CASE BASED DISCUSSION

Definite Infective Endocarditis

Presentan : dr. Pramadya V.M.

Pembimbing : dr. Hendry PB Sp.JP
 IDENTITAS PASIEN
Nama : Nn. Pitri
Usia : 19 Tahun
Alamat : Purworejo
Pekerjaan : Pelajar
Dirawat di : Anggrek 1
Indikasi Ranap : Diagnosis dan Terapi
Tanggal periksa : 26 Oktober 2017
Keluhan utama :
Demam naik turun sejak 3 bulan

Riwayat sekarang :
3 bulan SMRS, OS mulai demam naik turun, batuk(-), pilek(-),
sesak napas(+), mudah lelah(+), OS tidur dengan 3 bantal, kaki bengkak(-).
OS belum periksa. 1.5 bulan SMRS, OS masih demam naik turun  OS
periksa ke RS Purworejo dikatakan sakit jantung. OS mondok di RS
Purworejo dan saat pulang diminta kontrol ke RSS. 1 bulan SMES, OS
kontrol ke poli Jantung, sesak ketika aktivitas(+), demam naik turun(+),
lemas(+), batuk(-), pilek (-), DD(+), OP(+), PND(-), kaki bengkak(-), pasien
didiagnosis VSD dd ToF kemudian didaftarkan ekokardiografi  didapatkan
hasil vegetasi multipel pada arteri pulmonalis ukuran 35x10mm, VSD PMO
bidirectional shunt  OS diminta ke IGD untuk mondok  OS menolak.
HMRS karena demam masih naik turun & sesak napas, OS ke IGD, DD(+),
OP(+), PND(-)
Riwayat dahulu :
Riwayat operasi sebelumnya (-), riwayat cabut gigi(-),
riwayat sesak napas aat kecil (+), batuk(+) didiagnosis TB, riwayat
biru-biru (-)

Faktor risiko :
Drug abuse (-), alkoholisme (-), infeksi gigi (-)
Pemeriksaan fisik
KU : CM, sedang
TV : TD 93/65 mmHg , N 110x/mnt, RR 20x/mnt, t0 : 39.8, SpO2 82%
Kepala : konjungtiva pucat (+/+) sklera ikterik (-/-)
Leher : JVP 5+3 cmH2O, limfonodi tak teraba
Dada : p/ I : simetris, ketinggalan gerak (-), retraksi (-)
P : stem fremitus D = S
P : sonor +/+
A : vesikuler +/+, RBB -/-, RBK -/-, wheezing -/-
c/ I : IC tak terlihat
P : IC teraba di SIC V LMCS
P : batas jantung kanan : LPSD
batas jantung kiri : SIC V LMCS, kardiomegali (-), RV heaving (+)
A : S1-S2 normal, reguler, bising (+) PSM 3/6 di SIC III LPSS, ejeksi
sistolik 3/6 di SIC II LPSS, gallop (-)
Perut : flat, peristaltik (+) N, timpani, hepar dan lien tak teraba
Ekstr : oedem tungkai -/-, clubbing finger (+/+)
EKG 25/10/17 jam 16.00
 LABORATORIUM
Hb 8.4 BUN 13.7 PPT 16.6
AL 12.43 Cre 0.9 K 14.2
AT 243 APTT 36.2
AE 3.45 K 28.6
Hct 28.2 Alb 3.0 INR 1.25
SGOT 17
SGPT 11 HbsAg NR
GDS 104
S 80 Na 129
L 14.2 K 4.52
M 5.5 Cl 96.4
E 0.1
B 0.2
Hasil Konsul dg Bagian lain

• Mata  tidak didapatkan kelainan, tidak didapatka Roth Spot

• DV  tidak didapatkan Janeaway Lession dan Osler’s Nods
• Gigi  tidak ditemukan tanda-tanda fokal infeksi dari gigi dan
mulut
Diagnosis :
• Definite Infective Endocarditis
• VSD PMO bidirectional shunt
• PS infundibular severe
Terapi bangsal

• O2 3lpm kanul
• Inj. Ampicillin Sulbactam 3g/6 jam
• Inj. Gentamycin 3mg/kg/24jam
• Inj. Paracetamol 1gr/6jam (k/p)
• Propanolol 3x10mg
Plan :

•Rawat bangsal
•Lacak k/s darah dan UR
•Ro thorax
•echocardiografi evaluasi setelah Tx Ab 2 minggu
•Cukupi kebutuhan cairan
Infective
Endocarditis
 Definition
Infection of the endocardial surface of heart
characterized by
-Colonization or invasion of the heart valves
(native or prosthetic) or the mural endocardium
by a microbe,
-leading to formation of bulky, friable vegetation
composed of thrombotic debris and organisms
-often associated with destruction of underlying
cardiac tissue.
 Sites involved
• Heart valves
• Ventricular septum
defects
• Mural endocardium
• Intracardiac devices

• INFECTIVE ENDARTERITIS –
analogus
 Classification
ACUTE ENDOCARDITIS SUBACUTE ENDOCARDITIS
•Organisms of low virulence causing
•Destructive and infection in a previously abnormal
tumultuous infection, heart, particularly on deformed
frequently of a previously valves.
normal heart valve, with a
•Disease appear insidiously and
highly virulent organism
pursue a protracted course of weeks
•Hematogenoulsy seeds
to month
•If untreated, leads to •Recover after appropriate
death within weeks antibiotic treatment
 Predisposing factors
CARDIAC AND VASCULAR ABNORMALITIES HOST FACTORS
• RHD • Neutropenia
• Myxomatous mitral • Immunodeficiency
valve • Malignancy
• Degenerative calcific • Therapeutic
valvular immunosuppression
stenosis
• Diabetes mellitus
• Bicuspid aortic
• Alcohol
valves
• IV drug abuse
• Prosthetic valves
 Microbiology
• Staphylococcus aureus (35%) : Either healthy or deformed
valves, IV drug abusers (polymicrobial), devices
• Streptococcus viridans (32%) : Native but previously
damaged/abnormal valves
• Enterococci (8 %)
• CoNS - S. epidermidis (4%): Prosthetic valve endocarditis,
devices
• G –ve bacilli of HACEK group (4%)
• Yeast and Fungi(1%)
• Culture negative endocarditis (5 %)
 Pathogenesis
Portal of entry:
◦Dental / Surgical Procedures
◦Contamination by IV drug use
◦Obvious infections (RS/Skin)
◦Occult source from gut, oral cavity
◦Trivial injuries.
◦Intravascular catheter infection
◦Nosocomial wounds
◦Chronic invasive procedures
Endothelial Injury

