INFECTIVE ENDOCARDITIS MYOCARDITIS PERICARDITIS DR M KHONGA BSc

INFECTIVE ENDOCARDITIS, MYOCARDITIS & PERICARDITIS DR. M. KHONGA BSc, MBBS Department of Pathology and Medical Laboratory Sciences College of Medicine

LEARNING OBJECTIVES (1) • INFECTIVE ENDOCARDITIS – Describe endocarditis – Explain the predisposing factors of endocarditis – List the clinical presentation (including the Duke’s criteria) – Explain how to diagnose endocarditis – Learn the major causes of endocarditis in native and prosthetic valves – Describe the treatment of endocarditis – List indications for prophylaxis in endocarditis prevention – List the complications of endocarditis

LEARNING OBJECTIVES (2) • Myocarditis –List possible causes of myocarditis and diagnosis of the different causes –Learn the clinical presentation of myocarditis • Pericarditis –List the major causes of pericarditis –Learn the clinical presentation of pericarditis

INFECTIVE ENDOCARDITIS • DEFINITION: – Infection of the endocardial surface of the heart, which may include one or more heart valves, the mural endocardium or septal defect. – May occur in an acute or subacute form • Categories of IE: – Native valve endocarditis (NVE) – Prosthetic valve endocarditis (PVE) • Early (within 60 days) and Late (after 60 days) – Intravenous drug abuse (IVDA) endocarditis

Pathogenesis • Occurs as a consequence of a non-bacterial thrombotic endocarditis – Results from turbulence or trauma to the endothelial surface of the heart – Thrombus: sterile platelet/fibrin vegetation • Transient bacteremia then seeds the sterile thrombus attracting further fibrin & platelet deposition • Pathologic effects due to infection can include – Local tissue destruction – Embolic phenomena, e. g. pulmonary infarcts – Secondary autoimmune effects, e. g. glomerulonephritis

• Transient bacteremia: – Dental procedures – Vigorous teeth cleaning & flossing – Surgical procedures • I &Ds • Heart valve replacement

Risk Factors • Native valve endocarditis: – Acquired valvular disease • Degenerative, e. g. Marfan syndrome, syphilitic disease • Post infective, e. g. rheumatic heart disease – Congenital heart disease • E. g. patent ductus arteriosus, ventricular septal defect, tetralogy of Fallot, etc • Prosthetic valve – Valves in the mitral position more susceptible than aortic position • Intravenous drug abuse

Etiological agents PATIENT GROUP MAJOR ETIOLOGIC AGENTS OF IE NATIVE VALVE 1. 2. 3. 4. 5. Oral Streptococci (viradans) & Enterococci Staphylococcus aureus Coaugulase negative s. Streptococci Gram negative (enteric) rods Fungi (mainly Candida) INTRAVENOUS DRUG ABUSE 1. 2. 3. 4. 5. Staphylococcus aureus Oral Streptococci (viradans) & Enterococci Gram negative (enteric) rods Fungi (mainly Candida) Coagulase negative Streptococci PROSTHETIC VALVE (EARLY) 1. 2. 3. 4. 5. Coagulase negative Streptococci Staphylococcus aureus Gram negative (enteric) rods Oral Streptococci (viradans) & Enterococci Fungi (mainly Candida) PROSTHETIC VALVE (LATE) 1. 2. 3. 4. 5. Oral Streptococci (viradans) & Enterococci Staphylococcus aureus Coagulase negative Streptococci Gram negative (enteric) rods Fungi (mainly Candida)

• Rarer causes: – HACEK organisms: • Haemophilus aphrophilus, • Actinobacillus actinomycetemcomitans, • Cardiobacterium hominis, • Eikella corrodens, • Kingella kingae – Coagulase negative organisms: • Chlamydia pneumoniae, Coxiella burnetii

Clinical Presentation • SYMPTOMS – Commonly vague: emphasize constitutional complaints, cardiac effects or secondary embolic phenomena – Relate to 4 ongoing processes: • Infectious process on the valve/local complications • Septic embolization to virtually any organ • Bacteremia , often with metastatic foci of infection • Circulating immune complexes

• SIGNS: • Main symptom: – fever (almost always) & (new) heart murmur • Non specific symptoms: – Anorexia, weight loss, malaise, chills, nausea, vomiting and night sweats – Classic signs: • • Splinter hemorrhages Olser nodes Janeway lesions Roths spots – Neurologic: • Embolic stroke • Intracerebral hemorrhage • Multiple microabscesses – Others: • Cardiac arrhthmia, pericardial rub, pallor, organ infarction

Splinter hemorrhage Osler nodes

Diagnosis • No specific: – WBC, ESR, CRP, Urine(microhaematuria) • Cardiac: Echocardiography – Transthoracic echocardiography (TTE) for native valves – Transesophageal echocardiography (TEE) for prosthetic valve • Microbiological: – Blood cultures: 3 sets – Serological: if culture negative suspected

Microbiological tests • Blood culture; – criterion standard test for diagnosing IE – Need to draw 3 separate sets of blood cultures over 24 hrs to document continuous bacteremia – Have to grow the same organism from different culture sets • Sensitivity testing: – Help with appropriate treatment therapy

