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

2. 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

3. 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

4. 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

5. 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

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

7. 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

8. 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)

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

10. 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

11. 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

12. Splinter hemorrhage
Osler nodes

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

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

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