INFECTIVE ENDOCARDITIS, MYOCARDITIS & PERICARDITIS DR. M. KHONGA BSc, MBBS Department of Pathology and Medical Laboratory Sciences College of Medicine

LEARNING OBJECTIVES (1) INFECTIVE ENDOCARDITIS Describe endocarditis Explain the predisposing factors of endocarditis List the clinical presentation (including the Duke’s criteria) Explain how to diagnose endocarditis Learn the major causes of endocarditis in native and prosthetic valves Describe the treatment of endocarditis List indications for prophylaxis in endocarditis prevention List the complications of endocarditis

LEARNING OBJECTIVES (2) Myocarditis –List possible causes of myocarditis and diagnosis of the different causes –Learn the clinical presentation of myocarditis •Pericarditis –List the major causes of pericarditis –Learn the clinical presentation of pericarditis

INFECTIVE ENDOCARDITIS DEFINITION: Infection of the endocardial surface of the heart, which may include one or more heart valves, the mural endocardium or septal defect. May occur in an acute or subacute form Categories of IE: Native valve endocarditis (NVE) Prosthetic valve endocarditis (PVE) Early (within 60days) and Late (after 60days) Intravenous drug abuse (IVDA) endocarditis

Pathogenesis Occurs as a consequence of a non-bacterial thrombotic endocarditis Results from turbulence or trauma to the endothelial surface of the heart Thrombus: sterile platelet/fibrin vegetation Transient bacteremia then seeds the sterile thrombus attracting further fibrin & platelet deposition Pathologic effects due to infection can include Local tissue destruction Embolic phenomena, e.g. pulmonary infarcts Secondary autoimmune effects, e.g. glomerulonephritis

Transient bacteremia: Dental procedures Vigorous teeth cleaning & flossing Surgical procedures I &Ds Heart valve replacement

Risk Factors Native valve endocarditis: Prosthetic valve Acquired valvular disease Degenerative, e.g. Marfan syndrome, syphilitic disease Post infective, e.g. rheumatic heart disease Congenital heart disease E.g. patent ductus arteriosus, ventricular septal defect, tetralogy of Fallot, etc Prosthetic valve Valves in the mitral position more susceptible than aortic position Intravenous drug abuse

Etiological agents PATIENT GROUP MAJOR ETIOLOGIC AGENTS OF IE NATIVE VALVE Oral Streptococci (viradans) & Enterococci Staphylococcus aureus Coaugulase negative sStreptococci Gram negative (enteric) rods Fungi (mainly Candida) INTRAVENOUS DRUG ABUSE Coagulase negative Streptococci PROSTHETIC VALVE (EARLY) PROSTHETIC VALVE (LATE)

Rarer causes: HACEK organisms: Haemophilus aphrophilus, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikella corrodens, Kingella kingae Coagulase negative organisms: Chlamydia pneumoniae, Coxiella burnetii

Clinical Presentation SYMPTOMS Commonly vague: emphasize constitutional complaints, cardiac effects or secondary embolic phenomena Relate to 4 ongoing processes: Infectious process on the valve/local complications Septic embolization to virtually any organ Bacteremia , often with metastatic foci of infection Circulating immune complexes

Non specific symptoms: SIGNS: Classic signs: Splinter hemorrhages Olser nodes Janeway lesions Roths spots Neurologic: Embolic stroke Intracerebral hemorrhage Multiple microabscesses Others: Cardiac arrhthmia, pericardial rub, pallor, organ infarction Main symptom: fever (almost always) & (new) heart murmur Non specific symptoms: Anorexia, weight loss, malaise, chills, nausea, vomiting and night sweats Splinter hemorrhages: dark red linear lesions in nail beds Osler nodes: tender subcutaneous nodules usually found on distal pads of digits Janeway lesions: non tender maculae on palms and soles Roth spots: retinal hemorrhages with small clear centers

Splinter hemorrhage Osler nodes

Diagnosis No specific: Cardiac: Echocardiography Microbiological: WBC, ESR, CRP, Urine(microhaematuria) Cardiac: Echocardiography Transthoracic echocardiography (TTE) for native valves Transesophageal echocardiography (TEE) for prosthetic valve Microbiological: Blood cultures: 3 sets Serological: if culture negative suspected

Microbiological tests Blood culture; criterion standard test for diagnosing IE Need to draw 3 separate sets of blood cultures over 24hrs to document continuous bacteremia Have to grow the same organism from different culture sets Sensitivity testing: Help with appropriate treatment therapy

Duke Classification Criteria Combine clinical, microbiological, pathologic and echocardiographic characteristics of a single case Used to make a definitive diagnosis of IE Major Microbiological (blood culture) criteria 2 blood cultures positive for organisms found in IE Blood cultures persistently positive for one of these organisms (drawn more than 12hrs apart) 3 or more separate blood cultures drawn at least 1hr apart

