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ACUTE RHEUMATIC FEVER + INFECTIVE ENDOCARDITIS
Malak Abu-aqulah & Rahaf Hasan
6
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ACUTE RHEUMATIC FEVER
PS. At least there will be 6 questions about these two lectures inthe exam
In the past there were a lot of children have tonsillitis, their
parents may give them poached eggs or lemon or whatever and
after a period of time the child will develop joint pain, it was very
common (rheumatic fever), but now when the child have feverthey give him good antibiotic so the rheumatic fever significantly
decreased especially in Jordan.
Rheumatic feveris an acute systemic immune disease, when
bacteria attack the throat specifically tonsils the body start to
form antibodies against those bacteria and the result will be
immune complex, this immune complex has many complications,
the most important is pancarditis.
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The bacteria that is responsible to cause rheumatic fever is Group
A beta- hemolytic Streptococcal infection in the pharynx mainly
in tonsils, the same bacteria may attack the skin and cause scarlet
fever and skin lesions but it will not cause rheumatic fever, it mustbe in the throat.
There was a question about this point last year
Rheumatic fever with its immune complex has many
complications the most important one affects the heart, also
another complications on joints, skin, subcutaneous tissue and
brain.
In sum the immune complex form nodules called aschoff nodules
it depends where these nodules reach then it will cause
symptoms.
At the beginning the child have sore throat, tonsillitis and fever,
after a period of time there will be joint pain, joint pain usually
not important although it may develop to acute mono-arthritis itdoes not leave any deformities in the bone, just we are concern
about knowing that it is rheumatic fever to prevent pancarditis.
The incubation period for this disease about 2-3 weeks, the child
might have sore throat and tonsillitis and it will be subsided after
taking simple antibiotic, after 2-3 weeks incubation period joint
pain may reveal with the symptoms of rheumatic fever.
The most common ages affected by rheumatic fever are the
children between 5-15 years old, so its peak incidence 5-15 yrs
old, rarely we see patients pre to this period < 4 or after 40 yrs
old.
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Question: Why 5-15 yrs old is the most common ages to develop
rheumatic fever?
First of all we have to know that rheumatic fever cause
destruction to the main mitral (tricuspid) valve in the heart.
Answer: There are many theories to explain that, one of them
said that the structure of the mitral valve between 5-15 yrs old
exactly similar to the structure of the bacteria!, so the antibodies
attack against the bacteria and the heart. Before 4 yrs old and
after 40 yrs old the structure is different; the structure of the
tricuspid valve is different from the structure of the bacteria.
Another theory said that the immune complex end to have fibrin
and anti-inflammatory cells over it which will form aschoff
nodules which will cause many things that we will see later on.
It is not necessary that everyone have infection in beta hemolytic
anemia will develop rheumatic fever, it is just up to 3% even now
it is less than that.
Question: Does every patient or child come to us with sore throat
or tonsillitis and a little joint pain mean that he has rheumatic
fever?
Answer: no it doesnt.
We have criteria help establishing rheumatic fever called modified
JONES CRITERIA
*We have major and minor, minor criteria are not important but if
we have two major it is rheumatic fever
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MODIFIED JONES CRITERIA
Major criteria
Polyarthritis Carditis
Chorea
Subcutaneous nodules
Erythema marginatum
Polyarthritis usually happens on large joints like ankle and knee,
but it will not lead to any deformity, migratory; patient has pain inleft knee and after 2-3 days it will subside and begin in the right
ankle.
Carditis it may cause pancarditis, patient might come with severe
heart failure and it may lead to death.
Chorea involuntary coarse movement: the name refers to monk
his name is SYDENHAM CHOREA who had his own dance withstrange random movements difficult to describe and dont have
any specific characteristics.
Subcutaneous nodules: which are the aschoffs nodules
composed of immune complex with collagen, fibrin and
inflammatory cells, might be subcutaneous and we can feel it.
