Right sided valve infective endocarditis by dr adeel
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Transcript of Right sided valve infective endocarditis by dr adeel
Bio dataName Usman S/O Zulfiqar Ali Khan
Age 24 years
Sex Male,
Religion Muslim,
Resident of Allama Iqbal Town, Lahore.
M.O.A= Out Patient Dept., Mayo Hospital, Lahore
D.O.A= 29/3/14
History of presenting illnessPatient is , normotensive, normoglycemic known I.V drug abuser for 7 years presented with complains of fever from last 15 days. Fever was sudden in onset, high grade, associated with rigors and chills that relieved by taking medication, along with fever patient also complains of malaise generalized body weakness .
For last 7 days patient also complaining of shortness of breath there is no history of orthopnea and PND.
Cough was associated with sputum that was white in color and small in quantity.
Past historyHistory of visits to hospital OPD
No history of hospital admissions for any other disease
No history of any surgery in the past
Family historyHe is married male
Divorced his wife
No family history of diabetes hypertension IHD asthma or TB.
General physical examinationAn ill looking young man lying 0n bed, well oriented in time, place and person, i/v line passed in left arm.
Vitals are:
Pulse: 88/min,
B.P: 100/60
Temp: 100 F
Respiratory rate: 22/min
GPE ….. Pallor +ve Cyanosis -ve Clubbing -ve Koilonychia -ve S /hemorrhage -ve Osler nodes absent Heberden nodes absent Boucard nodes absent Palmer erythema -ve Dupuytren contrature -ve Skin rash -ve Axillary nodes not palpable JVP not raised Thyroid normal Ankle edema absent Sign of dehyration +ve
CVSOn inspection; Shape of chest is normal.
On palpation; Apex beat in 5th intercostal space just medial to mid clavicular line,no other sound is palpable,no thrill,no murmur.
On auscultation; On Auscultation S1, S2 of normal intensity, A grade III,pan-systolic murmur with maximum intensity at left lower sternal border, high pitched, blowing in character and loud during inspiration best audible with diaphragm not radiating to any side.
RespiratoryOn inspection; Rate 22/m abdomino thoracic
shape of chest is normal with no striea no scar mark no pulsation.
On palpation; Trachea is central,apex beat in 5th in midclavicular line,chest movement and expansion within normal range,no vocal fremitus.
On purcussion; upper border of liver is in 5th
intercostal space.
On auscultation; Breath sounds are normal,noronchi,bi-basilar fine crepitations are there.
Gastro-intestinal systemOn inspection; Oral hygiene is poor , shape of
abdomen is normal,umblicus normal,no pulsation and no scar mark.
On palpation; Abdomen is mildly tender, no ascites,no visceromegaly.
On purcusion; Normal
On auscultation; B/S are audible,no bruit is present.
Hernial orifices and genitalia are normal.
PR not done.
Recap A 24 years male who is I/V drug abuser presented with
history of high grade fever,associated with rigors, complaining of shortness of breath for last 7 days, pallor on general physical examination and a murmur.
Assessment planAll baseline investigations (CBC, LFTs, RFTs, BSL,
Viral Markers)
Blood cultures from three different sites
ECG
Echocardiography
Urine complete
Chest X-ray
Sputum for AFB
ESR
HIV serology
Urine Complete COLOUR Deep yellow
PH 6
Specific gravity 1.030
Protein: +ve
Sugar: nil
Blood: +++
Pus cell : 3-5 cells
summary A 24 years old patient who is I/V drug abuser (Anti-
HCV,Anti- HIV +VE)presented with history of fever, that is high grade associated with rigors and chills,alsohaving history of malaise for up to a similar period,forlast 7 days he was complaining of shortness of breath ,pallor on general physical examination,anemia on FBC, tricuspid valve vegetation on echo and proteinurea and +++ red cell on urine complete
Modified Duke criteria1 A) Positive blood culture with typical IE microorganismTypical microorganism consistent with IE from 2 separate blood
culutre Viridans-group streptococci Streptococcus bovis, orHACEK group, orStaphylococcus aureus, orCommunity-acquired Enterococci,
B)Microorganisms consistent with IE from persistently positive blood cultures defined as: Two positive cultures of blood samples drawn >12 hours apart, or
All of 3 or a majority of 4 separate cultures of blood (with first and last sample drawn 1 hour apart)
Coxiella burnetii detected by at least one positive blood culture or antiphase I IgG antibody titer >1:800
2) Evidence of endocardial involvement with
positive echocardiogram
Oscillating intracardiac mass on valve
Abscess, or
New partial dehiscence of prosthetic valve or
New valvular regurgitation
Minor criteriaPredisposing factor: known cardiac lesion,
recreational drug injection
Fever >38°C
Evidence of embolism: arterial emboli, pulmonary infarcts, Janeway lesions, conjunctival hemorrhage.
Immunological problems: glomerulonephritis, Osler's nodes
Positive blood culture (that doesn't meet a major criterion) or serologic evidence
Positive echocardiogram (that doesn't meet a major criterion) (this criterion has been removed from the modified Duke criteria)
Clinical criteria
a) 2 major
b) 1 major 3 minor
c) 5 minor
Possible IE
a) 1 major 1 minor
b) 3 minor
Rejected
a) Fewer criteria
b) Alternative explaination identified
c) Fever resolved within 4 days
IE in Addicts Staph aureus 60%
80-90% involve tricuspid valve
Enterococci streptococci 20- 30%
Remainder 10%
Gram –ve aerobic bacilli and fungi
complicationsCongestive heart failure
Most common complication
Main indication to surgical treatment
60% of IE patients
Uncontrolled infection
Persisting infection
Peri-valvular extension in infective endocarditis
Systemic embolism
Brain, spleen and lungs
Treatment Inj. Vancomycin 1g I/V B.D
Inj. ceftriaxone 2g I/V B.D
Cap. omeprazole 40mg 1 P.O B.D
Inf. Normal Saline 1000cc I/V O.D
Tab. Panadol 2 PO TDS
Role of surgeryIndication Acute heart failure unresponsive to medical treatment
Infection (unresponsive to medical treatment) 10 days
Fungal endocarditis
Septal abscess
Fragile vegetation on echo
Role of AnticoagulationNative valveContra indicated(intracerebral hemorrhage)
Prosthetic valveControversial(because reversal leads to thrombosis)
Discontinue anticoagulation during septic phase of staph aureus
Staph Aureus prosthetic valve IE+CNS embolism (discontinue anticoagulation for first 2 week therapy)
Role of TherapyDefervescence occur in 3-4 days in case of
viridans,enterococci
Fever commonly persists 9-12 days
Blood culture should be taken for sterilization
Relapse occur 1-2 month after completion of therapy
ProphylaxisCardiac condition Prosthetic cardiac valve
Previous infective endocarditis
Conginital heart diseases
Non cardiac condition All dental procedure
Respiratory tract procedure that involve incision
Procedure of infected skin
Musculoskeletal tissue
Prophylaxis…Oral Amoxicillin 2 g 1 hr before procedure
Clindamycin 600 mg
Penicillin allergy clarithromycin azithromycin 500mg
Parenteral
Ampicillin 2g I/V,I/M 30 min before procedure
Clindamycin 600 mg
Cefazolin 1g