Infective endocarditis

Infective Endocarditis in Children: an overview

Dr.B.BALAGOBI

Points to ponder...• IE is infection of the cardiac tissue/related structures -

valves• Is a complication of congenital and acquired heart

disease can change the outcome of the heart disease

• Lesion associated with a high velocity jet of blood or an intra cardiac prosthesis

• Predisposing factors - dental or surgical procedure, following cardiac surgery

• Relatively rare in children• Pre-antibiotic era: mortality was nearly 100%

Infective Endocarditis

• Febrile illness• Persistent bacteremia• Characteristic lesion of microbial infection

of the endothelial surface of the heart

– Variable in size– Amorphous mass of fibrin & platelets– Abundant organisms– Few inflammatory cells

The vegetation

Distinction between Acute and Subacute Bacterial Endocarditis

Feature Acute Subacute

Underlying Heart Disease

Heart may be normal RHD,CHD, etc.

Organism S. aureus, Pneumococcus

S. pyogenes,

Enterococcus

viridans

Streptococci,

Entercoccus

Therapy Prompt, vigorous and initiated on empirical ground

Can often be delayed until culture reports and susceptibilities available

Prevention – the underlying lesion

• High risk lesions– Prosthetic valves

– Prior IE

– Cyanotic congenital heart disease

– PDA

– AR, AS, MR,MS with MR

– VSD

– Coarctation

– Surgical systemic-pulmonary shunts

• Intermediate risk– MVP with murmur– Pure MS– Tricuspid disease– Pulmonary stenosis– ASH– Bicuspid Ao valve with no

hemodynamic significance

Lesions at highest risk

Prevention – the underlying lesion

• Low/no risk– MVP without murmur– Trivial valvular regurg.– Isolated ASD– Implanted device

(pacer, ICD)– CAD– CABG

Culprits...

• Viridans group of streptococci ( haemolytic strep) - flora of mouth

• Enterococci - gastrointestinal tract

• Staphylococcus aureus

• Fungi

Pathophysiology

• Embolization• Clinically evident 11 – 43% of patients• Pathologically present 45 – 65%• High risk for embolization

» Large > 10 mm vegetation» Hypermobile vegetation» Mitral vegetations (esp. anterior leaflet)

• Pulmonary (septic) – 65 – 75% of i.v. drug abusers with tricuspid IE

When to suspect…?• Congenital/acquired

heart lesion• Continued fever• Anorexia, weight loss,

malaise• Pallor - demonstrate a

drop in Hb%• Clubbing, petechiae• Splinter haemorrhages

etc - not usually found

• Murmur - failure, changing murmurs

• Splenomegaly• Embolic phenomena

to lungs/kidneys/brain limbs (rare since use of antibiotics)

• Urine - microscopic haematuria (immune complex)

The echocardiogram in IE

Splinter Hemorrhage

Roth’s Spots

Sequelae

• Neurologic manifestations, 20%– Cerebral emboli, mycotic aneurysms,

cerebritis, brain abscess, hemorrhage, etc.

• Peripheral embolization– Ischemia, infarction, mycotic aneurysms, etc

• Pulmonary infarction

• Renal insufficiency

• Congestive heart failure

Prophylaxis...

• Any procedure likely to cause bacteriaemia • dental treatment • abdominal surgery • surgery or instrumentation of upper respiratory or genitourinary tract • following burns • IV alimentation

• Dental procedures - Amoxycillin/Erythromycin

• GU/GI procedures, previous endocarditis, intracardiac prostheses - Ampicillin and Gentamicin Vancomycin and Gentamicin

T/F Infective endocarditis?

A. Diagnosis is based on Duckett Jone’s criteria

B. ASD is a common cause

C. Cause firm splenomegaly

D. Associated with Streptococcus Viridans infection

E. Vegetations are sterile

F. Never cause embolisation

T/F features of Infective endocarditis?

A. Clubbing

B. Haematuria

C. Fever

D. Arthralgia

E. Chorea

T/F Regarding Infective endocarditis?

A. Normal WBC count exclude the diagnosis

B. 2D echocardiography is not useful in diagnosis

C. Blood for culture is taken at the peak of the fever

D. Macroscopic haematuria is common

E. Clubbing is an early feature.

T/F Diastolic murmur in 7 year old?

A. Mitral stenosis

B. Anaemia

C. Infective endocarditis

D. Tetralogy of fallot

E. Acute Rheumatic carditis

T/F Infective endocarditis in children?

A. Is often caused by Streptococcal pneumonia

B. Is seen in child with PDA

C.Cause haematuria

D.Cause clubbing during first week of the illness

E. IV antibiotics is given for 2 weeks