms and scant microorganisms and scant inflammatory cells.inflammatory cells.

INFECTIVE ENDOCARDITIS :INFECTIVE ENDOCARDITIS :

Infection most commonly involves Infection most commonly involves heart valvesheart valves

May also occur on the ventricular May also occur on the ventricular septum (on the lower pressure site)septum (on the lower pressure site)

Or on the mitral endocardiumOr on the mitral endocardium

CLASSIFICATION BASE ON :CLASSIFICATION BASE ON :

Temporal evolution of diseaseTemporal evolution of disease

Site of infectionsSite of infections

The cause of infectionsThe cause of infections

Predisposing risk factor Predisposing risk factor

PORTAL OF ENTRY :PORTAL OF ENTRY :

Community-acquired native valve Community-acquired native valve

Endocarditis :Endocarditis :

Oral cavityOral cavity

Skin Skin

Upper respiratory tractUpper respiratory tract

Etiology :Etiology :- Viridans streptococciViridans streptococci- StaphylococciStaphylococci- HaemophilusHaemophilus- ActinobacillusActinobacillus- CardiobacteriumCardiobacterium- EikenellaEikenella- KingellaKingella

PORTAL OF ENTRY :PORTAL OF ENTRY :

Community-acquired :Community-acquired :

Gastrointestinal tractGastrointestinal tract

Genitourinary tractGenitourinary tract

Etiology :Etiology :

StreptococcusStreptococcus

EnterococciEnterococci

PORTAL OF ENTRY :PORTAL OF ENTRY :

Nosocomial infection :Nosocomial infection :

Intravascular catheterIntravascular catheter

Nosocomial woundNosocomial wound

Urinary tract infectionsUrinary tract infections

Etiology :Etiology :

Staphylococci (coagulase-negative)Staphylococci (coagulase-negative)

S. aureusS. aureus

Gram negative bacilliGram negative bacilli

DiphtheroidDiphtheroid

Fungi Fungi

Etiology of endocarditis among injection Etiology of endocarditis among injection

drug users :drug users :

S. aureusS. aureus

Pseudomonas aeruginosaPseudomonas aeruginosa

CandidaCandida

BacillusBacillus

LactobacillusLactobacillus

CorynebacteriumCorynebacterium

5-15% of patients with endocarditis have 5-15% of patients with endocarditis have negative blood culturenegative blood culture

1/3 – ½ of these cases, cultures negative 1/3 – ½ of these cases, cultures negative because of prior antibiotic exposurebecause of prior antibiotic exposure

The remainder of these patients are The remainder of these patients are infected by fastidious organismsinfected by fastidious organisms

Pathogenesis :Pathogenesis :

The normal endothelium is resistant to The normal endothelium is resistant to infectionsinfections

Direct infections by virulent organisms (S. Direct infections by virulent organisms (S. aureus can adhere directly to intact aureus can adhere directly to intact endothelium or exposed sub-endothelium endothelium or exposed sub-endothelium tissue)tissue)

Development of an uninfected platelet-fibrin Development of an uninfected platelet-fibrin thrombus thrombus serves as site of bacterial serves as site of bacterial attachmentattachment

Diagnosis :Diagnosis :

The diagnosis of infection endocarditis is The diagnosis of infection endocarditis is

Established with certainty only when :Established with certainty only when :

Vegetations obtained at cardiac Vegetations obtained at cardiac surgerysurgery

At autopsyAt autopsy

Or from an embolus are examined Or from an embolus are examined histologically and microbiologicallyhistologically and microbiologically

Tabel 1. The Duke Criteria for the Clinical Diagnosis of Infective Tabel 1. The Duke Criteria for the Clinical Diagnosis of Infective Endocarditis Endocarditis