Erythema marginatum: redness in the skin which will expand and
the center of it will disappear and improve eventually forming a
ring and the center of it will be normal skin.
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Minor criteria
Fever
Polyarthralgia
Previous rheumatic fever or heart disease Prolongation in P-R interval Increase in ESR Positive ASO Positive throat culture
Fever, anyone with infection will have fever.
Polyarthralgia,joint pain.
Previous rheumatic fever or heart disease, if we do ECG for the
patient, the PQR complex between P-R interval should be less
than 0.2 or less than large square on the ECG paper. But with
patient has rheumatic fever as a result of infection there will be
an effect on AV node which is responsible in controlling heart
rate, may cause elongation in P-R interval.
ESR: as a dentist you have to do it, any patient complain from
anything with high ESR, this is significant, so means that if ESR
high there is something wrong.
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If ESR above 100 it is alarm sign, because most of malignancies
associated with ESR above 100.
*So 40, 60 or 80 it is normal.
How do we perform the ESR test?
ESR: elimination sedimentation rate, we put a sample of blood in
a tube in the laboratory and then we see during the first hour how
much there is separation between RBCs and plasma, it is
measured by milliliter.
ASOanti-streptolysin O if it positive that means there isinfection
Positive throat culture; we take swap culture from throat, it will
give streptococcal antigen, rarely we do it because the mouth full
of flora, so with normal patient it may give positive culture.
*DR return to the major criteria.
Polyarthritis it is migratory may be sever bone for example at
day one there is severe knee pain and in the second day in the
ankle and the third day in the wrist, so it is called flitting and
fleeting; means it will not lead to any effect.
It affects mainly large joints not small ones like fingers.
*rheumatoid arthritis is another disease affect
small joints like in fingers not large ones and
cause deformity*
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It affect large joints sequentially as we said 2-3 days pain in the
right ankle then disappears completely and develop again in the
left ankle.
Usually affect just a single joint in adults 25-30 yrs old just knee
pain or ankle pain.
Pain last for 1-5 weeks then it will be disappeared there Is no
more joint pain.
Happens with 75% of patients who have rheumatoid arthritis (I
think it is rheumatic fever)
If we have 2 major criteria or more with some minor then we can
say that it is rheumatic fever.
(but may we have rheumatic fever without any arthritis)
It subsided without any residual deformity leaving normal joints.
If there is sever joint pain, Rheumatic response to aspirin and non
steroidal so the pain will completely disappear.
Carditis
Most likely happened in children, above 80 yrs old rheumatic
fever is not as harmful as it happens in the childhood, because the
structure of the valve and the myocardium differ from the that ofbacteria.
It is a difficult issue to say this myocarditis or pancarditis as simple
as that.
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It happens in one third of cases while polyarthritis happens in
75% of case two thirds or more, here (carditis) less than
polyarthritis.
We have to have one of these:
Mitral regurg MR or aortic regurgAR murmur (normal valve
but dilated ventricle)
As we know each ventricle connected by two valves (mitral
valve in the left ventricle and tricuspid valve in the right
ventricle, aortic valve from the left ventricle, and pulmonary
valve from the right. The normal blood circulation we have to
know about it. Any new murmur (abnormal heart sound) dueto dilated ventricle lead to dilated valve and mitral or tricuspid
regurg, may we have short diastolic murmur, means there are
more blood flow during the valve it may be due to high volume
state or due to mitral regurg itself.
Change in quality of heart sound (just you have to know about
it but not to practice it), you cannot gauge this is abnormal
heart sound even practitioner cannot know if it diastolic or
systolic murmur in some cases.
Tachycardia even at rest. The normal heart rate between 60-
100 if we have heart rate more than 100 this is tachycardia,
below 60 this is bradycardia.
Cardiomegaly on chest X-ray or on echo (echo-cardiogram).
Pericarditis, picture of pericarditis (retrosternal chest pain,
increase the respiration associated with diffuse ST changes in
the ECG, it is acute pericarditis and pericardial effusion.
