INFECTIVE INFECTIVE ENDOCARDITISENDOCARDITIS

Mr. ALFRIN ANTONYMr. ALFRIN ANTONYAsst. LecturerAsst. Lecturer

DEPARTMENT OF PATHOLOGYDEPARTMENT OF PATHOLOGY

+919738286092+919738286092

ENDOCARDITISENDOCARDITIS Inflamation of endocardium Inflamation of endocardium A. Non-InfectiveA. Non-Infective Rheumatic EndocarditisRheumatic Endocarditis Atypical Verrucous EndocarditisAtypical Verrucous Endocarditis Non bacterial thrombotic EndocarditisNon bacterial thrombotic Endocarditis B. InfectiveB. Infective Bacterial endocarditisBacterial endocarditis Other Infective types (tuberculosis,Other Infective types (tuberculosis, syphilitic, fungal, viral, syphilitic, fungal, viral,

rickettsial)rickettsial)

Infective EndocarditisInfective Endocarditis

Febrile illnessFebrile illness Persistent bacteremiaPersistent bacteremia Characteristic lesion of microbial Characteristic lesion of microbial

infection of the endothelial surface of infection of the endothelial surface of the heart the heart

Variable in sizeVariable in size Amorphous mass of fibrin & plateletsAmorphous mass of fibrin & platelets Abundant organismsAbundant organisms Few inflammatory cellsFew inflammatory cells

the vegetation

BACTERIAL BACTERIAL ENDOCARITISENDOCARITIS

DEFINITION:-DEFINITION:- Bacterial Bacterial endocarditis is serious infection of endocarditis is serious infection of the valvular and mural endocardium the valvular and mural endocardium caused by different forms of bacteria caused by different forms of bacteria (other than tubercle bacilli and (other than tubercle bacilli and bacterial micro organisms) and bacterial micro organisms) and characterized by typical infected and characterized by typical infected and friable vegetationsfriable vegetations

CLASSIFICATIONCLASSIFICATIONdepending on severitydepending on severityAcute Acute

Acute bacterial Acute bacterial endocarditis:- is the endocarditis:- is the fulminant and fulminant and obstructive acute obstructive acute infection of the infection of the endocardium by endocardium by highly virulent highly virulent bacteria in a bacteria in a previously normal previously normal heart (heart (fatal2-6 fatal2-6 weeks)weeks)

SubacuteSubacute Subacute bacterial Subacute bacterial

endocarditis is endocarditis is caused by less caused by less virulent bacteria in virulent bacteria in a previously a previously diseased heart and diseased heart and has a gradual down has a gradual down hill course in a hill course in a period of 6 weeks period of 6 weeks to months-yearsto months-years

INCIDENCEINCIDENCE

Bacterial endocaditis may occur at Bacterial endocaditis may occur at any ageany age

Most cases more than 50yeasMost cases more than 50yeas Males > femalesMales > females

ETIOLOGYETIOLOGY1.Infective agents1.Infective agents

SABESABE

1.1. Streptococci with Streptococci with low virulencelow virulence

2.2. Streptococcus Streptococcus viridans (mouth)viridans (mouth)

3.3. Streptococci bovis Streptococci bovis (stomach)(stomach)

4.4. Streptococcus Streptococcus pneumoniaepneumoniae

5.5. Staphylococcus Staphylococcus epidermidisepidermidis

ABEABE

1.1. Staphylococci Staphylococci (staphylococcus (staphylococcus aureus)aureus)

2.2. PneumococciPneumococci

3.3. GonococciGonococci

4.4. Beeta-streptococciBeeta-streptococci

5.5. Enterococci Enterococci

Predisposing factorsPredisposing factors

1.1. Bacteraemia, septicemia and Bacteraemia, septicemia and pyaemiapyaemia

2.2. Underlying heart diseaseUnderlying heart disease

3.3. Impaired host defenceImpaired host defence

PathogenesisPathogenesis

1.1. The circulating bacteria are lodged The circulating bacteria are lodged much more frequently on previously much more frequently on previously damaged valves from disease, chiefly damaged valves from disease, chiefly RHD nad CHD than healthy valvesRHD nad CHD than healthy valves

2.2. Conditions producing haemodynamic Conditions producing haemodynamic stress on the valves are liable to cause stress on the valves are liable to cause damage to the endocardium, favouring damage to the endocardium, favouring the formation platelets thrombi which the formation platelets thrombi which gets infected from circulating bacteriagets infected from circulating bacteria

3.3. Non-bacterial thrombotic endocarditis Non-bacterial thrombotic endocarditis occurs from prolonged stressoccurs from prolonged stress

PATHOLOGIC CHANGESPATHOLOGIC CHANGES

MACROSCOPICALLYMACROSCOPICALLY Lesions are in Lesions are in

mitral>aortic>both > mitral>aortic>both > right heartright heart

SABE > ABESABE > ABE

MICROSCOPICALLYMICROSCOPICALLY The out layer consists The out layer consists

of eosinophilic of eosinophilic material composed of material composed of fibrin plateletsfibrin platelets

