Infections of the Cardiovascular System1[1]

7/25/2019 Infections of the Cardiovascular System1[1]

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Infections of the

Cardiovascular System

DR M P OKEMWA

PATHOLOGIST


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CATEGORIES

Infective Endocarditis

Acute and subacute

Mocarditis

!acteria"# vira" and fun$a"

Pericarditis!acteria"# vira" and fun$a"


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A%ATOM&


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Endocarditis: Definition

Infective Endocarditis: a microbial infection ofthe endocardial surface of the heart

Common site: heart valve, but may occur atseptal defect, on chordae tendinae or in themural endocardium

Classification:

acuteor subacute-chronicon temporal basis,severity of presentation and progression By organism Native valve or prosthetic valve


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ENDOC!DI"IS

Characteristic pathological lesion: vegetation,

composed of platelets, fibrin, microorganismsand inflammatory cells#


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Pat'o$enesis

ltered valve surface Ani(a" e)*eri(ents su$$est t'at IE is a"(ost i(*ossib"e to

estab"is' un"ess t'e va"ve surface is da(a$ed Turbu"ent b"ood f"o+

!acteria" co"onisation (ore "i,e" to occur around "esions+it' 'i$' de$rees of tubu"ence

e$- s(a"" .SD# va"vu"ar stenosis Lar$e surface areas# "o+ f"o+ and "o+ turbu"ence are "ess

"i,e" to cause IE e$ "ar$e .SD# Scarrin$ / r'eu(atic fever# sc"erosis E)trinsic intervention


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Pat'o$enesis

De*osition of *"ate"ets and fibrin / nonbacteria"t'ro(botic ve$etation

!acterae(ia !acteria attac' to *"ate"et0fibrin de*osits

123 of cases caused b sta*'"ococci# stre*tococci andenterococci

Severea" surface "i$ands t'at a""o+ attac'(ent to occur

4ibrin bindin$ *rotein# e)so*o"sacc'arides Protected fro( neutro*'i"s Mu"ti*"ication Mature ve$etation


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Pat'o$enesis

!acterae(ia !acterae(ia occurs +'en a 'eavi" co"onised (ucosa"

surface is trau(atised Denta" e)traction Periodonta" sur$er Tonsi""ecto( O*erations invo"vin$ t'e res*irator# GI or G5 tract (ucosa Oeso*'a$ea" di"atation

!i"iar tract sur$er Transient bacterae(ia

Most cases of endocarditis are not *receeded b a s*ecific event Toot' brus'in$# c'e+in$


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CLASSI4ICATIO%

Acute

0 Affects nor(a" 'eart due to viru"ent

or$anis(s (a,in$ it *otentia"" fata" Subacute

0Affects da(a$ed va"ves and is due to "ess

viru"ent or$anis(s


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AC5TE I%4ECTI.E

E%DOCARDITIS

S"i$'t" over 623 occur in nor(a" 'earts

Often t'ere is a source of infection e-$ 5TI

Caused b 'i$'" viru"ent or$anis(s

0Sta*'"ococcus aerus0623

0Stre*ococcus *o$enes0 763

0%o or$anis(s iso"ated in 60823- Attributed todifficu"t in cu"turin$ and *revious antibiotic

t'era*


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Aetio"o$ica" A$ents

Staphylococci Staphylococcci have surpassed

viridans streptococcias the most common causeof infective endocarditis

S. aureus %ative va"ves

acute endocarditis Coa$u"ase0ne$ative sta*'"ococci

Prost'etic va"ve endocarditis


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S5!AC5TE I-E-

Muc' (ore insidious and "ess dra(atic-

Caused b "ess viru"ent or$anis(s

0 Stre*ococcus viridans0 623

0 Enterococci0 863

0

G0ve bacteria08230 Di*t'eroids# candida# co)ie""a burnetti#

actino(ces# ric,etsia


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Aetio"o$ica" A$ents

Stre*tococci .iridans stre*tococci9:0'ae(o"tic stre*tococci

S. mitis, S. sanguis, S. oralis S. bovis

Associated +it' co"onic carcino(a

Enterococci

E. faecalis, E. faecium Associated +it' G59GI tract *rocedures A**ro)- 823 of *atients +it' enterococca"

bacterae(ia deve"o* endocarditis


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Aetio"o$ica" A$ents

Gra(0ne$ative rods HACEK $rou*

Haemophilus aphrophilus, Actinobacillus

actinomycetemcomitans, Cardiobacterium hominis, Eikenellacorrodens, Kingella kingae-

4astidious oro*'arn$ea" G%!s

E. coli, Klebsiellaetc 5nco((on

Pseudomonas aeruginosa I.DA

eisseria gonorrhoae Rare since introduction of *enici""in


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Aetio"o$ica" A$ents

6- Ot'ers 4un$i

Candida s*ecies# As*er$i""us s*ecies ; fever

C'"a(dia

!artone""a Le$ione""a


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Ris, Grou*s

%ative va"ve Con$enita" 'eart disease

R'eu(atic 'eart disease Mitra" va"ve *ro"a*se De$enerative va"ve "esions

Prost'etic .a"ve I.D5 %osoco(ia" IE


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CLI%ICAL 4EAT5RES

Ra*id" *ro$ressive 'i$' fever and c'i""s Heart fai"ure sets in +it' cardiac (ur(urs