Duke Classification Criteria • Combine clinical, microbiological, pathologic and echocardiographic characteristics of a single case • Used to make a definitive diagnosis of IE A. Major Microbiological (blood culture) criteria – – – 2 blood cultures positive for organisms found in IE Blood cultures persistently positive for one of these organisms (drawn more than 12 hrs apart) 3 or more separate blood cultures drawn at least 1 hr apart

B. Major echocardiography criteria: Echocardiogram positive for IE: – • – – – Oscillating intracardiac mass on a valve, in the path of regurgitant jets, or implanted material, in the absence of an anatomic explanation Myococardial abscess Development of partial dehiscence of a prosthetic valve New-onset vulvular regurgitation

C. Minor criteria include: – predisposing heart condition or drug abuse – Fever of 38⁰C or higher – Vascular phenomenon: • Major arterial emboli, septic pulmonary infarcts, intracranial hemorrhage, conjunctival hemorrhage or Janeway lesions – Immunologic phenomenon: • Glomerulonephritis, Osler nodes, Roths spots and rheumatoid factor – Positive blood culture results not meeting major criteria or serologic evidence of active infection

• A definitive diagnosis can be made based on: – 2 major criteria; or – 1 major criteria & 3 minor criteria; or – 5 minor criteria • A possible diagnosis of IE: – 1 major criterion & 1 minor criterion; or – 3 minor criteria • Rejected: – Firm alternative diagnosis – Resolution of IE syndrome with antibiotic therapy for <4 days – Don’t meet criteria for possible IE as above

Management principles • Antibiotics – – Intravenous to get acceptable levels Higher doses than in other individuals Combinations may be necessary for synergy Given over 4 to 6 wks • Monitor course of therapy – Clinical response, CRP • Consider surgery: – Extensive valvular damage – Early prosthetic valve endocarditis – Cardiac failure, embolic disease, fungal disease

Specific antibiotic treatment Group of organism Antibiotics Penicillin sensitive Streptococci Penicillin Reduced sensitivity Streptococci or Enterococci Penicillin plus gentamicin Penicillin resistant Streptococci or Enterococci Vancomycin plus gentamicin + rifampicin MSSA Cloxacillin MRSA Vancomycin plus rifampicin + gentamicin

Complications of IE • Myocardial infarction, pericarditis, cardiac arrhythmia • Congestive heart failure • Aortic root or mycordial abscesses • Arterial emboli • Arthritis • Glomerulonephritis, acute renal failure • Stroke syndromes • Mesenteric or splenic abscess or infarct

Prophylaxis against IE • Maintain good oral hygiene!! • Consider for people with: – Presence of a prosthetic heart valve – History of endocarditis • In patients undergoing surgical procedures that can cause transient bacteremia: – Dental procedures – Any procedure involving incision in the respiratory mucosa – Procedure on infected skin or musculoskeletal tissue, including incision & drainage of an abscess

LEARNING OBJECTIVES (2) • Myocarditis –List possible causes of myocarditis and diagnosis of the different causes –Learn the clinical presentation of myocarditis • Pericarditis –List the major causes of pericarditis –Learn the clinical presentation of pericarditis

MYOCARDITIS • Inflammatory disease of the myocardium – Has a wide range of clinical presentations • Usually manifests in a healthy person & can result in progressive (often fatal) heart failure & arrhythmia • Can be classified as: – Fulminant mycarditis: usually fatal – Acute myocarditis: may progress to dilated cardiomyopathy – Chronic active: clinical relapses – Chronic persistent myocarditis: histologic changes without ventricular dysfunction

Causes of myocarditis • Viral: – Coxsackie B, adenovirus, cytomegalovirus, Epstein_Barr virus, HIV-1, herpes simplex virus, rabies • Bacterial: – Diphtheria, tuberculosis, streptococci, clostridia, staphylococci • Fungal: – Candidiasis, aspergillosis, cryptococcosis • Drugs: – Chemotherapy drugs, antibiotics, antihypertensives, antiseizures

Clinical presentation • Usually present with signs and symptoms of acute heart failure – – Tachycardia Gallop ryhthm Mitral regurgitation Peripheral edema • Can also present with – Fever, chest pain, sweats, chills & dysnea

diagnosis • Lab studies may include: – Full blood count – Erythrocyte sedimentation rate (& other acute phase reactants, e. g. C-reactive protein) – Rheumatologic screening to rule out systemic inflammatory diseases – Cardiac enzymes, e. g. creatinine kinase, cardiac tropinin – Serum viral antibody titers for viral myocarditis – Myocardial biopsy for histology

PERICARDITIS • Inflammation of the pericardium – Characterised by chest pain, pericardial friction rub & serial ECG changes • Signs & symptoms: – Chest pain: with referral to trapezius ridge, neck, left shoulder or arm – Fever, dyspnoea, cough, – Signs of heart failure – In TB pericarditis: fever, night sweats, weight loss, pericardial effusion

Causes of pericarditis • Idiopathic • Infectious: viral, bacterial, tuberculous • Inflammatory disorders: rheumatic fever • Metabolic disorders: renal failure, • Cardiovascular disorders: acute MI

• Diagnosis: – ECG, cardiac echo, chest radiography & lab studies • Management: – Directed according to the underlying cause – Example: TB pericarditis • Antituberculous drugs & steroids • ? pericardiocentesis