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ECG changes, changes in contour of P wave due to
depolarization and contraction of both atria (p wave means
atrial contraction), if we have dilated ventricle, mitral regurgand tricuspid regurg may we have dilated atria and the P wave
will be changed in shape and size. Inversion of T-waves (it must
be positive and must go with the QRS direction, but in this case
we may have inverted T wave). Prolonged PR interval as we
said before.
SYDENHAMS CHOREA
Involuntary choreo- athetoid movements (like ballet dance he
move one hand alone then he start to move the other).
It exists in 50% of patients.
So as we said the most common is polyarthritis 75%, pancarditis
or cadiac involvement in one third, and here (Sydenhams chorea)
in 50% of cases.
Girls affected more frequently than males.
*And as we said all these manifestations are rare in adult patients
Erythema Marginatum
There is ring enlarges slowly and there is pale area in the center,
may be raised over the skin and can feel it, most likely it is
transient means after a period it will disappear but in some cases
it may be persistent and continue to be there.
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Subcutaneous Nodule
Feel it on the external joints like elbow, wrist or knee. Small fairnontender , rarely see it in adults it is childhood disease, it is not
painful important point, attached to fascia or tendon sheaths
over bony prominences so it can move, where there is
prominence bone over the joints we see nodules ,it may persist
for days or weeks, recurrent may disappear and come back again.
Indistinguishable from rheumatoid nodules, there is another
disease rheumatoid arthritis it affects the small joints and sharesome manifestations with rheumatic fever and one of these is
subcutaneous nodules.
To reach a diagnosis we have to have two major
criteria or one major with two minor
Differential diagnosis
Rheumatoid arthritis involving the small joints with deformities,patients affected by it cannot do anything by their hands
Osteomyelitis Endocarditis Chronic meningococcemia SLE systemic lupus erethromatosus, very bad disease
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Lyme disease Sickle cell disease
Surgical abdomen
The question about them in the exam may come as :All of the following is considered as differential diagnoses
except
You dont have to know the details about them just knowthem by name ^_^
Treatment
The most important thing is to eradicate the bacteria from the
pharynx, otherwise accordingly if the patient has pancarditis we
do bed rest, give him non-steroidal or steroids.
Polyarthritis: non-steroidal or high dose aspirin, their action like a
magic with it.
But again the most important thing to prevent rheumatic fever
and to prevent another attack, each attack take more risk to have
complications, because of that children with documented
rheumatic fever we should give them Benzathene penicillin 1.2
million units, sometimes in two weeks or monthly for at least 5years after the last attack or till age of 18 yrs old and in some
cases till 25 yrs old (monthly needle injection till 25 yrs old).
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*If the patient has penicillin allergy we give him erythromycin or
oral penicillin not important point
If we leave the patient without any treatment the sequence will
not affect the joint but it will destroy the heart valves.
As a result if we dont make a good treatment with good
antibiotic we may have rheumatic heart disease.
Rheumatic heart disease: destruction of the heart valves, the
bacteria beta-hemolytic streptococcus eventually the immunecomplex will destruct mainly the mitral valve (between the left
atrium and the left ventricle).
In majority of case 50% mitral valve alone involved, but mitral +
aortic in 25% of cases. Pure aortic uncommon, to have patients
with pure aortic stenosis due to rheumatic fever it is rare. If we
have patient 35 yrs old with mitral stenosis always we ask about
history of rheumatic fever or history of recurrent tonsillitis.
Patient presented with sever mitral stenosis or mitral regurg, in
about 60% they remember that they had some joint pain or
tonsillitis or recurrent tonsillitis while he/she was a child.