E(bo"ic *'eno(ena fro( t'e 'eartve$etations0


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Oslers nodes

Tender, s/c

Nodules-immune

complex

Janeway

lesions

Nontender

erythematous,

haemorrhagic,

or pustular

lesions oftenon palms or

soles.-infective


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MORPHOLOG&

Aortic and (itra" va"ve is invo"ved 120=23-

!u", friab"e (asses of t'ro(bi containin$

t'e causative or$anis( are found 'an$in$on va"ve "eaf"ets-

Are bu",ier so(e u* to > c( across (ore

so in AIE


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HISTOLOG&

Irre$u"ar# a(or*'ous tan$"ed (asses offibrin# *"ate"ets and (asses of(icroor$anis(s are seen on t'eve$etations-

In AIE t'ere is an acute inf"a((atore)udate +it' tissue destruction-

Se?u"ae 'ence is *eforation of va"vu"ar

"eaf"ets# erosion of c'ordae tendinae anddisse(ination on (icroor$anis(s infra$(ents as e(bo"i- 4or( abscesses+'ere t'e "od$e


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$!OS"%E"IC &'&ES

()*+ of cases of infective endocarditis

"he rates of infection are the same at + years for

both mechanical and bioprostheses, but higher

for mechanical in first - months

Culmulative ris.: -#/ at /* months and +#( at

01 months post surgery

Onset:

2ithin * months of surgery earlyand usually

hospital ac3uired

/* months post surgery lateonset and usually

community ac3uired


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Nosocomial Infective

Endocarditis

>0@=3 of a"" cases seen in tertiar referra"

'os*ita"sAt "east 'a"f "in,ed to intravascu"ar devices

Ot'er sources G5 and GIT *rocedures or

sur$ica"0+ound infection


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CLI%ICAL 4EAT5RES A%D

O5TCOME

Presents +it' "o+ $rade fever# ane(ia anddebi"it- Man recover on treat(ent-

.e$etations deve"o* s"o+" and cardiacsi$ns are "ess obvious-

Ri$'t side va"ves (ore invo"ved es*ecia""

tricus*id in dru$ addicts- .e$etations are si(i"ar to t'ose in AIE but

usua"" 'an$in$ on va"ve *rost'esis-


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Investi$ations

8- !"ood cu"ture

@- Ec'o TTE

TOE

7- 4!C9ESR9CRP

- R'eu(atoid 4actor

6- MS5


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Modified Du,e Criteria for

Dia$nosis of IEBC"in- Inf- Dis- 7277# @222

DefiniteInfective Endocarditis

0 @ (aFor0 8 (aFor 7 (inor

0 6 (inor

$ossibleInfective Endocarditis0 8 (aFor 8 (inor

0 7 (inor


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MaFor Criteria !"ood cu"tures for endocarditis

0 @ se*arate !-C- +it' t*ica" or$anis(s inc"udin$S- aureus associated +it' "ine se*sis BOR0 Persistent B@ 8@ ' a*art or 7 over 8 '

Evidence of endocardia" invo"ve(ent

ec'o B*atients +it' Possib"e IE a TEE isreco((ended BOR0 ne+ re$ur$itant (ur(ur

Positive ; fever sero"o$ or sin$"e !C) forCo)ie""a burnetii


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Du.e Criteria

Definite

@ (aFor criteria

8 (aFor and 7 (inor criteria

6 (inor criteria

*at'o"o$9'isto"o$ findin$s

Possib"e 8 (aFor and 8 (inor criteria

7 (inor criteria

ReFected fir( a"ternate dia$nosis

reso"ution of (anifestations of IE +it' dasanti(icrobia" t'era* or "ess


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Minor Criteria

Predis*osin$ 'eart condition or I.D5

4ever 71JC

.ascu"ar *'eno(enon

I((uno"o$ic *'eno(enon

Sin$"e *ositive !C +it' t*ica" or$anis(


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CO4$'IC"IONS O5

ENDOC!DI"IS

Cardiac : congestive cardiac failure)valvular damage,

more common 2ith aortic valve endocarditis,

infection beyond valve6 CC5, higher mortality,need for surgery, )&, fascicular or bundlebranch bloc., pericarditis, tamponade or fistulae

