CPD II: endocarditis and pericarditis

endocarditis is an inflammation of the endocardium, generally from a bacterial or fungal infection. individuals with endocardial disorders from congenital defects or valvular disorders, or those with infections in blood are at higher risk for infectious endocarditis. endocarditis can develop due to turbulent blood flow which causes trauma to the endocardium, causing platelets and fibrin to gather, called vegetations, which act as petri dishes for bacteria to colonize on. for unknown reasons, endocarditis occurs mainly on the valves of the left side but for IV drug users, a high risk group, mainly on the right side of the heart. complications might include local consequences such as abscess, conduction defect, heart failure, while systemic consequences result from septic emboli that may form. diagnosis is through 3 serial blood cultures and the TTE.

within infective endocarditis there are two categories; subacute bacterial endocarditis and acute bacterial endocarditis. both are generally due to strep and staph, although ABE is likely due to fungal infections if it occurs after valve replacement surgery. as suggested by their names, subacute has a gradual onset of vague symptoms such as fatigue, fever, night sweats, murmur, while acute has a more severe, acute onset of the same symptoms. subacute also manifests in the skin (as petechiae, janeway lesions, and osler nodes), in the eye as roth spots or flame hemorrhages, and in the fingernails as splinter hemorrhages.

non infective endocarditis is distinguished from either acute or subacute bacterial endocarditis in that there is no microorganism, just the inflammation and vegetation. this can be due to a variety of reasons: such as immune complexes, hypercoagulability, catheter injury, anti-phospholipid syndrome. a patient with a chronic illness that suddenly develops an arterial embolism in the absence of an infection is a prime candidate for diagnosis of non infective endocarditis. diagnosis is by echo to detect the vegetations and blood cultures to rule out infection.

pericarditis is inflammation of the pericardial sac that surrounds the heart, and has a variety of etiologies as well: idiopathic, infection (usually viral), MI, trauma, tumors, metabolic disorders, alcoholism. there are several different varieties of pericarditis: constrictive is an uncommon and idiopathic variant that results from stiffening of pericardium and can be diagnosed with ECG, catherization and CXR (to detect calcification). pericardial effusion is a common phenomenon in pericarditis and can be detected via echo, CXR, and ECG (severe pericardial effusion will result in the heart's floating position within the pericardial sac, leading to alternating voltage of ECG waves). cardiac tamponade is a severe variant of pericarditis in which the heart is constricted to the point of reduced cardiac output and lower arterial pressure, and also exhibits pulsus paradoxus (just like severe asthma does)

questions
infective endocarditis...
1. what is infective endocarditis?
2. what are some predisposing factors for IE? X√
3. describe the pathogenesis of IE. √
4. 80-90% of IE is caused by which microorganisms? √
5. where on the heart is IE more likely to occur? what about IV drug users? √
6. describe the local and systemic consequences of IE. †
7. what clinical symptoms would lead one to suspect a diagnosis of IE? X†
8. what are the diagnostic tests for IE? X√
9. what might blood tests in a patient with IE show? XXX
10. what is the prognosis of IE? X√√

subacute bacterial endocarditis...
11. SBE commonly due to...
12. describe the onset and clinical picture of SBE.
13. what are some common symptoms of SBE?
14. what are some PE findings for a patient with SBE?

acute bacterial endocarditis...
15. after valve replacement surgery ABE might be caused by...
16. signs and symptoms of ABE...
17. what is the prognosis of ABE of fungal vs. bacterial etiology?
18. prognosis of left vs. right side ABE?
19. what is the treatment for ABE?

non infective endocarditis...
20. what is non infective endocarditis? what causes it?
21. what are the symptoms of NIE?
22. describe a patient picture that would raise suspicion for the diagnosis of NIE.
23. how is the diagnosis of NIE made?
24. prognosis of NIE.