Uninfected Platelet-Fibrin thrombus (NBTE)

Transient bacteremia and attachment at

NBTE

Proliferation and pro-coagulant state

Infected, friable, bulky vegetation

 Morphology
• Friable, bulky vegetation containing fibrin, inflammatory
cells, and microbes
• Aortic and mitral valves involved most commonly.
• Right side valve involvement in iv drug users.
 Clinical features
Symptoms Constitutional
symptoms
-Damage to intracardiac
structures --- Cytokine
-Embolization of release ?
vegetation fragments
-Hematogenous
infection
-Immune complex
 Sub-acute
Endocarditis
• Persistent fever
• Constitutional
symptoms
• New signs of
valve
dysfunction
• Heart failure

• Embolic Stroke
• Peripheral arterial
embolism
• Other features
Modified Dukes Criteria for
diagnosis of Infective
DefinitiveEndocarditis
Endocarditis if,
-Two major or,
-One major and three minor or,
-five minor

Possible Endocarditis if,

-One major and one minor or,
-Three minor
 Major Criteria
Positive blood culture
◦Typical organism from two cultures
◦Persistent positive blood cultures taken > 12 hours
apart
◦Three or more positive cultures taken over more than
1 hour.
Endocardial involvement
◦Positive echocardiographic findings of vegetations
◦New valvular regurgitation
 Minor Criteria
• Predisposition: Predisposing valvular or cardiac
abnormality
• Intravenous drug misuse
• Pyrexia ≥38°C (≥100.4°F)
• Embolic phenomenon
• Vasculitic/ immunologic phenomenon
• Blood cultures suggestive: -organism grown but not
achieving major criteria
• Suggestive echocardiographic findings
INVESTIGATION
S
 .
Microbiology
Blood cultures:
Key diagnostic investigation in infective
endocarditis.
Isolation of microorganism from culture is
important for diagnosis and also for treatment.
At least 3 sets of samples should be taken from
different venepuncture sites over 24 hours.
 Serology
 Can be sent when the diagnosis is suspected and the
cultures are negative.
 They aid in cases where the organisms will not grow in
blood cultures(Coxiella,Legionella,Bartonella)
 ECG
To detect complications like MI,conduction
abnormalities.
 CHEST X RAY
 .
 Echocardiography
 It can identify the presence and size of
vegetations,detect intracardiac complications and
assess cardiac function.
 Transthoracic echocardiography is noninvasive and
has high specificity for visualising vegetations.
 Transoesophageal echocardiography is more
sensitive than TTE.It can detect small
vegetations,prosthetic endocarditis and intra
cardiac complications.
 .
 Complete blood counts
may show anamia and increased WBC counts.
 Urea dan creatinine may be elevated due to glomerulonephritis
 Liver biochemistry:
Serum alkaline phosphatase may be increased
 Inflammatory markers

CRP,ESR are increased in infection .CRP also helps in monotoring

response to therapy.
 Urine
proteinuria and hematuria occur frequently.
 TREATMENT
Antimicrobial Therapy
Therapy requires identification of
specific pathogen and its susceptibility
to antimicrobials.
Empirical therapy should be started as
soon as possible targeting most likely
pathogens.
Bactericidal drugs should be used.
Antibotic regimen for infective endocarditis
Streptococci
Benzyl penicillin (1.2g 4 hourly) 4-6 weeks
Gentamicin (1mg/kg 8-12 hourly) 4-6 weeks
Enterococci
oAmpicillin sensitive

Ampicillin (2 g 4 hourly) 4-6 weeks, and Gentamicin (1mg/kg 8-12 hourly)

oAmpicillin resistant

Vancomycin(1g 12hourly) 4-6 weeks, and Gentamicin (1mg/kg 8-12 hourly)

Staphycocci
oPenicillin sensitive
Benzyl penicillin I.V(1.2 g 4 hourly)
oPenicillin resistant but methicillin sensitive
Flucloxacillin I.V (2g 4 hourly )
oBoth penicillin and methicillin resistant
Vancomycin I.V (1g 12 hourly) and
Gentamicin
 .
Surgery Indications
patients with direct extension of infection to
myocardial structuires.
Prosthetic valve dysfunction.
Congestive heart failure.
Badly damaged valves.
IE caused by fungi or gram-ve or resistant organisms.
Large vegetations on echocardiography
Recurrent embolic attacks.
Prophylaxis
High risk category
prosthetic cardiac valves
Previous bacterial endocarditis,even
in absense of heart disease.
Complex cyanotic congenital heart
disease(TGA,TOF)
Surgically constructed systemic
pulmonary shunts.
Regimen for IE prophylaxis Standard oral regime
Amoxicillin 2 g 1hr before procedure Inability to take oral med
Ampicillin 2g IV or IM 1hr before procedure
 Penicillin allergy Clindamycin 600 mg Clarithromycin 500 m
Cephalexin 2 g.
Thank
you.