Rheumatic fever. Etiology. Diagnostic criteria. Compliсations Rheumatic fever. Etiology. Diagnostic criteria. Compliсations. Principles of treatment. Endocarditis. ass. prof. Yarema N.Z.

© Polyarthritis Migrate character of poly arthritis acute short duaration effect NAID without deformation large joints 2

Streptococcus pyogenes Impetigo Pharrhyngitis Rheumatic fever Glomerulonephritis Scarllet fever Any signs

WHO – 1987, AHA - 1992 І. Major criteria 1.Carditis 2. Polyarrthritis © Diagnostic criteria 1.Carditis 2. Polyarrthritis 3. Chorea by Cidenham 4. Erythema anulare 5. Reumatic nodules І. Major criteria WHO – 1987, AHA - 1992

ІІ. Minor criteria Clinical: Anamnesis Arrthalgia Fever Lab: © Diagnostic criteria Clinical: Anamnesis Arrthalgia Fever Lab: Inflamatory changes incresing P-Q ІІ. Minor criteria

© Chorea

© ERYTHEMA ERYTHEMA NODOSUM ANNULARE, -infection MARGINATUM -alergic -sarcoidosis

INFECTIVE ENDOCARDITIS Vegetations (arrows) due to viridans streptococcal endocarditis involving the mitral valve.

Infective endocarditis (IE) is an infection of the endocardial surface of the heart. The intracardiac effects of this infection include severe valvular insufficiency, which may lead to congestive heart failure and myocardial abscesses. IE also produces a wide variety of systemic signs and symptoms through several mechanisms, including both sterile and infected emboli and various immunological phenomena.

ETIOLOGY Organisms Causing Major Clinical Forms of Endocarditis: Staphylococcus aureus infection is the most common cause of IE, including PVE, acute IE, and IVDA IE. Approximately 35-60.5% of staphylococcal bacteremias are complicated by IE. More than half the cases are not associated with underlying valvular disease. The mortality rate of S aureus IE is 40-50%.

ETIOLOGY Organisms Causing Major Clinical Forms of Endocarditis: Streptococcus viridans This organism accounts for approximately 50-60% of cases of subacute disease. Most clinical signs and symptoms are mediated immunologically. Streptococcus intermedius group These infections may be acute or subacute. S intermedius infection accounts for 15% of streptococcal IE cases. S intermedius is unique among the streptococci; it can actively invade tissue and can cause abscesses.

Acute endocarditis usually occurs when heart valves are colonized by virulent bacteria in the course of microbemia. The most common cause of acute endocarditis is Staphylococcus aureus; other less common causes are Streptococcus pneumoniae, Neisseria gonorrhoeae, Streptococcus pyogenes, and Enterococcus faecalis.

Bacteremia can result from various invasive procedures Endoscopy Rate of 0-20% CoNS, streptococci, diphtheroids Colonoscopy Escherichia coli, Bacteroides species Barium enema Enterococci, aerobic and anaerobic gram-negative rods Dental extractions Rate of 40-100% S viridans Transurethral resection of the prostate Rate of 20-40% Coliforms, enterococci, S aureus Transesophageal echocardiography S viridans, anaerobic organisms, streptococci

primary portals

primary portals oral cavity, skin, upper respiratory tract gastrointestinal tract genitourinary tract The incidence of nosocomial bacteremias, mostly associated with intravascular lines, has more than doubled in the last few years. Up to 90% of bloodstream infections (BSIs) caused by these devices are secondary to the placement of various types of central venous catheters.

primary portals 18

Clinical and Laboratory Features of Infective Endocarditis Fever 80-90 % Chills and sweats 40-75 % Anorexia, weight loss, malaise 25-50 % Myalgias, arthralgias 15-30 % Back pain 7-15 % Heart murmur 80-85 % New/worsened regurgitant murmur 10-40 %

Clinical and Laboratory Features of Infective Endocarditis Arterial emboli 20-50 % Splenomegaly 15-50 % Clubbing 10-20 % Neurologic manifestations 20-40 % Peripheral manifestations (Osler's nodes, subungual hemorrhages, Janeway lesions, Roth's spots) 2-15 %

Clinical and Laboratory Features of Infective Endocarditis Petechiae 10-40 % Laboratory manifestations: Anemia 70-90 % Leukocytosis 20-30 % Microscopic hematuria 30-50 % Elevated erythrocyte sedimentation rate>90 %