Underneath layer is Underneath layer is the basophilic zone the basophilic zone containing colonies of containing colonies of bacteriabacteria

The deeper zone The deeper zone consists of non-consists of non-specific inflammatory specific inflammatory reactionreaction

SymptomsSymptoms

AcuteAcute High grade fever High grade fever

and chillsand chills Arthralgias/ Arthralgias/

myalgiasmyalgias Abdominal painAbdominal pain Pleuritic chest painPleuritic chest pain Back painBack pain

SubacuteSubacute Low grade feverLow grade fever AnorexiaAnorexia Weight lossWeight loss FatigueFatigue Arthralgias/ Arthralgias/

myalgiasmyalgias Abdominal painAbdominal pain

The onset of symptoms is usually ~2 weeks or less from the initiating bacteremia

SignsSigns Fever Fever Heart murmurHeart murmur Nonspecific signs – petechiae, Nonspecific signs – petechiae,

subungal or “splinter” hemorrhages, subungal or “splinter” hemorrhages, clubbing, splenomegaly, neurologic clubbing, splenomegaly, neurologic changeschanges

More specific signs - Osler’s Nodes, More specific signs - Osler’s Nodes, Janeway lesions, and Roth SpotsJaneway lesions, and Roth Spots

PetechiaePetechiae

Photo credit, Josh Fierer, M.D. medicine.ucsd.edu/clinicalimg/ Eye-Petechiae.html

Harden Library for the Health Scienceswww.lib.uiowa.edu/ hardin/md/cdc/3184.html

1.Nonspecific2.Often located on extremities

or mucous membranesdermatology.about.com/.../ blpetechiaephoto.htm

Splinter HemorrhageSplinter Hemorrhage

Splinter HemorrhagesSplinter Hemorrhages

1. Nonspecific2. Nonblanching3. Linear reddish-brown lesions found under the nail bed4. Usually do NOT extend the entire length of the nail

Osler’s NodesOsler’s Nodes

Osler’s NodesOsler’s Nodes

1. More specific2. Painful and erythematous nodules3. Located on pulp of fingers and toes4. More common in subacute IE

American College of Rheumatologywebrheum.bham.ac.uk/.../ default/pages/3b5.htm www.meddean.luc.edu/.../

Hand10/Hand10dx.html

Janeway LesionsJaneway Lesions

Janeway LesionsJaneway Lesions

1. More specific2. Erythematous, blanching macules 3. Nonpainful4. Located on palms and soles

Subconjunctival Subconjunctival HemorrhagesHemorrhages

COMPLICATIONSCOMPLICATIONS

CARDIACCARDIAC Valvular stenosis or Valvular stenosis or

insufficiencyinsufficiency Perforation, rupture Perforation, rupture

and aneurysm of and aneurysm of valve and leafletsvalve and leaflets

Abscesses in the Abscesses in the valve ringvalve ring

Myocardial abscessesMyocardial abscesses Suppurative Suppurative

pericarditispericarditis Cardiac failureCardiac failure

EXTRA CARDIACEXTRA CARDIAC Infracts in spleen, Infracts in spleen,

kidneys and brainkidneys and brain Pulmonory abscessesPulmonory abscesses Petechiae (skin Petechiae (skin

conjunctiva)conjunctiva) Osler’s nodes(SABE)Osler’s nodes(SABE) Janeway’s spots (ABE)Janeway’s spots (ABE)

Local Spread of InfectionLocal Spread of Infection

Acute S. aureus IE with perforation of the aortic valve and aortic valve vegetations.

Acute S. aureus IE with mitral valve ring abscess extending into myocardium.

Septic Pulmonary EmboliSeptic Pulmonary Emboli

http://www.emedicine.com/emerg/topic164.htm

Septic Retinal EmbolusSeptic Retinal Embolus

Roth’s SpotsRoth’s Spots

TUBERCULOUS TUBERCULOUS ENDOCARDITISENDOCARDITIS

It is characterized by presence of It is characterized by presence of typical tubeculosis on the typical tubeculosis on the valvular as well as mural valvular as well as mural endocardium and form endocardium and form tuberculosis thrombo embolituberculosis thrombo emboli

Syphilis endocaditisSyphilis endocaditis

Aortic valvular incompitance Aortic valvular incompitance (severe)(severe)

Fungal endocaditisFungal endocaditisOppurtunistic fungal Oppurtunistic fungal infections like candidiasis infections like candidiasis ans aspergillosis are seen I ans aspergillosis are seen I patients receiving long term patients receiving long term anti biotic therapyanti biotic therapy

Viral endocarditisViral endocarditis

Only in experimentOnly in experiment

Rickettsial endocarditisRickettsial endocarditis

Another rare cause of Another rare cause of endocaditis is form endocaditis is form infection in Q feverinfection in Q fever