pericarditis...
25. what are some potential etiologies of pericarditis?
26. what is the difference between acute and chronic pericarditis?
27. what is constrictive pericarditis?
28. large amounts of fluid in pericarditis might be due to...
29. what is cardiac tamponade?
30. what are the most common signs and symptoms of acute pericarditis?
31. what aggravates and ameliorates patients with acute pericarditis?
32. what are the signs/symptoms of pericardial effusion?
33. what are the signs/symptoms of cardiac tamponade?

diagnosis and treatment of pericarditis...
34. what imaging tests are used to diagnose acute pericarditis?
35. what imaging tests are used to diagnose pericardial effusion?
36. what imaging tests are used to diagnose cardiac tamponade?
37. what imaging tests are used to diagnose constrictive pericarditis?
38. what might be found in blood tests of patients with pericarditis?
39. what is the conventional treatment of pericarditis?
40. what is the naturopathic treatment of pericarditis?

answers
1. infection of the endocardium, usually with bacteria or fungi.
2. endocardial abnormality (congenital heart defect, rheumatic valve disease, etc), sepsis.
3. turbulent flow leads to endocardial trauma leads to vegetations on endocardium lead to colonization.
4. staph and strep.
5. left side, more often on valves. IV drug users on the right.
6. in the heart: abscesses, conduction abnormalities, regurgitation, heart failure, death. systemic: embolization of infective material. [ieeeee! my abs are conducting a failed gorge of death!]
7. fever with no obvious cause combined with murmur, or when blood cultures are positive in valve disease, or in IV drug users. [fever+murmur, culture+valve, drugs+IV]
8. 3 serial blood cultures within 24 hours. TTE,
9. high WBC, CRP, anemia, elevated ESR.
10. fatal without treatment.

11. strep, sometimes staph.
12. insidious and may mimic other conditions with no obvious source of infection.
13. vague symptoms: fever, night sweats, fatigue, arthralgia, malaise.
14. fever, change in murmur/new murmur, tachycardia. may have petechiae, osler nodes, roth spots, janeway lesions, splinter hemorrhages.

15. fungi.
16. sudden onset of fever, murmur, toxic appearance. symptoms similar to SBE but more severe and acute.
17. treated bacterial cases are 10% mortality, fungi is nearly 100%.
18. better for right sided compared to left.
19. prolonged IV antimicrobial therapy. valve repair surgery to replace valves or remove vegetations.

20. formation of vegetations without associated infection: trauma (catheter injury), hypercoagulability, circulating immune complexes, anti-phospholipid syndrome.
21. generally of underlying disorder, and only if emboli form.
22. chronically ill patients who develop arterial embolism.
23. echo to detect vegetations, blood culture to rule out infection.
24. poor prognosis.

25. idiopathic, infection (usually viral), MI, trauma, tumors, metabolic disorders, alcoholism. [MI idiot virus caused drama when it drank in a meta-tomb]
26. less or more than 6 months.
27. uncommon and idiopathic variant that results from stiffening of pericardium.
28. tumors.
29. a severe condition of impaired cardiac function (filling and CO) due to constriction of pericardium.
30. angina, pericardial friction rub, dyspnea, ischemic pain.
31. better sitting up, leaning forward. worse with thoracic motion, cough, breathing.
32. muffled heart sounds, pericardial rub, decreased breath sounds, crackles.
33. like cardiogenic shock: decreased CO, low arterial pressure, tachycardia, dyspnea, pulsus paradoxus.

a34. ECG: elevated ST segment. echo: pericardial effusion.
35. echo, CXR (enlarged silhouette) ECG (decreased QRS voltage and alternating voltages).
36. pericardiocentesis, ECG (low voltage, alternating voltage)
37. catheterization, ECG (low voltage, abnormal T waves, A fib), CXR (for calcification).
38. high ESR and WBC.
39. aspirin, NSAIDS, colchicines, opiods, corticosteroids.
40. anti inflammatory diet and supplements.