pericarditis, myocarditis & infective endocarditis Editing file Cardiovascular Block - Microbiology 438 Team Color index: ● Important, ● Doctor Notes Objectives ● Extra, TN ● NOT important Endocarditis • Definition, Pathogenesis, Risk factors, Clinical presentation, Diagnosis, Culture negative endocarditis, Management and Prophylaxis Myocarditis & Pericarditis • Describe the epidemiology, risk factor for myocarditis, Explain the pathogenesis of myopericarditis, Differential between the various types of myocarditis and pericarditis, Name various etiological agents causing myocarditis and pericarditis, Describe the clinical presentation and differential diagnosis of myocarditis and pericarditis, Discuss the microbiological and non microbiological methods for diagnosis of myocarditis and pericarditis and Explain the management ,complication and prognosis of patient with myocarditis and/or pericarditis. Dr. Khalifa overview Prof. Hanan ● It’s important to know the cause of each one ● Myocarditis: inflammation of the heart and how to mange. clinical presentations Infectious: are SO IMPORTANT Viral : Coxsackie B. (most common cause) Bacterial: corynebacterium, syphilis ● blood culture usually negative “ because Non infectious: commonly it’s a virus or bacteria like: TB, SLE, autoimmune, drugs, chemotherapy, radiation chlamydia or mycoplasma pneumonia which Giant cells (very serious cause and can be fatal) need a special culture to grow. Rarely, blood Symptoms (more non specific): chest pain, arrhythmia, fever culture will be positive if it started from the Diagnosis: cardiac enzymes are high, ECG (nonspecific ST-T changes), heart biopsy, radiological studies lung like: klebsiella and S.auros.” Treatment: Mainly supportive (mild and self limiting , mostly viral) Most patients are young (20’s-30’s) ● Myocarditis: can be sudden or not, symptoms similar to fever, can be infectious or ● Pericarditis: inflammation of the pericardium Dr’s noninfectious, if “troponin and CK-MB” are Infectious: evaluated → we know that there is a problem Viral : Coxsackie B & A. Bacterial: same as acquired pneumonia (acute) and TB (chronic) with heart muscle (myocardium). chest X-ray (not the most common) will show cardiomegaly. risk of sudden death. Non infectious: SLE, autoimmune, drugs, chemotherapy, radiation, myocardial infarction notes: ● Pericarditis: sudden, acute or chronic(TB). Uremic carditis (related to kidney problems) usually infectious and rarely noninfectious. chest pain relieved by sitting forward. 5 Main types: Caseous (TB),fibrinous, hemorrhagic (TB), serous (viral), purulent/suppurative (bacterial pericardial rub and thickening more than because bacterial infections come with pus especially S.aureus) 5mm. chest X-ray will show enlarged cardiac Symptoms (more specific): chest pain (positional, can hear a pericardial friction rub, related to shadow. the best way to reduce the pressure breathing), ECG (specific changes: ST elevation, RP depression, T-wave inversion) is Pericardiocentesis. Diagnosis: Cardiac enzymes are high if the pericarditis extends to the myocardium, Echo is important, has ● both diseases are self limiting when it caused to check the amount of fluid around the heart, radiological studies, blood culture, TB lab for AFB culture, by a virus. we use antivirus only in severe biopsy, sample taken either diagnostic or therapeutic cases. Treatment: supportive but you have to look for the cause (is it bacteria or virus?, signs of pneumonia or TB, is there any Renal issues, previous myocardial infarction? Then decide on the treatment) In case of Tamponade, use Pericardiocentesis ● Both disease are potentially infectious and non infectious ● Both need general blood work and have high ESR Prof. Somily Dr. Fawzia ● Numbers are NOT important ● Important to Know: ● heart infections are not common, because 1- heart is sterile 2- It's the site of the ○ Risk Factors secondary immune system, its so strong and ○ Identifying causative agents. power. ○ methods of diagnosis ○ Treatment ● Types: Acute → s.aureus - normal valve ● Infection of endocardial is very critical because it involve the valves. Subacute → S.viridans - damaged valve ● Acute endocarditis: ● prosthetic valves infections divided into ○ Patient will deteriorate within 2-3 days or 1 week, high fever, 1-early (during a year after valve transplant palpitation, myalgias, and leads to high mortality. surgery)-S.epidermidis \ 2- late (after one year of the surgery) ○ Staph aureus is the most common cause. ● Subacute endocarditis: Dr’s ● Organisms (normal flora) enter blood ○ gradual onset, mild -low fever & gradual fever, myalgias, rash, & less circulation through some ways: tooth mortality. extraction - bleeding during teeth brushing - ○ Strept. viridans is the most