B. Major echocardiography criteria: Echocardiogram positive for IE: Oscillating intracardiac mass on a valve, in the path of regurgitant jets, or implanted material, in the absence of an anatomic explanation Myococardial abscess Development of partial dehiscence of a prosthetic valve New-onset vulvular regurgitation

C. Minor criteria include: predisposing heart condition or drug abuse Fever of 38⁰C or higher Vascular phenomenon: Major arterial emboli, septic pulmonary infarcts, intracranial hemorrhage, conjunctival hemorrhage or Janeway lesions Immunologic phenomenon: Glomerulonephritis, Osler nodes, Roths spots and rheumatoid factor Positive blood culture results not meeting major criteria or serologic evidence of active infection

A definitive diagnosis can be made based on: 2 major criteria; or 1 major criteria & 3 minor criteria; or 5 minor criteria A possible diagnosis of IE: 1 major criterion & 1 minor criterion; or 3 minor criteria Rejected: Firm alternative diagnosis Resolution of IE syndrome with antibiotic therapy for <4days Don’t meet criteria for possible IE as above

Management principles Antibiotics Intravenous to get acceptable levels Higher doses than in other individuals Combinations may be necessary for synergy Given over 4 to 6wks Monitor course of therapy Clinical response, CRP Consider surgery: Extensive valvular damage Early prosthetic valve endocarditis Cardiac failure, embolic disease, fungal disease

Specific antibiotic treatment Group of organism Antibiotics Penicillin sensitive Streptococci Penicillin Reduced sensitivity Streptococci or Enterococci Penicillin plus gentamicin Penicillin resistant Streptococci or Enterococci Vancomycin plus gentamicin + rifampicin MSSA Cloxacillin MRSA Vancomycin plus rifampicin + gentamicin

Complications of IE Myocardial infarction, pericarditis, cardiac arrhythmia Congestive heart failure Aortic root or mycordial abscesses Arterial emboli Arthritis Glomerulonephritis, acute renal failure Stroke syndromes Mesenteric or splenic abscess or infarct

Prophylaxis against IE Maintain good oral hygiene!! Consider for people with: Presence of a prosthetic heart valve History of endocarditis In patients undergoing surgical procedures that can cause transient bacteremia: Dental procedures Any procedure involving incision in the respiratory mucosa Procedure on infected skin or musculoskeletal tissue, including incision & drainage of an abscess

LEARNING OBJECTIVES (2) Myocarditis –List possible causes of myocarditis and diagnosis of the different causes –Learn the clinical presentation of myocarditis •Pericarditis –List the major causes of pericarditis –Learn the clinical presentation of pericarditis

MYOCARDITIS Inflammatory disease of the myocardium Has a wide range of clinical presentations Usually manifests in a healthy person & can result in progressive (often fatal) heart failure & arrhythmia Can be classified as: Fulminant mycarditis: usually fatal Acute myocarditis: may progress to dilated cardiomyopathy Chronic active: clinical relapses Chronic persistent myocarditis: histologic changes without ventricular dysfunction

Causes of myocarditis Viral: Bacterial: Fungal: Drugs: Coxsackie B, adenovirus, cytomegalovirus, Epstein_Barr virus, HIV-1,herpes simplex virus, rabies Bacterial: Diphtheria, tuberculosis, streptococci, clostridia, staphylococci Fungal: Candidiasis, aspergillosis, cryptococcosis Drugs: Chemotherapy drugs, antibiotics, antihypertensives, antiseizures

Clinical presentation Usually present with signs and symptoms of acute heart failure Tachycardia Gallop ryhthm Mitral regurgitation Peripheral edema Can also present with Fever, chest pain, sweats, chills & dysnea

diagnosis Lab studies may include: Full blood count Erythrocyte sedimentation rate (& other acute phase reactants, e.g. C-reactive protein) Rheumatologic screening to rule out systemic inflammatory diseases Cardiac enzymes, e.g. creatinine kinase, cardiac tropinin Serum viral antibody titers for viral myocarditis Myocardial biopsy for histology

PERICARDITIS Inflammation of the pericardium Signs & symptoms: Characterised by chest pain, pericardial friction rub & serial ECG changes Signs & symptoms: Chest pain: with referral to trapezius ridge, neck, left shoulder or arm Fever, dyspnoea, cough, Signs of heart failure In TB pericarditis: fever, night sweats, weight loss, pericardial effusion

Causes of pericarditis Idiopathic Infectious: viral, bacterial, tuberculous Inflammatory disorders: rheumatic fever Metabolic disorders: renal failure, Cardiovascular disorders: acute MI

Diagnosis: Management: ECG, cardiac echo, chest radiography & lab studies Management: Directed according to the underlying cause Example: TB pericarditis Antituberculous drugs & steroids ?pericardiocentesis