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Infective Endocarditis Fall 2012

Tricupsid mitral or aortic regurgitation splenomegaly

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Tricupsid, mitral, or aortic regurgitation Splenomegaly Embolic phenomenon (lungs, kidneys, brain) Peripheral manifestations Skin lesions (Osler nodes, Janeway lesions) Other
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Peripheral Manifestations of IE Osler nodes Purplish or eryhematous subcutaneous papules or nodules on the pad of fingers and toes Painful and tender Result of emboli/immune complexes Image: http://meded.ucsd.edu/clinicalimg/skin_oslers_nodes.htm
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Peripheral Manifestations of IE Janeway lesions Flat, hemorrhagic plaques on palms of hands or soles of feet Painless Result of emboli Splinter hemorrhages Thin linear Images: Jefferson Clinical Images
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Peripheral Manifestations of IE Petechiae Small, erythematous, painless lesions Anywhere on skin, usually on anterior trunk, buccal mucosa and palate, and conjunctivae Image: http://meded.ucsd.edu/clinicalimg/eye_petechiae.htm
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Peripheral Manifestations of IE Roth spots Retinal infarct with central pallor and surrounding hemorrhage Finger clubbing Image: http://www.kellogg.umich.edu/theeyeshaveit/optic-fundus/roth-spot.html
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Objective Findings: Laboratory Nonspecific WBC (normal or slightly elevated) Anemia (normochromic, normocytic) Thrombocytopenia ↑ ESR and/or C-reactive protein
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Objective Findings: Microbiology Positive blood cultures Continuous or sustained bacteremia is hallmark finding Bacteria are shed from vegetations into bloodstream Blood cultures are positive in >95% of IE cases Collection 3 sets should be collected within 24 hours, each set from a different site Ideally hold antibiotics prior to collecting cultures Repeat cultures every 24-48 hours until negative (to document clearance of bacteremia)
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Objective Findings: Echocardiogram Determine presence and size of vegetation(s), and assess cardiac and valvular function Two types Transthoracic echocardiogram (TTE) Advantage: Easier to perform Disadvantage: Less sensitive Transesophageal echocardiogram (TEE) Advantage: More sensitive Disadvantage: Patient needs to be sedated (more involved) Negative echo does not rule out IE
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Objective Findings: Echocardiogram Moss R. Heart 2003;89:577-81
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Diagnosis of IE Based on modified Duke criteria Major and minor criteria (Table 120-3) Do NOT memorize Classified as definite IE, possible IE, or IE rejected Definite IE 2 major criteria OR 1 major + 3 minor criteria OR 5 minor criteria
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Case 1 A 32 yo male with a history of rheumatic heart disease presents to the ED complaining of fever, chills, and fatigue, that have been worsening over the past few days. He also states that he has developed a rash all over his stomach and painless red spots on his toes. He states that he
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