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Let me sum up with you the main points in the lecture:
Rheumatic fever is an acute systemic immune disease, affect thepharynx
Caused by Group A beta- hemolytic Streptococcus bacteriaMost important complication is pancarditis cause of formation of
aschoff nodules
Incubation period is 2-3 weeksPeak incidence 5-15 yrs old, rare 403% of people develop rheumatic feverMODIFIED JONES CRITERIA-major criteria
Polyarthrits affect75%, pain last for 1-5 weeks, 2-3 daysmigratory between large joints
Carditis affect1/3 of cases, MR or AR, tachycardia, cardiomegaly,abnormal heart sounds, pericarditis, changes in contour of Pwave, inversion of T wave, prolonged P-R interval
SYDENHAMS CHOREA, affect 50% of cases Subcutaneous Nodule, affect external joints, non painful, nontender,
recurrent, indistinguishable from those of rheumatoid arthritisnodules
Erythema marginatumMODIFIED JONES CRITERIA-minor criteria
Fever Polyarthralgia Previous rheumatic fever or heart disease Prolongation in P-R interval Increase in ESR, above 100 Positive ASO Positive throat culture, not commonly do it
To reach a diagnosis we have to have two major criteria or one majorwith two minor
Refer to page 11 to know the Differential diagnosisTreatment, Benzathene penicillin 1.2 million units, at least for 5 years
End of part 1
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Infective Endocarditis
As we said One of the causesof Infectious Endocarditis isRHEUMATIC
FEVER, when there is a destructive valve
now, let's start :
(IE): an infection of the heartsEndocarditisInfectious
endocardial surface
There are many Classification of Infectious Endocarditis
We Classify IE into four groups:firstly,
i. Native Valve IE
ii. Prosthetic Valve IEiii. Intravenous drug abuse (IVDA) IE, as Addiction on heroiniv. Nosocomial IE
Why were classified in this way?
There are different bacteria organisms
1-The patients with IV drug uses have Staphylococci auras withdestructive tricuspid valve.
2- The patient with mitral valve rarely seen severe Infectious
Endocarditis.
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3-The patient with Prosthetic Valve IE have vegetation prosthesis.
4-Patients in Nosocomial IE have very aggressive bacteria usually
MRSA.
Further Classification:
i.Acute IE
ii.Sub-acute IE
How to differentiate between Acute IE and Sub-acute IE?
Sub acute IEoften affects damaged heart valves with RF , mitral stenosis, mitral leakages thicken valve
Acute IEaffects normal heart valves Commonly Staph. Rapidlydestructive valveIf not treated, usually fatal within 6 weeks
seen patient with Acute IE when they areRarely , wecarefulBe
already taken available antibiotics like Ampicillin, Amoxicillin,
Zinnate
Etiology( Important)::
*Native valve Endocarditis- Streptococcus viridians,Staphylococci, HACEK -*
*Prosthetic Valve Endocarditis- Coagulase negativeStaphylococci, S.Aureus (very bad bacteria as when we make
gastric band patient will died from S .Aurous pneumonia
exposure)
*IV Drug abuse endocarditis:- Tricuspid valve ,MRSA
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*Nosocomial- we see in patient with Infectious Endocarditis inhospital , pacemaker lead- and/or implanted defibrillator
associated endocarditis , also in depleted patient (long time
central line patient )
5-15% may be culture negative?? Although blood culture is a
because of priorEndocardiaInfectioussitmajors criteria to say
HACEKantibiotic exposure and there's a special organism like
group need special media to growth.
Pathophysiology:
Which patient susceptibility more to have Infectious
Endocarditis?
Turbulent blood flow, when we have mitral stenosis, calcified
mitral valve or mitral leakage the blood flow from atrium to
ventricles or from ventricle to aortic will have bad way which
lead injury to valve if we have wound it will form a clot why this
clot isnt inside a vessel? To prevent bacteria to catch theinternal part of vessel, also injury to valve turbulent blood flow
make a good area to colonization a bacteria.
