INFECTIVE ENDOCARDITIS

EFRIDA WARGANEGARA

INTRODUCTION

Infective endocarditis is an uncommon disease that often present as a Pyrexia of Unknown Origin (PUO), and is fatal if untreated

Infection involves the endothelial lining of the heart, including the heart valves

Occurs as an acute, rapidly progressive disease or subaccute form

Term infective endocarditis, first used by Thayer 1930, and later popularized by Lerner and Weinstein, is preferable to the old term bacterial endocarditis. Since Chlamudia, Rickettsia, Mycoplasma, fungi , and perhaps even virus may be responsible for the syndrome.

INTRODUCTION

In about 1/3 of patient, there is a pre-existing : - heart defect (congenital; acquired : result of rheumatic fever) or a prosthetic heart valve insitu

However, the patient may be unaware of any defect prior to the infection

INTRODUCTION

Etioloic Agent in Infective Endocarditis

AgentPercentage of

CasesStreptococci 60-80 Viridans streptococci 30-40 Enterococci 5-18 Other streptococci 15-25Staphylococci 20-35 Coagulase-positive 10-27 Coagulase-negattive 1-3Gram-negative aerobic bacilli 1.5-13Fungi 2-4Miscellaneous bacteria <5Mixed-infection 1-2"culture negative" <5-24

AetiologyAlmost any organism can cause

endocarditis, but infection of native valves is caused most commonly by species of Oral Streptococci : Viridans streptococcus (Strep. sanguis, Strept. oralis, Strept. mitis)

Alfa-hemolytic (but they may be nonhemolytic), most prevalent members of the normal flora of the URT and important for the healthy state of the mucous membranes there

About 1/4 - 1/3 of cases are caused by Staphylococcus and 80-90% of these due to Coagulase positive S. aureus attacks normal heart valves in 1/3 patient

Staphylococcus epidernidis is an important agent in prosthetic valve endocarditis and in infant with umbilical venous catheters in neonatal intensive care unit.

Aetiology

Coagulase-negative Staphylococcus are common causes of early prosthetic-valves endocarditis and are probably acquired at the time of surgery

The species causing late infection (>3 months) after cardiac surgery resemble more closely those seen in native valve endocarditis

Aetiology

Gram negative aerobic bacilli Narcotic addicts, prosthetic valve recipients, and patient with cirrhosis appear to be at an increased risk for the developed of gram negative bacillary endocarditis.

Unusual Gram negative bacteria, e.g. Neisseria gonorrhoeae – before the introduction of penicillin, but is now rarely.

Aetiology

Gram Positive bacilli : Infective endocarditis due to various sprecies of Corynebcterium (diphtheroid) is uncoomon and usually occurs on damaged or prosthetic velves, although native valves infection are rarely reported

Other bacteria, include Acinetobacter

Aetiology

Etiology Infective Endocarditis in Addicts Staph. aureus, P. aeruginosa, C. albicans, Enterococcus .

Fungi Most of fungal endocarditis can be grouped into 3 categories :1) Narcotic addicts; 2) patient after reconstructive cardiovarcular surgery; and 3) patient after prolonged intravenous and/or antibiotic therapy.

Aetiology

PathogenesisEndocarditis is an endogenous infection

acquired when m.o. entering the bloodstream establish themselves on the heart valves. Thus any bacteriemia may potentially result in endocarditis

Most commonly streptococcus from the oral flora enter the bloodstream (during dental procedure or vigourus teeth cleaning or flossing), and adhere to damaged heart valves

In the course of the bacteriemia, viridans streptococci, penumococci, or enterococci may settle on normal or previously deformed heart valves producing Accute Endocarditis

Subaccute endocarditis often involves abnormal valves (congenital deformities and rheumatic, or atherosclerotic lesion).Subaccute endocarditis, most frequently due to members of the normal flora of the resp. or intestinal tract that have accidently reached the blood

Pathogenesis

Subaccute Bacterial Endocarditis (SBE)

Viridans streptococcus ordinarily the most prevalen members of the upper resp trac flora, are also the most frequent cause of SBE

Group D streptococcus (enterococcus and S. bovis) also are common causes SBE, that 5-10% cases are due to enterococcus originating in the gut or urinary trac.

Pathogenesis

The lesion is slowly progressive, and a certain amount of healing accompanies the active inflammation : vegetation consist of fibrin, platelet, blood cells, and bacteria adherent to the valve leaflets multiplication attract further deposition of fibrin and platelet they are protected from the host defences and vegetation can grow to several centimeters in size

Pathogenesis

The clinical course is gradual, quite slow process and correspondingly the time period between the initial bacteriemia and the onset of symptom is around 5 weeks

The disease is variably fatal in untreated cases

Pathogenesis

Clinical FeatureThe patient almost always has a fever,

anemia, weakness, a heart murmur, embolic phenomena, and enlarged spleen and renal lesion

Also complain of nonspesific sympyom : anorexia, weight loss, malaise, chills, nausea, vomiting, and night sweats

Periheral manifestation may also be evident in the form of splinter haemorrhages and Osler’s nodes

Microscopic haematuria resulting from immune complex deposition in the kidney is a characteristic

Diagnosis

The blood culture is he single most important laboratory test.

Ideally 3 separate samples of blood should be collected within a 24-hour periode and before antimicrobial therapy

Isolation of the causative is essentially to enable antibiotic susceptibility test to be performed and optimal therapy

Treatment and PreventionTo complete eradication takes

several weeks Penicillin for susceptibility

streptococcus is a choice, if allergy erythromycin

For enterococus : combination penicillin/ampicillin with aminoglycoside

For staphylococcus : b-lactamase stable penicillin (oxacillin, may be combination with an aminoglycoside, rifampicin or fucidic acid. For methycillin-resistance stapylococcus : vancomycin or teicoplanin

Prevention : people with known heart defect should be given prophylactic antibiotic to protec them during dental surgery and any other invasive procedure that is likely to cause a transient bacteriemia

Treatment and Prevention

Myocarditis and Pericarditis

Efrida Warganegara

Aetiology and TransmissionGroup B, and to a lesser extend

group A coxsackieviruses and certain enteroviruses, are the main viral causes of myocarditis and pericarditis

Both condition are seen principally in adult male and are important because they can be mistaken for myocardial infarction, yet the prognoses is good and complete recovery is rule

Spread by fecal-oral and occasionally from pharyngeal sectretion

Mumps and influenzae are less common causes of myocarditis or pericarditis

Rubella can causes myocardiris and associated congenital lesion in the foetus

Aetiology and Transmission

Clinical Features and Pahogenesis

Ingested coxsackievirus spread from the pharynx or gut wall to the lymphatics and then to the blood

Invasion of heart or pericardium takes place across blood vessels and result in acute inflamation.

In the heart and pericardium this gives rise to dyspnoe, pain in the chest, and sometimes mimics a myocardial infarction

Diagnosis, treatment and prevention

Coxsackievirus may be isolated from throat swab, fecal specimens or pericardial fluid

Rising titres of neutralizing antibody may be demonstrable, or the presence of IgM antibodies in ELISA test

There are no spesific treatments and no vaccine for coxsackievirus infection

Terima Kasih