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Heart valves (view source)

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→‎Infective endocarditis: split out
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==Infective endocarditis==
==Infective endocarditis==
:''Bacterial endocarditis'' and ''subacute bacterial endocarditis'' redirect here.
{{Main|Infective endocarditis}}
*Abbreviated ''IE''.
===General===
*Infection of the endocardium - often involves the valves (which are covered by endocardium).
*Before the time of antibiotics -- 100% fatal.
 
====Organisms====
Most common organism overall:
*''Staphylococcus aureus''.<ref name=pmid12092480>{{Cite journal  | last1 = Petti | first1 = CA. | last2 = Fowler | first2 = VG. | title = Staphylococcus aureus bacteremia and endocarditis. | journal = Infect Dis Clin North Am | volume = 16 | issue = 2 | pages = 413-35, x-xi | month = Jun | year = 2002 | doi =  | PMID = 12092480 }}</ref>
 
Organisms associated with particular clinical scenarios:
*IV drug users / normal valves = ''Staphylococcus aureus''.<ref name=Ref_PCPBoD8_298>{{Ref PCPBoD8|298}}</ref>
*Previously damaged valve = ''Streptococcus viridans''.
*Prosthetic valves = ''Staphylococcus epidermidis''.<ref name=pmid19660339>{{Cite journal  | last1 = Alonso-Valle | first1 = H. | last2 = Fariñas-Alvarez | first2 = C. | last3 = García-Palomo | first3 = JD. | last4 = Bernal | first4 = JM. | last5 = Martín-Durán | first5 = R. | last6 = Gutiérrez Díez | first6 = JF. | last7 = Revuelta | first7 = JM. | last8 = Fariñas | first8 = MC. | title = Clinical course and predictors of death in prosthetic valve endocarditis over a 20-year period. | journal = J Thorac Cardiovasc Surg | volume = 139 | issue = 4 | pages = 887-93 | month = Apr | year = 2010 | doi = 10.1016/j.jtcvs.2009.05.042 | PMID = 19660339 }}</ref>
 
Organisms that less commonly cause ''IE'' are known as the ''HACEK group'':<ref name=Ref_PCPBoD8_298>{{Ref PCPBoD8|298}}</ref>
*'''''H'''aemophilus'' (''Haemophilus parainfluenzae'', ''Haemophilus aphrophilus'', ''Haemophilus paraphrophilus'').
*'''''A'''ctinobacillus'' (''Actinobacillus actinomycetemcomitans'', ''Aggregatibacter aphrophilus'').
*'''''C'''ardiobacterium hominis.
*'''''E'''ikenella corrodens''. †
*'''''K'''ingella'' (''Kingella kingae'').
 
Notes:
* † ''Enterococci'' are not included in this list but are lumped with the ''HACEK organisms''.<ref name=Ref_PCPBoD8_298>{{Ref PCPBoD8|298}}</ref>
 
Others:
*''Stenotrophomonas maltophilia'' (previously ''Pseudomonas maltophilia'') - Gram-negative bacillus,<ref>{{Cite journal  | last1 = Gautam | first1 = V. | last2 = Ray | first2 = P. | last3 = Vandamme | first3 = P. | last4 = Chatterjee | first4 = SS. | last5 = Das | first5 = A. | last6 = Sharma | first6 = K. | last7 = Rana | first7 = S. | last8 = Garg | first8 = RK. | last9 = Madhup | first9 = SK. | title = Identification of lysine positive non-fermenting gram negative bacilli (Stenotrophomonas maltophilia and Burkholderia cepacia complex). | journal = Indian J Med Microbiol | volume = 27 | issue = 2 | pages = 128-33 | month =  | year =  | doi = 10.4103/0255-0857.49425 | PMID = 19384035 }}</ref> rarely causes endocarditis,<ref name=pmid23021356>{{Cite journal  | last1 = Carrillo-Córdova | first1 = JR. | last2 = Amezcua-Guerra | first2 = LM. | title = Autoimmunity as a possible predisposing factor for Stenotrophomonas maltophilia endocarditis. | journal = Arch Cardiol Mex | volume = 82 | issue = 3 | pages = 204-7 | month =  | year =  | doi = 10.1016/j.acmx.2012.03.001 | PMID = 23021356 }}</ref> high mortality.<ref>{{Cite journal  | last1 = Fontenier | first1 = G. | last2 = Freschard | first2 = R. | last3 = Mourot | first3 = M. | title = Study of the corrosion in vitro and in vivo of magnesium amodes involved in an implantable bioelectric battery. | journal = Med Biol Eng | volume = 13 | issue = 5 | pages = 683-9 | month = Sep | year = 1975 | doi =  | PMID = 1186330 }}</ref>
 
====Clinical====
*Diagnosed (clinically) using the ''Duke criteria''.<ref>[http://www.medcalc.com/endocarditis.html http://www.medcalc.com/endocarditis.html]</ref><ref>{{cite journal |author=Durack DT, Lukes AS, Bright DK |title=New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service |journal=Am. J. Med. |volume=96 |issue=3 |pages=200-9 |year=1994 |month=March |pmid=8154507 |doi= |url=}}</ref>
**Positive blood cultures.
**Cardiac involvement - vegetation.
**+/-Febrile.
 
