…………Myocarditis and pericarditis Infective Endocarditis….. …………Myocarditis and pericarditis Dr.P.K.Rajesh.M.B.B.S:M.D

Learning outcomes At the end of this activity, the student should be able to discuss the risk factors for developing infective endocarditis (IE). list the organisms that cause IE.(tricky) discuss the lab diagnosis of IE.(include updates) categorize pericarditis according to the type of effusion (serous, fibrinous, hemorrhagic, casseous). Dr.P.K.Rajesh.M.B.B.S:M.D

Introduction Infective endocarditis is an infection of the endocardium. The high risk group Rheumatic Heart Disease-already diseased valve Congenital Heart Disease - PDA, VSD Mitral valve prolapse-MVD or AVD Prosthetic valves Chronic indwelling catheters Intravenous drug abusers Dr.P.K.Rajesh.M.B.B.S:M.D

Critical thinking Dr.P.K.Rajesh.M.B.B.S:M.D

Aetiopathology Dr.P.K.Rajesh.M.B.B.S:M.D

Procedural risk Dental procedures (Streptococcus viridans) ENT surgery What if Streptococcus bovis is isolated? Sorry! If I were you…I would check whether he has colon CA Strep bovis in blood culture is a microbiological marker for colon CA Dental procedures (Streptococcus viridans) ENT surgery Genitourinary (Enterococcal) Obstetric and gynecological (On prosthetic valve) Dr.P.K.Rajesh.M.B.B.S:M.D

Causative agents-until recent Streptococcus spp 50% of which S.viridans,α hemolytic 35% S.bovis 12% Others <5% Staphylococcus spp. 30% of which Staph. aureus 25% CONS 5% Enterococcus sp 7% HACEK* <5% Coliforms,anearobic <5% Fungi (Candida) <5% Dr.P.K.Rajesh.M.B.B.S:M.D

Better clinical microbiologists Increase in Staphylococcus isolation due to-increased IV drug users, increase in IV medication/nutrition dependant patients, Better clinical microbiologists Rajesh Dr.P.K.Rajesh.M.B.B.S:M.D

NOW WHAT IF I GET THIS STUPID MCQ? The most common causative organism of IE is Staphylococcus aureus Staphylococcus epidermidis Streptococcus viridans Streptococcus bovis Depends on cause/valve/time i.e source/native or prosthetic/early or late Dr.P.K.Rajesh.M.B.B.S:M.D

HACEK GROUP Haemophilus aprophilus(paraprophilus) (H) Actinobacillus actinomycetemcomitans (A) Cardiobacterium hominis (C) Eikenella corrodens (E) Kingella kingae (K) FASTIDUOUS-WON’T GROW WITH ROUTINE CULTURE METHODS Dr.P.K.Rajesh.M.B.B.S:M.D

Dr.P.K.Rajesh.M.B.B.S:M.D

Lab diagnosis Routine Blood culture 3 samples from….3 sites….. before antibiotics Cultured on enrichment media Sub-Culture on enriched Agar Antibiotic sensitivity Caution-Culture Negative Endocarditis Dr.P.K.Rajesh.M.B.B.S:M.D

Dr.P.K.Rajesh.M.B.B.S:M.D

Sub-culture & Sensitivity testing

Antibiogram

Update-keep it simple

Bactec Bacteria auto detect-(importance of liquid media) Caution-machines are as good/bad as US.

Dr.P.K.Rajesh.M.B.B.S:M.D

Dr.P.K.Rajesh.M.B.B.S:M.D

Bactec’s been around for 20 years Dr.P.K.Rajesh.M.B.B.S:M.D

Hic! hot and wet! A 46-year-old homeless male with a history of excessive alcohol consumption presented to the emergency department with a two-week history of fever and night sweats. Dr.P.K.Rajesh.M.B.B.S:M.D

The works….yawn!!! The diagnosis of infective endocarditis was considered when he was found to have a systolic ejection murmur in the aortic area as well as an early diastolic murmur along the left sternal border. A transthoracic echocardiogram revealed an aortic valve vegetation with moderate aortic regurgitation Dr.P.K.Rajesh.M.B.B.S:M.D

Now what? Two sets of blood cultures drawn prior to initiation of intravenous ceftriaxone and vancomycin yielded no growth after extended incubation in the microbiology laboratory. Valve tissue obtained at the time of aortic valve replacement was sterile despite five days of culture. Dr.P.K.Rajesh.M.B.B.S:M.D

REMEMBER PKR Polymerase chain reaction (PCR) of the 16S–23S rDNA intergenic spacer region with sequencing of the PCR product confirmed the causative agent to be Bartonella quintana. Dr.P.K.Rajesh.M.B.B.S:M.D

Email rajesh.perumbilavil@gmail.com 2 examples from the 1000+ other methods of determining antibiotic resistance/sensitivity Email rajesh.perumbilavil@gmail.com for details Phage assay Plasmid profiling

Molecular methods can determine if the strains are the same/different in recurrent IE apart from drug resistance

Dr.P.K.Rajesh.M.B.B.S:M.D

Duke’s criteria for diagnosis of IE (Rajesh’s made easy version ) Modified Duke’s includes molecular evidence Major criteria- I. Positive blood culture for IE (Isolation of typical microorganism from 2 separate cultures) II. Evidence of endocardial involvement (Positive ECHO for IE ) Minor criteria- Clinical evidence Microbiological and Radiological evidence Modified Duke’s includes molecular evidence Dr.P.K.Rajesh.M.B.B.S:M.D

Clinical features are seldom due to microorganisms-they are due to immunity! RAJESH Dr.P.K.Rajesh.M.B.B.S:M.D

Dr.P.K.Rajesh.M.B.B.S:M.D

Pericarditis Inflammation of Pericardium Serous,Fibrinous,Purulent,Caseous,Haemorrhagic (Pericardial effusion/Empyema) Can follow-Lobar pneumonia/parotitis Can spread by Haematogenous/Lymphatic Direct-cardiotomy? (stab) can introduce organisms Dr.P.K.Rajesh.M.B.B.S:M.D

Pericarditis-summary Serous-viral Fibrinous-viral Purulent-bacterial Caseous-Mycobaterium Hgic-Mycobaterium Dr.P.K.Rajesh.M.B.B.S:M.D

Rheumatic pancarditis Group-A-β hemolytic Streptococci Cross immune hypothesis Duckett Jones Criteria PANCARDITIS-aschoff body Penicillin prophylaxis Dr.P.K.Rajesh.M.B.B.S:M.D

Dr.P.K.Rajesh.M.B.B.S:M.D

Self study/references This a PPP-do not consider this as NOTES per se Infective endocarditis Rheumatic Heart disease Lab diagnosis of Gram positive cocci Blood cultures and BACTEC. Duke’s criteria (Original, Modified, PKR versions) Study material suggested Churchill’s pocketbook of Clinical Microbiology-TJJ.Inglis Elsevier’s Medical Microbiology, Mims et al,3rd Ed Dr.P.K.Rajesh.M.B.B.S:M.D