Clinical and Laboratory Features of Infective Endocarditis Rheumatoid factor 50 % Circulating immune complexes 65-100 % Decreased serum complement 5-40 %

Common Peripheral Manifestations of Infective Endocarditis Common Peripheral Manifestations of Infective Endocarditis. Splinter hemorrhages (A) are normally seen under the fingernails. They are usually linear and red for the first-two to three days and brownish thereafter. Panel B shows conjunctival petechiae. Osler's nodes (Panel C) are tender, subcutaneous nodules, often in the pulp of the digits or the thenar eminence. Janeway's lesions (Panel D) are nontender, erythematous, hemorrhagic, or pustular lesions, often on the palms or soles. 23

Noncardiac Manifestations Janeway’s lesions. Hemorrhagic, infarcted macules and papules on the volar fingers in a patient with S. aureus endocarditis.

Noncardiac Manifestations Septic vasculitis associated with bacteremia. Dermal nodule with hemorrhage and necrosis on the dorsum of a finger. This type of lesion occurs with bacteremia (e.g., S. aureus) and fungemia (e.g., Candida tropicalis).

Noncardiac Manifestations subconjunctival hemorrhage. Submucosal hemorrhage of the lower eyelid in an elderly diabetic with enterococcal endocarditis; splinter hemorrhages in the midportion of the nail bed and Janeway lesions were also present.

Splinter haemorrhages are linear haemorrhages lying parallel to the long axis of finger or toe nails. 27

Noncardiac Manifestations Vasculitis

Clubbing. Seen in patients with chronic lung disease, cyanotic heart disease, cirrhosis and infective endocarditis.

Infective endocarditis: metastatic infections due to emboli.

Noncardiac Manifestations Computed tomography of the abdomen showing large embolic infarcts in the spleen and left kidney of a patient with Bartonella endocarditis.

Activity of process: active, nonactive. Classification of infective endocarditis due to recommendation of Ukranian society of cardiologists (confirmed by VI National Congress of Ukranian Cardiologists, 20000. Activity of process: active, nonactive. Native valvular endocarditis: primary, secondary (trauma, foreign body); prosthetic valve endocarditis. Site: mitral valve, aortic valve, tricuspid valve, valve of the pulmonary artery, endocardium. Etiology: Gram-positive bacilli, Gram-negative bacilli, L-forms, rickttsia, fungi Stage of valvular disease, of cardiac insufficiency. Complications.

Antibiotic Treatment for Infective Endocarditis Caused by Common Organisms Streptococci Penicillin-susceptible streptococci, S. bovis Penicillin G 2-3 million units IV q4h for 4 weeks Penicillin G 2-3 million units IV q4h plus gentamicin 1 mg/kg IM or IV q8h, both for 2 weeks Ceftriaxone 2 g/d IV as single dose for 4 weeks Vancomycind 15 mg/kg IV q12h for 4 weeks

Antibiotic Treatment for Infective Endocarditis Caused by Common Organisms Relatively penicillin-resistant streptococci - Penicillin G 3 million units IV q4h for 4-6 weeks plus gentamicin 1 mg/kg IV q8h for 2 weeks Penicillin-resistant streptococci, pyridoxal-requiring streptococci (Abiotrophia spp.) - Penicillin G 3-4 million units IV q4h plus gentamicinc 1 mg/kg IV q8h, both for 4-6 weeks

Antibiotic Treatment for Infective Endocarditis Caused by Common Organisms Enterococci Penicillin G 3-4 million units IV q4h plus gentamicinc 1 mg/kg IV q8h, both for 4-6 weeks Ampicillin 2 g IV q4h plus gentamicin 1 mg/kg IV q8h, both for 4-6 weeks Vancomycin 15 mg/kg IV q12h plus gentamicin 1 mg/kg IV q8h, both for 4-6 weeks

Antibiotic Treatment for Infective Endocarditis Caused by Common Organisms Methicillin-resistant, infecting prosthetic valves (Staphylococci) Vancomycin 15 mg/kg IV q12h for 6-8 weeks plus gentamicin 1 mg/kg IM or IV q8h for 2 weeks plus rifampin 300 mg PO q8h for 6-8 weeks HACEK organisms Ceftriaxone 2 g/d IV as single dose for 4 weeks Ampicillin 2 g IV q4h plus gentamicin 1 mg/kg IM or IV q8h, both for 4 weeks

Thank you for attention 40