Sste(ic e(bo"i

!is. depends on valve 7mitral8aortic9, sie ofvegetation, 7high ris. if 8/1 mm9

*1);1 of patients 2ith endocarditis, ris. decreases once appropriate antimicrobial

therapy started#


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--

De*osit in ,idnes in u*to 897 of *atients

causin$ foca" e(bo"ic $"o(eru"one*'ritis-

Sste(ic co(*"ications0 re"ated toe(bo"ic *'eno(ena / Cerebra" e(bo"i

0S*"enic infarcts and

abscess 0Lun$ abscess


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CA5SES O4 DEATH

Cardiac fai"ure0 va"vu"ar da(a$e# ru*ture

of c'ordae tendinae "eadin$ to dsfunction

E(bo"ic *'eno(ena to 'eart0resu"ts in MI !rain infarcts

5ncontro""ed se*sis

Arr't'(ias

Ru*ture of (cotic aneurs(s


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"herapy

Anti(icrobia" t'era* 5se a bactericida" re$i(en 5se a reco((ended re$i(en for t'e or$anis(

iso"ated E-$- A(erican Heart Association 8>2087-#

!ritis' Societ for Anti(icrobia" C'e(ot'era*

Re*eat b"ood cu"tures unti" b"ood is de(onstrated to

be steri"e Sur$er

Get cardiot'oracic tea(s invo"ved ear"


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A%ATOM&


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Mocarditis

Myocarditis is an inflammation of themyocardium, the thick muscular

layer making up the major portion ofthe heart. Often fo""o+s 5RTI

Ma *resent +it' c'est *ain Beit'er*"euritic or non0s*ecific or si$ns of 'eartfai"ure +'en ra*id in onset-


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Infectious Noninfectious

Viruses

1. Coxsackie B

2. HIV

Systemic Diseases:

1. SLE

2. Sarcoidosis3. Vasculitides!e"e#e

r$s%

&. Celiac disease

Bacterial

1. Cory#e'acteriumdi()t)eriae

*eo(lastic i#+ltratio#

,roto-oa#

1. ry(a#osoma cru-i

C)a"asdisease%

Dru"s / toxi#s:

1. Et)a#ol

2. Cocai#e3. 0adiatio#

&. C)emot)era(eutica"e#ts Doxoru'ici#

S(iroc)ete

1. Borrelia 'ur"doreri


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Si$ns S(*to(s

Das to +ee,s after onset of acute febri"e

i""ness +it' 'eart fai"ure or +it'out an

,no+n antecedent s(*to(s- Onset of 'eart fai"ure (a be abru*t and

fu"(inant or $radua"-

Ma (i(ic acute MI +it' ST e"evation#*ositive cardiac (ar,ers# re$iona" +a""

(otion abnor(a"ities


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Hospital CaseHospital CaseTransvenous myocardial biopsy of right ventricular septumTransvenous myocardial biopsy of right ventricular septum

- myocarditis with intense inflammatory infiltrates,- myocarditis with intense inflammatory infiltrates, primarily eosinophils, and myocyte necrosisprimarily eosinophils, and myocyte necrosis


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PERICARDITIS

Ma resu"t fro( bacteria"# vira" or fun$a"

infection

Can be associated +it' sste(ic diseasessuc' as autoi((une disorders# r'eu(atic

fever# rena" fai"ure and '*ot'roidis(

Heart attac, Radiation t'era*

InFur to t'e 'eart0trau(a or sur$er


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PERICARDITIS

!acteria"0 tubercu"ous

0ot'ers inc"ude sta*'"ococci#stre*tococci#

.ira"0entero0# ec'o0# adeno0# cto(e$a"o0#Ebstein !arr0# 'er*es si(*"e)0# inf"uena#*arvo !8=# 'e*atitis C# HI.# etc

4un$a"0 (ain" due to ende(ic fun$i

BHisto*"as(a# Coccidioides# or nonende(ic/ o**ortunistic fun$i BCandida# As*er$i""us#!"asto(ces and se(ifun$i B%ocardia#

Actino(ces-


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T5!ERC5LO5S PERICARDITIS

T!C *ericarditis in t'e deve"o*ed

countries 'as been *ri(ari" seen in

i((unoco(*ro(ised *atients BAIDS 5sua"" as an e)tension fro( "un$

T'e (orta"it rate in untreated acute

effusive T!C *ericarditis a**roac'es 163- Pericardia" constriction occurs in 72/623-


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CLI%ICAL 4EAT5RES

MaForit of *atients +it' tubercu"ous

*ericarditis inc"ude fever# tac'cardia#

*"eura" du""ness# increased Fu$u"ar venous*ressure#

'e*ato(e$a"# ascites# and *eri*'era" ede(a

%ot eas to differentiate tuberc"ous fro( nontuberc"ous disease

CNR# PERICARDIAL ASPIRATE A%D !IOPS&

One of the main objectives for TB controlDia"#osis dia"#osis / dia"#osis5


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One of the main objectives for TB controlDia"#osis4 dia"#osis / dia"#osis!illiam 6sler

Histolo"y

Cli#ical sus(icio#

7icro'iolo"y


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(c?

Infective endocarditis

A- T'e aortic and tricus*id va"ves are t'e (ostco((on sites of infection

!- Invo"ves abnor(a" va"ves in (ost acute cases

C- Is confir(ed b *ositive b"ood cu"tures in "ess t'an623 of cases

D- Ma cause s*"enic infarctionE- Ma cause MacCa""u(s *"a?ues to for( on

affected va"ves

Infections of the Cardiovascular System1[1]

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