Bacteremia, the most important sources of Bacteremia a tooth
brush, mouth bacteria that go inside blood stream iftheres no
suitable area to attack, it will go to spleen and destructed. ,but
if have suitable area to attack like (mitral ring, aortic ring ),itwill adhesive and form vegetation with bacteria, fibrin,
inflammatory cell ,WBC SO we have amass called vegetation
with Eventual invasion of the valvular leaflets
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:So,, Pathophysiology
We have Turbulent blood flow disrupts the endocardium makingit sticky
Bacteremia delivers the organisms to the endocardial surfaceAdherence of the organisms to the endocardial surfaceEventual invasion of the valvular leaflets
As the result
Turbulent blood flow causes endothelial injury- direct infection
theres
OR
Nonbacterial thrombotic endocarditic s as in- platelet fibrin thrombus
which seen in some cases of vegetation without endocarditic mainly in
CLEpatient
Epidemiology
Much more common in males than in femalesMay occur in persons of any age and increasingly common in
elderly
Mortality ranges from 20-30%
Risk Factors
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Intravenous drug abuse, with recurrent skin infection and
destructive tricuspid valve
Artificial heart valves , (prostheses valve ) and pacemakers
Acquired heart defects, especially with Turbulent blood flow
and injury to intimae of the valveCalcific aortic stenosis
Mitral valve prolapsed with regurgitation up to 50%Congenital heart defects, patient with VCD more common
associated with Infectious Endocarditic while patient with ACD
must associated with other Congenital heart defects to cause
Infectious EndocarditisIntravascular catheters
Symptoms:
Symptoms of infection fever, myalgia, Abdominal pain, joint pain,
back pain, Leukocytosis without obvious source, the onset of
symptoms is usually ~2 weeks or less from the initiating bacteremia,
and not responding to antibiotic
Signs
(the doctor search it)
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Cardiac Manifestations
New regurgitant murmurs-
CHF- valvular damage (aortic), myocarditis-
Perivalvular abscess-
-Fistulae connection between cardiac chambers right and left
-Pericarditis
Heart block/ MI due to embolic phenomena-
-Anemia ,it a chronic process with
more than 2 week fever for
unknown origin so we chickInfectious Endocarditis
-Microscopic hematuria
Elevated ESR, CRP-
-Decreased serum complement
-Immune complexes
-Rheumatoid factor in patient with
RHEUMATIC ARTHRITIS will be
positive while in patient with
Infectious Endocarditic it will be
positive due to Immune complexes
-Fever
-Clubbing
Splenomegaly-
Neurological manifestations-
-Heart murmur abnormal heart
sound
-Peripheral manifestations-
Oslers nodes, Subungual
hemorrhage, Janeway lesions
- Leukocytosis
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in chest x ray Septic Pulmonary Emboli with some infraction in lung
manifestationsNon cardiac
In general in asystemic dieses when there are vegetation with
abesses in heart and showing Emboli ,they will go to brain with
nurigical manifestations, to lung with abscess and cause ischemic
toes subungual hemorrhageJaneway noduls and glomunthrits in
kidney(if it immune complex or vegetation)
Petechiae
Nonspecific (without any causes )Often located on extremities or mucous membranes mainly hard
palate ,skin, congigtiva
plinter HemorrhagesS
NonspecificNon blanching, dont disappear while we pressesLinear reddish-brown lesions found under the nail bedUsually do NOT extend the entire length of the nail
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Mechanism:
-Vessel damage from swelling of the blood vessels (vacuities)
from immune complex
-Tiny clots that damage the small capillaries (micro emboli) from
vegetation (source infection).
