Endocarditis and Myocarditis

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Endocarditis andMyocarditis

• Laura Wexler, M.D.
• 475-6383
• wexlerl_at_ucmail.uc.edu

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• Case
• A 45-year-old stockbroker comes to your office
• complaining of generalized fatigue and dyspnea.
  His
• symptoms began approximately three months ago
  and
• have slowly progressed. Two months ago, he saw
  another
• physician who told him he had the flu and mild
  anemia and
• prescribed iron pills. His appetite has
  decreased and he
• has lost 10 lbs. He denies chest pain and he
  has no
• prior history of heart disease or cardiac
  abnormality
• other than a heart murmur that was first noted
  in
• childhood.

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• He has no history of hypertension or diabetes,
• he does not smoke and his lipid profile was
  normal
• when it was checked a year ago. He has no
  family
• history of heart disease. He denies drug abuse
• and takes no medications other than an
  occasional
• aspirin. Six months he underwent extraction of
  an
• abscessed tooth other than that, he has had no
  medical
• procedures.

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Physical Examination

• BP 155/45, P 78 reg, RR 14, T 99.8?
• JVP is estimated at 5 cm.
• Carotid upstrokes are very brisk
• There are rales at both lung bases.
• The PMI is diffuse, heaving and displaced
  laterally to the anterior axillary line .
• The first and second heart sounds are normal.
  There is an S3 at the apex.
• At the lower left sternal border there is a mid-
  peaking, 3/6 systolic ejection murmur and a 4/6
  diastolic decrescendo blowing murmur.
• Examination of the abdomen and extremities is
  unremarkable.

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Infective Endocarditis

• Infection of the endocardial surface of the
  heart ? Usually valvular
• Classifications
• ? Course acute vs. subacute
• ? Substrate native vs. prosthetic valve
• ? Valve Aortic, mitral, tricuspid
• ? Organism staphylococcal, fungal, etc.

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Pathogenesis

• Endocardial surface injury
• - High velocity jet of blood, usually across
  abnormal valve (70)
• - Intravascular hardware intravenous
• catheters, prosthetic valves
• Platelet adherence and thrombus formation at the
  site of injury
• Bacterial entry into the circulation
• Bacterial adherence to the injured endothelial
  surface

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Sites of endocarditis
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Determinants of Infectivity of an Organism in
Endocarditis

• Access to the blood stream
• Survival in the circulation
• Adherence to the endocardial surface
• Size of the inoculum (number of organisms)

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Common Causes of Infective Endocarditis

• Organism Incidence ()
• Streptococci 70
• - Viridans 35
• - Enterococci 10
• - Other 25
• Staphylococci 20
• - S. aureus 18
• - Coagulase negative 2
• Other organisms 10
• (e.g. gram neg., haemophilus, fungi)

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Clinical Presentations of Infective Endocarditis

• Fever
• Fatigue, anorexia, myalgias, night sweats,
  weakness
• Heart failure
• Stroke, abdominal pain
• Arthralgias

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Physical Findings

• Skin splinter hemorrhages, Oslers nodes,
  Janeway lesions
• Mucosal surfaces petechiae
• Funduscopic exam Roth spots
• Heart Murmurs, especially new or increasing
  regurgitant murmur
• Abdomen Enlarged, tender spleen

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Splinter hemorrhages
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Oslers nodes
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Janeway Lesions
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Conjunctival petechiae
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Diagnosis

• Blood cultures (at least 3 sets) 95 likely to
  be positive
• Culture negative endocarditis
• - Fastidious organisms
• - Recent exposure to antibiotics

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Adjunctive Diagnostic Tests in Infective
Endocarditis

• ECG New AV block (first, second or third
  degree), PVCs
• Chest X-ray septic pulmonary emboli (TV
  endocarditis)
• Echocardiogram valvular vegetation

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Septic pulmonary emboli
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Aortic valve vegetations
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Complications of Infective Endocarditis

• Embolization of infected vegetation skin,
  brain, kidney, spleen, lungs
• Metastatic infection (e.g. osteomyelitis)
• Valve destruction and regurgitation
• Local extension of infection
• - Valve ring abscess,
• - Myocardial or conduction system abscess,
• - Pericarditis
• Immune complex injury deposition of
  antigen-antibody complex arthritis,
  glomerulonephritis

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Laboratory Tests in Infective Endocarditis

• Evidence of infection/inflammation
• Elevated erythrocyte sedimentation rate (ESR)
• Leukocytosis
• Anemia
• Evidence of immune complex formation
• Elevated serum globulins
• Rheumatoid factor
• Antinuclear antibody (ANA)
• Hypocomplementemia
• Evidence of renal involvement
• Hematuria
• Proteinuria
• RBC casts

