| Rheumatic fever definition | multi-system disorder resulting from an abnormal autoimmune response to a preceding streptococcal upper respiratory tract infection (SURI); proliferative inflammatory reaction involving CT |
| rheumatic fever: major criteria (JONES) | Carditis: Pancarditis/endocarditis/myocarditis/pericarditis
Polyarthritis: >2 joints, painful w/ movements & tender
Chorea minor: rapid uncoordinated jerking movements (hands, face, feet)
Erythema marginatum: erythematous nodules/ normal centre, painless no itching (hands, inner legs, back, abdomen, face)
subcutaneous nodules: firm painless 1mm-2cm, movable skin, not inflammed - coexists with carditis |
| Rheumatic fever: minor criteria (JONES) | Clinical: arthralgia, fever 38c for 1-2 weeks
Laboratory: ESR, CRP >10mg/l, leukocytosis, ASO >250U
Anamnesis: strep A infection (pharyngitis, angina, scarlet fever)
ECG: PR prolonged |
| Rheumatic fever: treatment principles | Bed chair regime 2-6 wks (in case of carditis & diffuse myocarditis)
1. Antibiotics for strep for 10 days: PenIcillin G 2m U 4-6doses IV: Amoxicillin 2g/day; Cefadroxil 1.0/p (recurrent)
if penicillin sensitive: erythromycin 250mg 4/day
2. NSAIDS- until ESR normal to relieve arthralgia & arthritis: Diclofenac 150mg/d
3.Glucocorticoids- until CRP normal. for HF, Recurrent attacks & cardiomegaly: oral prednisolone 1-2mg every 3-5days. Severe- IV pantoprazole
4. Diazepam 2.5mg 3/day for chorea minor
5. Surgical treatment for sever AR & MR (aortic/mitral valve repair or bio-prothesis, LV assist device in HF) |
| Rheumatic fever: Primary prevention | -accurate diagnosis
-appropriate treatment of strep
-Abx prophylaxis in high risk populations (children, doctors, teachers, soldiers, after heart surgery or prosthetic valves) |
| Rheumatic fever: Secondary prevention | Abx prophylaxis to prevent recurrence:
Penicillin G benzathine 1.2m U IM every 3wks
Penicillin V potassium 200mg orally BID
Sulfadiazine 1g orally once daily
Macrolide/ Azalide abx for penicillin + sulfadiazine allergy
Duration: RHF w/out carditis: 5yrs or age 21 ; RHF w/ carditis& w/out VHD: 10yr or age 21; RHF w/ VHD: 10yrs after last attack, until 40 or lifelong |
| Rheumatic fever: pathogenesis | - Connective tissue disorganisation, fragmentation, exudative inflammation, interstitial and cellular edema, vasculitis, collagen fiber fragmentation
- Aschoff bodies (plasma cells, lymphocytes, eosinophilic leukocytes, fibrinoid material, macrophages) in myocardium and interstitium - persist long time, subclinical rheumatic activity
-Acute period: regurgitating valves
- Chronic period: sclerosis, deformation, stenotic valves, commissural fusion |
| Infective Endocarditis: Definition & Epidemiology | - Infection of the endocardium, usually with bacteria (staphylococci, streptococci, enterococcus, HACEK group0 or fungi.
- Forms: Acute, Subacute, Persistent
- can occur at any age, but risk increases with age (peak: 70-80yrs)
- Male:Female ratio 2:1 |
| Infective Endocarditis: Risk Groups | - Elderly (70-80yrs)
- IV drug users
- Immunocompromised individuals
- Patients with prosthetic heart valves/ intra-cardiac devices |
| Infective Endocarditis: Pathogenesis | (A) cell apoptosis due to blood turbulence
(B) Deposit of fibrin & thrombocytes
(C) colonisation of microbes & neutrophils; chemoattraction
(D) Neoangiogenesis,valve destruction |
| Infective Endocarditis: Forms | -Subacute: aggressive; develops insidiously & progresses slowly (weeks-months). Usually no source of infection or portal of entry evident (streptococci most common cause).
- Acute: develops abruptly & progresses rapidly (days). Evident source of infection or portal of entry ( s.aureus, group A strep, pneumococci, gonococci). If massive bacteria - can affect normal valve,
- Prosthetic: develops within1 year after valve replacement; aortic>mitral . Affects mechanical and biprosthetic valves equally |
| Infective Endocarditis: Major Criteria | 1- Blood culture +ve for IE
(a) + 2 separate blood cultures (every 30 mins). Typical: s. aureus, s. viridans, s.gallolyticus, HACEK gr. or enterococci
(b) + 2 separate blood cultures (12 hours apart):
(c) + 1 blood culuture (C. burnetii) or phase 1 IgG Ab titre >1:800
2- Imaging:
(a) echo: vegetation, abscess, pseudoaneurysm, fistula, valvular perforation/aneurysm, prosthetic valve defect (dehiscence)
(b) PET: abnormal activity around prosthetic valve (18F-FDG PET/CT if >3m, or radio-labelled leukocytes SPECT/CT)
(c) Cardiac CT: definite paravalvular lesions |
| Infective Endocarditis: Minor Criteria | 1- Anamnesis (predisposition): underlying heart disease, IV drug abuse
2- Clinical: Fever ≥ 38°
3- Vascular phenomena: emboli, septic pulmonary infarcts, infectious aneurysm, intracranial/conjunctival haemorrhages, Janeway's lesions
4- Immunological phenomena: Glomerulonephritis, Osler's nodes, Roth's spots, Rheumatoid factor
5- Microbiological evidence: + blood culture but doesn't meet major criteria |
| Infective Endocarditis : Streptococcal treatment | NVIE 4 weeks (6 weeks if Prosthetic):
-Penicillin G 12-18mln U/day IV (6 doses or cont.)or
- Amoxicillin 100-200mg/kg/day IV (4-6 doses) or
-Ceftriaxone 2g/day IV/IM (1 dose)
If NVIE 2 weeks: One of above + Gentamycin 3mg/kg/day IV/IM
(to avoid renal failure)
OR if B-lactam allergic: Vancomycin 30mg/kg/day in 2 doses for 4 weeks |
| Infective Endocarditis: Staphylococcal Treatment | - Native 4-6 weeks: Oxacillin / Cloxacillin 12g/day IV in (4-6 doses >6 weeks) -if methicillin susceptible
- Prosthetic > 6 weeks: Oxacillin/ cloxacillin 12g/day IV (4-6 doses) + Rifampin 900-1200mg IV or orally (2-3 doses) + Gentamycin 3mg/kg/day IV/IM (1or 2 doses for 2 weeks)
- MRSA: Vancomycin + Rifampin + Gentamycin for >6weeks (alternative: Daptomycin) |
| Infective Endocarditis: Enterococcus treatment | -MOST SAFE: Ampicillin 200mg/kg/day IV (4-6 doses for 6wks) + Ceftriaxone 4g/day IV/IM (2 doses for 6 weeks) or
- Ampicillin/ Amoxicillin + Gentamycin or
- Vancomycin + gentamycin |
| Infective Endocarditis: Empirical treatment | Before and w/out pathogen identification:
- Native / Late prosthetic: Ampicillin + Oxacillin + Gentamycin / Vancomycin + Gentamycin
- Health care native / Early prosthetic: Vancomycin + Gentamycin + Rifampin |