-Oslers Nodes
More specific rarely seen with other dieses so if we have mostlyassociated with Infectious Endocarditis
Painful and erythematous nodulesLocated on pulp of fingers and toesMore common in subacute IEMechanism :: immune complexJaneway Lesions
More specific-Erythematous, blanching macules -painful-Located on palms and soles--Mechanism: micro abscess of the dermis with marked necrosis and
inflammatory infiltrate not involving the epidermis ( vegetation)
yesthe eretina ofRoth Spots mainly seen in the**
http://en.wikipedia.org/wiki/Dermishttp://en.wikipedia.org/wiki/Necrosishttp://en.wikipedia.org/w/index.php?title=Epidermis(skin)&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Epidermis(skin)&action=edit&redlink=1http://en.wikipedia.org/wiki/Necrosishttp://en.wikipedia.org/wiki/Dermis7/30/2019 6-ARF & IE
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The Essential Blood Test
Blood Cultures
Minimum of three separate blood cultures-
-Three separate venipuncture sites (not in same syringe and then
disrupted in bottles)
- At least 1 hour apart- over 24 hours from certain person from
hospital they can deal with it (you have to have sterile gloves, gown,
and bottles aerobic or non-aerobic with specific media for bacteria)-Serology- bacteria dont deal with them -Imaging
*Chest x-ray as we said,more commonly, the chest x-ray may
reveal septic pulmonary emboli in a patient
*ECG Rarely diagnostic prosthetic valve but if we have
complete heart block or bradycardiain in infectious
Endocarditic may a signe of abbesses (infection) spread to AV
node so may have bradycardiain or tachycardia arrhythmias
Echocardiography*
Indications for Echocardiography
simple, non invasion,:thoracic echocardiography (TTE)Trans*
cheap test ,TTE has superior sensitivity, especially in detecting
native valve vegetations no need to further test , while in the
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prosthetic valve vegetation with echogenicity have a difficulty to
judge normal or not because of their artificial prosthetic valve so
we do what called Trans-esophageal echocardiography (TEE)
:esophageal echocardiography (TEE)-Trans*
- High risk patients, we have highly subspecialty of prosthetic
valve but in Trans-esophageal Echocardiograph there no more
important information
-Intra-cardiac complications, we can't say never ever this is
abbesses, fistulaetc. If there is any suspicion of IE, get a TTE.
-Inadequate TTE if we have patient with long standing
smoking, inflated lung (difficulty in window), obesity >100 kg
-Fungal or S.aureus or bacteremia , in Fungal infection there's a
difficulty in differentiation between thrombus and vegetations, he
saw thrombus with 4x4 cm so if I have fever or suspicion Infectious
Endocarditic, I can't say its thrombus or Fungal infection with larger
vegetation so we need Transthoracic echocardiography(TTE) to
judge .
Modified Duke Criteria (important)
These criteria are sensitive and specific and very rarely reject a
true endocarditis:
Definite IE*
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-Microorganism (via culture or histology) in a valvular vegetation,
embolized vegetation, or intra-cardiac abscess
Histologic evidence of vegetation or intra-cardiac abscess-
2 Major
1 Major + 3 minors
5 Minor
Possible IE*
1 major and 1 minor
3 minor
Treatment
6 weeks (long stay in hospital)forparenteral antibiotics-
-Prolonged treatment to kill dormant bacteria clustered in
vegetation (broad spectrum)
Costly-
So you need to be accurate in Infectious Endocarditis**
Poor Prognostic Factors
Female, more aggressive in male than female-.S.aureus ,you will have small abscess with very aggressive
bacteria
Vegetation size, when you have just 0.8 cm it easier to deal withmore than when we have multiple vegetation valves.
Aortic valve, more dangerous than mitral and tricuspid valvebecause its out flow tract so the blood will take fewer bacteria to
the body to brain.
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Prosthetic valve because there's no blood flow in Prosthetic valveso most likely we need to put another prostheses with a result
increasing in mortality rate
Low serum albumen they happen with liver problem , Diabetes,can't even eat patient
Paravalvular abscess, as a rule if we have abcsses and giveantibiotic we will never cure we need to drain it, so in
Paravalvular abscess when the abscess between valve and wall
most likely to do incision.
Embolic eventsOlder age
Good luck ^_^Malak Abu-aqulah
Rahaf Hasan
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