Thanks to Janhavi for presenting the case of a middle-aged man with no significant PMH presenting with acute onset of malaise, myalgias, and a “stubbed toe,” septic with petechiae on palms and soles, found to have mitral valve endocarditis.

Clinical Pearls:

• Endocarditis is more common in men (2:1)
• ~50% of cases of endocarditis occur in people with no known underlying valve disease
• 80% of cases are caused by staph and strep species
• TEE is the gold standard for diagnosis and recommended when clinical suspicion for endocarditis is high.  TTE is more helpful to rule out disease when clinical suspicion is low.
• Indications for early surgery based on this NEJM article include:
  • Heart failure
  • Uncontrolled infection
  • Prevention of embolic events

Duke’s criteria:

Major criteria:

• Blood culture positive:
  • Typical organism in two separate blood cultures
  • Persistently positive blood cultures
  • Single positive culture for Coxiella
• E/o endocardial involvement
  • Echo positive for vegetation
  • New valve regurgitation

Minor criteria:

• Predisposition to IE (i.e. IVDU, prosthetic valve, congenital cyanotic heart disease)
• Fever >38
• Vascular phenomena ⇒ arterial emboli, pulmonary infarcts, mycotic aneurysms, intracranial hemorrhage, conjunctival hemorrhage, Janeway lesions
• Immunologic phenomena ⇒ GN, Osler’s nodes, Roth’s spots, RF
• Microbiologic evidence: positive blood culture not meeting major criteria

Probability of endocarditis:

Definite IE:

• 2 major, 1 major + 3 minor, 5 minor

Possible IE:

• 1 major + 1 minor, or 3 minor

Rejected IE:

• Firmly established alternative diagnosis
• Resolution of symptoms < 4 days with antibiotics
• Does not meet definite/possible criteria

Indications for surgery:

• Valve dysfunction causing heart failure
• Perivalvular extension with development of abscess, fistula, and/or heart block
• Fungi or other highly resistant organisms that are difficult to treat with abx alone
• Persistent bacteremia despite maximal treatment
• Recurrent embolization with persistent vegetations
• Large vegetations (>1 cm) with severe valvular regurg
• S aureus prosthetic valve endocarditis

Indications for early surgery:

• Heart failure
• Uncontrolled infection
• Prevention of embolic events

Complications:

• Most common cause of death: heart failure
• Heart block
• Emboli
  • More likely with s. aureus or S. bovis, veg > 1 cm, or increased veg mobility on echo
  • Antiplatelet therapy initiation is not recommended because of increased risk of hemorrhagic conversion of septic emboli

Want more?

• Check out this blog post and this great review article in the NEJM.

Today, we learned about a young man with no significant medical history who presented with fever of unknown origin, noted to have R sided lymphadenopathy and a pericardial friction rub.  Work up revealed a moderate sized pericardial effusion, a thickened pericardium, and a necrotic LN showing caseating granulomas on biopsy consistent with TB pericarditis!

Clinical Pearls:

• Most common cause of pericarditis in the west is idiopathic.
• Indications for pericardiocentesis
  • Tamponade
  • Suspicion for purulent/tuberculous/neoplastic pericarditis
  • Moderate to large pericardial effusions not responding to anti-inflammatory therapy
• Purulent pericarditis occurs in 1% of infectious cases with staph aureus being the most common underlying pathogen.
• TB pericarditis:
  • Leading cause of pericarditis in high HIV prevalent and resource limited settings around the world
  • Treatment requires anti-TB medications.  Steroids are not routinely recommended but may benefit high risk populations
  • Leading complication is constrictive pericarditis, early therapy does not decrease likelihood of development.

Pericarditis

Diagnosis: (Requires 2 out of the following 4)

1. Typical chest pain
2. Pericardial friction rub
3. EKG with diffuse ST elevations
4. TTE with an effusion

Etiology:

• Idiopathic
  • Primary cause of pericarditis in the west
• Infectious
  • Viral
    • Coxsackie, EBV, adeno, HIV
  • Bacterial
    • Staph aureus (most common cause), TB, strep pneumo, neisseria, legionella, nocardia
  • Other
    • Toxoplasma
    • Echiconoccus
• Non-infectious:
  • Neoplastic
    • hematologic malignancies, lung CA, breast CA, melanoma, mesothelioma
  • Metabolic disorders
    • Uremia, hypothyroidism
  • Autoimmune diseases
    • SLE, RA, scleroderma, MCD, sjogren’s, vasculitides
  • Cardiac injury
    • Trauma, MI, post-PCI, post cardiothoracic surgery
  • Drugs
    • INH, doxorubicin

Indications for pericardiocentesis:

• Tamponade
• Suspicion for purulent/tuberculous/neoplastic process
• Moderate to large effusions of unknown etiology that are not improving with conservative management

 TB pericarditis 

• Diagnosis is often delayed or missed leading to constrictive pericarditis and increased mortality
• Occurs in 1-2% of patients with pulmonary TB.
• Symptoms:
  • Cough, dyspnea, CP, fever, night sweats, orthopnea, weight loss
• Exam
  • Fever
  • Tachycardia
  • Elevated JVP
  • Hepatomegaly
  • Ascites
  • Peripheral edema
  • Friction rub
  • Distant heart sounds
  • Kussmaul’s sign (lack of inspiratory decline in JVP), prominent Y descent, pericardial knock
• Evaluation
  • TTE
  • Sputum AFB and culture
  • PTB noted on CXR 32-72% of the time
  • Pericardiocentesis indicated for diagnosis but does not reduce likelihood of developing complications or death
    • Send fluid studies for cell count, protein concentration, LDH, AFB smear/culture, GS and bacterial culture, ADA, and cytology
    • Fluid has high protein content and lymphocytic/monocytic leukocytosis
• Complications
  • Constrictive pericarditis (30-60% of patients) even with prompt therapy, more common in HIV uninfected individuals
  • Effusive constrictive pericarditis
  • Myopericarditis
  • Cardiac tamponade
• Treatment:
  • Anti-TB therapy
  • Steroids?
    • Not routinely recommended and do not consistently prevent complications
    • Could consider in high risk groups with early signs of constriction
  • Pericardiectomy for those with persistent constriction