Major criteriaMajor criteria

1. Positive blood culture :1. Positive blood culture :

- Typical microorganisms for infective endocarditis from two separate blood - Typical microorganisms for infective endocarditis from two separate blood

cultureculture

- Persistently positive blood culture- Persistently positive blood culture

- Single positive blood culture for Coxiella burnetii or phase I IgG antibody t iter- Single positive blood culture for Coxiella burnetii or phase I IgG antibody t iter

of 1 : 800of 1 : 800

Major CriteriaMajor Criteria

2. Evidence of endocardial involvement2. Evidence of endocardial involvement

- positive echocardiogram- positive echocardiogram

- new valvular regurgitation- new valvular regurgitation

Minor CriteriaMinor Criteria

1.1. PredispositionPredisposition

2.2. FeverFever

3.3. Vascular phenomenaVascular phenomena

4.4. Immunologic phenomenaImmunologic phenomena

5.5. Microbiologic evidenceMicrobiologic evidence

Bacteremic Pattern

Definite infective endocarditisDefinite infective endocarditis

Two mayor criteriaTwo mayor criteria

One mayor criterion and 3 minor One mayor criterion and 3 minor criteriacriteria

Five minor criteriaFive minor criteria

Possible infective endocarditisPossible infective endocarditis

One mayor and 1 minor criterionOne mayor and 1 minor criterion

Three minor criteriaThree minor criteria

Treatment :Treatment :

Since all bacteria in the vegetation Since all bacteria in the vegetation must be killed, therapy for endocarditis must be killed, therapy for endocarditis must be bactericidal and must be given must be bactericidal and must be given for prolonged periodfor prolonged period

Are given par-enterallyAre given par-enterally

Requires precise knowledge of the Requires precise knowledge of the susceptibility of the causative susceptibility of the causative microorganismsmicroorganisms

MyocarditisMyocarditis

Cardiac inflammation is most commonly Cardiac inflammation is most commonly the result of an infectious processthe result of an infectious process

Most commonly caused by viruses, Most commonly caused by viruses, especially coxsackie virus Bespecially coxsackie virus B

Clinical manifestations :Clinical manifestations :

AsymptomaticAsymptomatic

Fulminant condition, with arrhytmia, Fulminant condition, with arrhytmia, heart failure, and deathheart failure, and death

Most often self-limited and without Most often self-limited and without sequelaesequelae

Or progresses to a chronic form and to Or progresses to a chronic form and to dilated cardiomyopathydilated cardiomyopathy

Often a history of flu-like syndrome, Often a history of flu-like syndrome, viral nasopharyngitis or tonsillitisviral nasopharyngitis or tonsillitis

Bacterial myocarditis :Bacterial myocarditis :

Usually as a complication of Usually as a complication of endocarditisendocarditis

Patients with diphtheria may develop Patients with diphtheria may develop diphtheritic myocarditisdiphtheritic myocarditis

Diagnosis :Diagnosis :

The isolation of virus from the stool, The isolation of virus from the stool, pharyngeal washing or other body fluidpharyngeal washing or other body fluid

Changes in specific antibody titersChanges in specific antibody titers

Endomyocardial biopsyEndomyocardial biopsy

MyocarditisMyocarditis

Treatment :Treatment :

Beta interferonBeta interferon

Bed restBed rest

Drug for congestive heart failureDrug for congestive heart failure

arrythmiaarrythmia

anticoagulationanticoagulation

MyocarditisMyocarditis

Full recovery is usualFull recovery is usual

Fulminant cases require heart Fulminant cases require heart transplanttransplant

Acute pericarditis :Acute pericarditis :

The most common pathologic process The most common pathologic process involving pericardiuminvolving pericardium

May be classified both clinically and May be classified both clinically and etiologicallyetiologically

Clinical manifestations :Clinical manifestations :

Chest pain, pericardial friction rub, Chest pain, pericardial friction rub, electrocardiographic change, electrocardiographic change, pericardial effusion with cardiac pericardial effusion with cardiac tamponade and paradoxal pulsetamponade and paradoxal pulse

Pain is often absent in a slowly Pain is often absent in a slowly developing tuberculosis, post-developing tuberculosis, post-irradiation, neo-plastic, or uremic irradiation, neo-plastic, or uremic pericarditispericarditis

Etiology of infective pericarditis :Etiology of infective pericarditis :

- Viral :- Viral :

– Coxsackie virus A and BCoxsackie virus A and B

– EchovirusEchovirus

– MumpsMumps

– Adenovirus Adenovirus

– HepatitisHepatitis

– HIVHIV

- Pyogenic bacteria :Pyogenic bacteria :

– PneumococcusPneumococcus

– StreptococcusStreptococcus

– StaphylococcusStaphylococcus

– NeisseriaNeisseria

– LegionellaLegionella

- M. tuberculosisM. tuberculosis

- Fungal :Fungal :