common cause. procedures involves gut - catheterization- ● Pathophysiology: colonoscopy .so, in history we need to notes: consider any procedure that patient did. ○ Usually it happens before abnormal valves of the heart, due to distributes in blood flow & can lead to damage of endothelium → which ● Physical examination is very important and leads to accumulation of blood & coagulation factors. critical: Fever, petechiae (check skin rash/ ● Risk factors: mucus membrane in mouth), nail bending ○ the most imp one is prosthetic valves. (splinter hemorrhage) ○ then abnormal valves, and aortic valve is the most common valve associate with endocarditis. ● Laboratory tests in endocarditis: 3 sets of ● The most important in laboratory findings is blood culture. blood culture + echocardiography ● When you have repeated culture growing +ve organism with valvular (ultrasounds of heart) ● Treatment of IE must follow 4 things: 1- IV vegetation → endocarditis. administration. 2- bactericidal antibiotic. 3- ● Culture negative: combination (B-lactam+aminoglycoside). 4- ○ some patients have vegetation but culture is negative, means that the 4 weeks of duration at least ( MIC should be organism difficult to grow (usually fastidious bacteria), or may be the done). organism cannot grow because the patient had antibiotics & kills the organisms. Pericarditis ➔ It is an inflammation of the pericardium, Usually by infectious etiology. ➔ Pathophysiology: 1 2 3 Fluid development Inflammation provokes normal transparent and Can cause pericardial fibrinous exudate with or glistening pericardium is scarring with adhesions without serous effusion turned into a dull, and fibrosis. opaque, and “sandy” sac Spread of Infection: Contiguous Lymphangetic Hematogenous Traumatic or -Spread from near organ; irradiation Lungs, pleura, mediastinal Through blood lymph nodes, myocardium, septicemia, toxin, aorta, esophagus, liver. neoplasm, metabolic Etiology Infectious etiology ➔ Viral Pericarditis:(Typical cause) ➔ Bacteria Pericarditis: ◆ Most common: ◆ Usually it’s a complication of pulmonary ● Coxsackie virus A & B, and Echovirus. infections (e.g. pneumonia, empyema, ◆ other viruses: TB). ● Herpes, Hepatitis B, HIV, Mumps, Influenza, Adenovirus, Varicella viruses. ◆ So organisms are similar to those in lung infections: ● S.pneumonia, M.tuberculosis, ➔ Disseminated Fungal Infection: ● S.aureus, H.influenzae, ◆ Histoplasma, and Coccidioides. ● Klebsiella pneumonia, & Legionella. ● M.catarrhails, Chlamydia pnemonia, ➔ Parasitic infections: (rare) Cats at home are the source of it Mycoplasma pneumonia. ◆ e.g. disseminated toxoplasmosis, NOT important ◆ contagious spread of Entamoeba histolytica. ◆ HIV patients may develop pericardial effusions by; ● M.tuberculosis, M.avium. Non-Infectious etiology ➔ Immune-mediated: as in rheumatic fever & SLE. ➔ Miscellaneous: e.g. due to myocardial infarction, malignancy & uremia. Classifications 1. Can be divided into 5 types according to the composition of the fluid that accumulates around the heart: 1- Caseous Pericarditis: 2- Serous Pericarditis: ➔ commonly tuberculosis in origin. ➔ due to autoimmune diseases (e.g. Rheumatoid arthritis, SLE), & viral infection. ◆ Transudative serous fluid (yellow clear fluid). 3- Fibrinous Pericarditis: 4- Purulent/Suppurative Pericarditis: ➔ due to acute Myocardial infarction (MI), uremia, ➔ due to Acute bacterial infection, fungi or parasites radiation. infections. ◆ Fibrinous exudative fluid. ◆ Purulent exudative fluid (formation of pus). 5- Hemorrhagic Pericarditis: ➔ usually caused by infection (e.g. TB) or malignancy. ◆ blood mixed with a fibrinous or suppurative effusion. 2. According to the clinical presentation and the duration: 1- Acute pericarditis. 2- Chronic pericarditis. Pericarditis Acute Pericarditis Chronic Pericarditis ➔ Tuberculous Pericarditis: ➔ CA Pneumonia organisms usually. ◆ Has insidious onset. ➔ Clinical presentation: ◆ Incidence of pericarditis in patients with pulmonary ◆ Sudden pleuritic chest pain1, which is TB ranges from 1-8%. (secondary) ◆ Clinical presentation: positional restrosterna (relieved by setting 2 forward). ● Fever, Pericardial friction rub , ◆ Dyspnea & fever. Hepatomegaly, If it’s secondary to PTB, could ◆ On examination: mention its symptoms (e.g. night sweats, weight loss). ◆ ● Pericardial friction rub2, exaggerated Tuberculin skin test usually positive. ◆ pulses, paradoxus JVP & tachycardia. Fluid smear for acid fast bacilli (AFB) often ● As the pericardial pressure increase → negative. ◆ palpitations, presyncope or syncope Pericardial biopsy more definitive. biopsy is better than fluid in cases of extrapulmonary TB because it specify the type of may occur. pericarditis ( caseous necrosis → TB ). ➔ Constrictive Pericarditis: ➔ Differential