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Management of Infective Endocarditis

• Targeted antibiotics 4-6 weeks of IV therapy
• Close surveillance for evidence of continued
  infection
• Close surveillance for evidence of valve
  destruction
• Valve replacement indications
• Heart failure
• Uncontrolled infection
• Massive vegetation
• Valve ring abscess
• Mechanical valve endocarditis

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Prevention of Bacterial Endocarditis

• Identify patient at risk
• Prompt, aggressive treatment of any infection
• Rigorous attention to dental care
• Prophylactic antibiotics during procedures likely
  to cause bacteremia

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Cardiac Lesions that Predispose to Infective
Endocarditis

• Aortic, mitral valve disease, pulmonic stenosis
• HOCM (IHSS)
• Some congenital lesions (high velocity jets, e.g.
  ventricular septal defect, coarctation of the
  aorta)
• Intravascular hardware
• Intravenous catheters
• Prosthetic heart valves

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Procedures Warranting Antibiotic Prophylaxis

• Dental work with gingival bleeding
• Upper respiratory procedures bronchoscopy,
  surgery
• Genitourinary procedures
• Indwelling bladder catheter
• Cystoscopy
• Prostatectomy
• Vaginal delivery if infection present
• Gastrointestinal surgery

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Antibiotic ProphylaxisAHA Recommendations

• Dental, upper respiratory procedures
• - Oral antibiotic 1-2 hours before
• procedure
• GI, genitourinary procedures
• - IV/Oral antibiotics before procedure

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CASE A 35 yo previously healthy woman comes to
your office complaining of fatigue and shortness
of breath. About four weeks ago she developed a
flu lke illness. Her myalgias and upper
respiratory tract symptoms abated but she
remained tired and noticed some shortness of
breath on exertion. This gradually progressed
until she noticed dyspnea with ordinary
activities like making her bed or walking on
level ground. About 5 days ago, she awoke from
sleep feeling breathless and had to sit at the
side of the bed to regain her breath. This has
recurred each night since then. Two days ago, she
noted swelling of her ankles.
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On physical exam you note signs of congestive
heart failure Her skin is cool and she is
anxious. BP is 90/60, HR 110 regular. RR 24. Her
JVP is 13cm. She has bibasilar rales. The PMI is
diffuse and laterally displaced to the anterior
axillary line. The first heart sound is soft, the
second heart sound is normal there is an S3 and
a murmur of mitral insufficiency. The liver is
enlarged and tender and there is pedal edema.
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ECG Sinus tachycardia, diffuse T wave
inversions. Chest Xray Cardiomegaly, pulmonary
congestion. ECHO 4 Chamber enlargement and
severely reduced systolic function of both
ventricles. The mitral and tricuspid leaflets are
normal but there is mitral insufficiency and
tricuspid insufficiency.
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Right and left heart catheterization Pressures
RA 10mmHg, RV 40/10, PA 40/25, PCW 25. Cardiac
output 2.5 L/min Coronary angiogram Normal Left
ventricular angiogram left ventricular dilation
and an ejection fraction of 20 with mild mitral
insufficiency.
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Myocarditis Infectious causes

• Viral Coxsackie A, B, polio, influenza,
  adeno, echo, rubeola, rubella, hepatitis,
  HIV
• Bacterial Rare
• Other Toxoplasmosis toxoplasma gondii
• Aspergillus
• Chagas Disease Trypanosoma cruzi

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Myocarditis Non-infectious causes

• Radiation
• Toxic or hypersensitivity reaction to drug
• Adriamycin (chemotherapy)
• Cocaine
• Collagen vascular (rheumatoid arthritis, lupus)
• Cardiac transplant rejection

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Natural History of Acute (Viral) Myocarditis

• Subclinical, no sequelae
• Fulminant cardiac dilation, heart failure,
  arrhythmias, death
• Self limited cardiac dysfunction with resolution
  in weeks/months
• Chronic cardiomyopathy

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Diagnosis of Acute Myocarditis

• Clinical Setting Acute onset heart failure
  without underlying cause
• Physical Exam Cardiac dilation, heart
  failure
• ECG Sinus tachycardia, diffuse T
  wave inversions
• Viral titers/cultures
• RV endomyocardial biopsy via R jugular vein

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Treatment of Acute Myocarditis

• Supportive Care
• Drugs for congestive heart failure
• Mechanical support
• Intra-aortic balloon counterpulsation
• Ventricular assist device
• Cardiac transplantation