– CandidaCandida

– HistoplasmaHistoplasma

– BlastomycesBlastomyces

– CoccidioidesCoccidioides

- Other infections :Other infections :

– SyphiliticSyphilitic

– ProtozoalProtozoal

– ParasiticParasitic

PericarditisPericarditis

Diagnosis :Diagnosis :

Echocardiography should be performed immediatelyEchocardiography should be performed immediately

- allows assesment of pericardial thickness, pericrdial- allows assesment of pericardial thickness, pericrdial

fluid and tamponadefluid and tamponade

- can be used to guide emergency pericariocentesis- can be used to guide emergency pericariocentesis

electrocardiogram shows diffuse ST and T changes,electrocardiogram shows diffuse ST and T changes,

depressed PR interval, decreased QRS voltagedepressed PR interval, decreased QRS voltage

Laboratory diagnosis :Laboratory diagnosis :

Pericardiocenthesis :Pericardiocenthesis :

Pericardial effusion nearly always has Pericardial effusion nearly always has the physical characteristics of an the physical characteristics of an exudateexudate

Bloody fluid is commonly due to Bloody fluid is commonly due to tuberculosistuberculosis

Or post-cardiac injury, post myocardial Or post-cardiac injury, post myocardial infarctions, and neoplasm, and effusion infarctions, and neoplasm, and effusion of rheumatic feverof rheumatic fever

Microscopic examination :Microscopic examination :

Gram-stain smear of the centrifuged Gram-stain smear of the centrifuged sediment of clear or slightly cloudy fluid sediment of clear or slightly cloudy fluid should be examinedshould be examined

Purulent material should be smeared Purulent material should be smeared directlydirectly

CultureCulture

Culture perform onto a variety of Culture perform onto a variety of specialized agar media for identification, specialized agar media for identification, base on microscopic examinationbase on microscopic examination

PericarditisPericarditis

Pericardial biopsy improves the diagnostic yieldPericardial biopsy improves the diagnostic yield

Viral or idiopathic pericarditis is self-limitingViral or idiopathic pericarditis is self-limiting

Purulent pericarditis requires emergency surgical Purulent pericarditis requires emergency surgical drainage and systemic antibioticdrainage and systemic antibiotic

Mortality is 30 %Mortality is 30 %

PericarditisPericarditis

Tuberculous pericarditis is treated with :Tuberculous pericarditis is treated with :

- a four-drug antituberculous regimen- a four-drug antituberculous regimen

= prednison to prevent constriction= prednison to prevent constriction

- calcific form requires pericardiectomy- calcific form requires pericardiectomy

Post streptococcal infection :Post streptococcal infection :

Following an acute Group A Following an acute Group A streptococcal infections (e.g. sore streptococcal infections (e.g. sore throat), there is a latent period of 1 – 4 throat), there is a latent period of 1 – 4 weeks after which rheumatic fever weeks after which rheumatic fever nephritis occasionally developsnephritis occasionally develops

Rheumatic fever :Rheumatic fever :

The most serious sequelae of The most serious sequelae of hemolytic streptococcal infectionshemolytic streptococcal infections

It results in damage to heart muscle It results in damage to heart muscle and valvesand valves

Antibodies of cell membrane antigen of Antibodies of cell membrane antigen of staphylococci cross react with the staphylococci cross react with the human tissue antigenhuman tissue antigen

The carditis characteristically leads to The carditis characteristically leads to thickened and deformed valvethickened and deformed valve

And to perivascular granulomas in the And to perivascular granulomas in the myocardium (Aschoff bodies) that are myocardium (Aschoff bodies) that are finally replace by scar tissuefinally replace by scar tissue

Rheumatic fever has marked tendency Rheumatic fever has marked tendency to be reactivated by recurrent to be reactivated by recurrent streptococcal infectionsstreptococcal infections

The first attack of rheumatic fever The first attack of rheumatic fever usually produce only slight cardiac usually produce only slight cardiac damagedamage

It is therefore important to protect such It is therefore important to protect such patient from recurrent beta-haemolytic patient from recurrent beta-haemolytic Group A streptococcal infectionsGroup A streptococcal infections