Subdivided into:
#Acute IE.
#*Classically due to ''Staphylococcus aureus''.
#Subacute IE.
#*Classically due to ''Streptococcus viridans''.
 
Treatment:<ref name=pmid23968767>{{Cite journal  | last1 = Gaca | first1 = JG. | last2 = Sheng | first2 = S. | last3 = Daneshmand | first3 = M. | last4 = Rankin | first4 = JS. | last5 = Williams | first5 = ML. | last6 = O'Brien | first6 = SM. | last7 = Gammie | first7 = JS. | title = Current Outcomes for Tricuspid Valve Infective Endocarditis Surgery in North America. | journal = Ann Thorac Surg | volume =  | issue =  | pages =  | month = Aug | year = 2013 | doi = 10.1016/j.athoracsur.2013.05.046 | PMID = 23968767 }}</ref>
*Usually medical management.<ref name=pmid16506645>{{Cite journal  | last1 = Chait | first1 = RD. | last2 = Midwall | first2 = J. | title = Tricuspid valvectomy: long-term survival and surgical options. | journal = Clin Cardiol | volume = 29 | issue = 2 | pages = 83-4 | month = Feb | year = 2006 | doi =  | PMID = 16506645 | URL = http://onlinelibrary.wiley.com/doi/10.1002/clc.4960290210/pdf }}</ref>
*Valve replacement.
*Valve repair.
*Valvectomy - for tricuspid valve.
 
===Gross===
*Location - left-sided involvement (mitral, aortic) more common than right-sided involvement (pulmonic, tricuspid).
**This is reversed in IV drug users.<ref name=Ref_PCPBoD8_298>{{Ref PCPBoD8|298}}</ref><ref name=pmid16401952>{{Cite journal  | last1 = Mathura | first1 = KC. | last2 = Thapa | first2 = N. | last3 = Rauniyar | first3 = A. | last4 = Magar | first4 = A. | last5 = Gurubacharya | first5 = DL. | last6 = Karki | first6 = DB. | title = Injection drug use and tricuspid valve endocarditis. | journal = Kathmandu Univ Med J (KUMJ) | volume = 3 | issue = 1 | pages = 84-6 | month =  | year =  | doi =  | PMID = 16401952 }}</ref>
*+/-Valvular destruction.
**More common in acute IE.
*+/-Distant emboli, e.g. [[splenic infarct]].
**More common in acute IE.
*+/-Valvular vegetations.
**Irregular ball of loosely adherent tissue - dull, irregular surface.
**On the ventricular aspect in aortic valve IE.
**Larger in acute IE.
 
Image:
*[http://www.flickr.com/photos/11462589@N05/1126726482/ Infective endocarditis - aortic valve (flickr.com)].
 
===Microscopic===
*Inflammatory infiltrate (key feature @ low power):
**+/-Plasma cells - subacute.
**+/-Neutrophils - typically abundant, may be rare in subacute.<ref>URL: [http://emedicine.medscape.com/article/216650-overview#a0104 http://emedicine.medscape.com/article/216650-overview#a0104]. Accessed on: 26 November 2013.</ref>
*Microorganisms - '''key feature''' (diagnostic).
**Hard to see (even at high power).
 
===Stains===
*[[GMS stain]] (Gomori Methenamine-silver stain).
**Look for [[fungi]].
*[[Gram stain]].
**Look for bacteria.
 
===Sign out===
<pre>
TRICUSPID VALVE, VALVECTOMY:
- FRAGMENTS OF VALVE WITH INFECTIVE ENDOCARDITIS -- ABUNDANT COCCI
  ORGANISMS IDENTIFIED.
- THIN RIM OF CARDIAC MUSCLE WITHOUT APPARENT PATHOLOGY.
</pre>
 
<pre>
MITRAL VALVE, VALVE REPLACEMENT:
- FRAGMENTS OF VALVE WITH INFECTIVE ENDOCARDITIS -- ABUNDANT COCCI
  ORGANISMS IDENTIFIED.
</pre>
 
====No microorganisms====
<pre>
AORTIC VALVE (BICUSPID), VALVE REPLACEMENT:
- BICUSPID VALVE WITH CALCIFIC AORTIC STENOSIS AND MILD ENDOCARDITIS.
- NO MICROORGANISMS APPARENT.
</pre>
 
====Micro====
The sections show valve tissue with an attached vegetation with abundant cocci organisms
and neutrophils. No calcification is apparent.
 
=====No microorganisms=====
The sections show valve tissue with marked calcification, scattered neutrophils and plasma cells. No microorganisms are identified with routine stains.


=Non-infective conditions=
=Non-infective conditions=
Michael
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