MCQ Dentogist
MCQ Dentogist
MCQ Dentogist
Lecture 5
:INFECTIVE ENDOCARDITIS
Abnormal valve or endothelium make infection more easy , but infective endocarditis
can involve normal valves and endothelium specially if the organism is highly
.virulent
infective endocarditis can be divided into acute and sub-acute according to the
severity and acuteness of symptoms ( really this reflect how virulent the
.microorganism is )
It's also resemble a challenge to the immune system , which will attack aggressively
.leading to immunologic manifestations of the disease
Pulmonary valve is a rare site for infective endocarditis , while tricuspid valve is
usually involved in intravenous drug users and the case is often acute rather than sub-
.acute infective endocarditis
Staph. aureus is the most common cause of acute infective endocarditis , especially
.in intravenous drug users
Viridans group of streptococci (from the upper respiratory tract or gums) and
enterococci (from the gut or urinary tract) are the most common cause of subacute
infective endocarditis.
Staph. epidermidis, ( post-operative endocarditis) (after cardiac surgery), Gram-
negative HACEK group (Haemophilus spp., Actinobacillus actinomycetemcomitans,
Cardiobacterium hominis, Eikenella spp. And Kingella kingae), Coxiella burnetii (Q
fever) , Brucella , Yeasts and fungi all can cause infective endocarditis
abnormal valve lesion or congenital heart disease , insertion of a foreign bodies into
the blood stream ( like catheters ) or a procedure which may induce bacteremia can
increase risk of infective endocarditis.
Prosthetic valve are prone to infection , in the first two month after operation by high
virulent microorganisms (like staph. aureus ) resembling acute infective endocarditis ,
After two months , low virulent organisms( coagulase negative staph or viridans
group) are more common leading to subacute infective endocarditis .
Clinical features :
First lets agree that when a valve is damaged the first thing to be affected is its closure
(regurgitation).
To simplify this imagine a well fitted door , if you hit this door strong enough to
cause damage or if you add a peace of wood to the door , its opening will not or will
be affected much less than its closure , cardiac valve is this door .
The two typical and expected signs of infective endocarditis are :
Fever (90%)..(its an infection)
Murmur (85%) ..(the abnormal sound heard when the blood passes through an
abnormal valve).. when we whistle ,we narrowed the opening of the mouth , this is
the same concept , the blood pass through narrow opening which remains due to
abnormal valve closure.
how acute and sever the symptoms and systemic manifestations ( embolic or
immunologic )depends on the virulence of the microorganism :
in acute infective endocarditis the fever is high grade , valve damage and heart
murmur is more obvious and septic emboli (like cerebral septic emboli or osler nodes
–which is painful subcutaneous nodules on the distal pads of the fingers or toes- may
occur.
In sub-acute infective endocarditis the course of the disease is more indolent , the
usual story is development of fever , sweating mainly at night , malaise and a new
valvular murmur in a patient with known congenital or valvular (including prosthetic
valves)heart disease , there may be a backache , joint pain and embolic and immune
complex mediated manifestations *( Osler’s nodes (painful, subcutaneous nodules on
the distal pads of the fingers or toes, Janeway’s lesions (hemorrhagic, nonpainful
macules on the palms and soles) and Roth’s spots(retinal hemorrhages with small
central clearing. Also the immune complexes may invade kidney causing interstitial
nephritis or glomerulonephritis or even renal failure.
Also infective endocarditis can change or initiate a heart murmur so finding a new
heart murmur or change already known murmur is a major criteria.
Treatment :
For treating infective endocarditis we should put in mind :
1. there is no role for oral antibiotics
2.Any source of infection (e.g. dental abscess) should be removed as
soon as possible.
3. the vegetation provide a shield to microorganisms so treatment duration should be
prolonged ( 4 to 6 weeks except in uncomplicated right sided native valve
endocarditis due to Methicillin sensitive bacteria , which can be treated for 2 weeks)
4. we should choose bactericidal antibiotics.
5. in patients with normal cardiovascular function ,awaiting culture results is
reasonable , in those with poor cardiovascular function empirical antibiotics should be
started while awaiting culture results and the following are a reasonable approach
Prevention
Provide prophylaxis for IE only in patients with the highest risk, including those with:
• prosthetic cardiac valve
• history of IE
• unrepaired cyanotic congenital heart disease
• repaired congenital heart defect with prosthesis or shunt (≤6 months post-procedure)
or residual defect
• valvulopathy following cardiac transplantation