1. Rheumatic fever. Etiology. Diagnostic criteria. Compliсations
Rheumatic fever. Etiology. Diagnostic criteria. Compliсations. Principles of treatment. Endocarditis.
ass. prof. Yarema N.Z.

2. © Polyarthritis Migrate character of poly arthritis
acute short duaration
effect NAID
without deformation
large joints 2

3. Streptococcus pyogenes
Impetigo
Pharrhyngitis
Rheumatic fever
Glomerulonephritis
Scarllet fever
Any signs

4. WHO – 1987, AHA - 1992 І. Major criteria 1.Carditis 2. Polyarrthritis
© Diagnostic criteria
1.Carditis
2. Polyarrthritis
3. Chorea by Cidenham
4. Erythema anulare
5. Reumatic nodules
І. Major criteria
WHO – 1987, AHA

5. ІІ. Minor criteria Clinical: Anamnesis Arrthalgia Fever Lab:
© Diagnostic criteria
Clinical:
Anamnesis
Arrthalgia
Fever
Lab:
Inflamatory changes
incresing P-Q
ІІ. Minor criteria

6. © Chorea

8. © ERYTHEMA ERYTHEMA NODOSUM ANNULARE, -infection MARGINATUM -alergic
-sarcoidosis

10. INFECTIVE ENDOCARDITIS
Vegetations (arrows) due to viridans streptococcal endocarditis involving the mitral valve.

11. Infective endocarditis (IE) is an infection of the endocardial surface of the heart.
The intracardiac effects of this infection include severe valvular insufficiency, which may lead to congestive heart failure and myocardial abscesses. IE also produces a wide variety of systemic signs and symptoms through several mechanisms, including both sterile and infected emboli and various immunological phenomena.

12. ETIOLOGY Organisms Causing Major Clinical Forms of Endocarditis:
Staphylococcus aureus infection is the most common cause of IE, including PVE, acute IE, and IVDA IE.
Approximately % of staphylococcal bacteremias are complicated by IE.
More than half the cases are not associated with underlying valvular disease.
The mortality rate of S aureus IE is 40-50%.

13. ETIOLOGY Organisms Causing Major Clinical Forms of Endocarditis:
Streptococcus viridans
This organism accounts for approximately 50-60% of cases of subacute disease.
Most clinical signs and symptoms are mediated immunologically.
Streptococcus intermedius group
These infections may be acute or subacute.
S intermedius infection accounts for 15% of streptococcal IE cases.
S intermedius is unique among the streptococci; it can actively invade tissue and can cause abscesses.

14. Acute endocarditis usually occurs when heart valves are colonized by virulent bacteria in the course of microbemia. The most common cause of acute endocarditis is Staphylococcus aureus; other less common causes are Streptococcus pneumoniae, Neisseria gonorrhoeae, Streptococcus pyogenes, and Enterococcus faecalis.

15. Bacteremia can result from various invasive procedures
Endoscopy
Rate of 0-20%
CoNS, streptococci, diphtheroids
Colonoscopy
Escherichia coli, Bacteroides species
Barium enema
Enterococci, aerobic and anaerobic gram-negative rods
Dental extractions
Rate of %
S viridans
Transurethral resection of the prostate
Rate of 20-40%
Coliforms, enterococci, S aureus
Transesophageal echocardiography
S viridans, anaerobic organisms, streptococci

16. primary portals

17. primary portals oral cavity, skin, upper respiratory tract
gastrointestinal tract
genitourinary tract
The incidence of nosocomial bacteremias, mostly associated with intravascular lines, has more than doubled in the last few years. Up to 90% of bloodstream infections (BSIs) caused by these devices are secondary to the placement of various types of central venous catheters.

18. primary portals 18

19. Clinical and Laboratory Features of Infective Endocarditis
Fever %
Chills and sweats %
Anorexia, weight loss, malaise %
Myalgias, arthralgias %
Back pain 7-15 %
Heart murmur %
New/worsened regurgitant murmur %

20. Clinical and Laboratory Features of Infective Endocarditis
Arterial emboli %
Splenomegaly %
Clubbing %
Neurologic manifestations %
Peripheral manifestations (Osler's nodes, subungual hemorrhages, Janeway lesions, Roth's spots) 2-15 %

21. Clinical and Laboratory Features of Infective Endocarditis
Petechiae %
Laboratory manifestations:
Anemia %
Leukocytosis %
Microscopic hematuria %
Elevated erythrocyte sedimentation rate>90 %

22. Clinical and Laboratory Features of Infective Endocarditis
Rheumatoid factor 50 %
Circulating immune complexes %
Decreased serum complement %

23. Common Peripheral Manifestations of Infective Endocarditis
Common Peripheral Manifestations of Infective Endocarditis. Splinter hemorrhages (A) are normally seen under the fingernails. They are usually linear and red for the first-two to three days and brownish thereafter. Panel B shows conjunctival petechiae. Osler's nodes (Panel C) are tender, subcutaneous nodules, often in the pulp of the digits or the thenar eminence. Janeway's lesions (Panel D) are nontender, erythematous, hemorrhagic, or pustular lesions, often on the palms or soles. 23

24. Noncardiac Manifestations
Janeway’s lesions. Hemorrhagic, infarcted macules and papules on the volar fingers in a patient with S. aureus endocarditis.

25. Noncardiac Manifestations
Septic vasculitis associated with bacteremia. Dermal nodule with hemorrhage and necrosis on the dorsum of a finger. This type of lesion occurs with bacteremia (e.g., S. aureus) and fungemia (e.g., Candida tropicalis).

26. Noncardiac Manifestations
subconjunctival hemorrhage. Submucosal hemorrhage of the lower eyelid in an elderly diabetic with enterococcal endocarditis; splinter hemorrhages in the midportion of the nail bed and Janeway lesions were also present.

27. Splinter haemorrhages are linear haemorrhages lying parallel to the long axis of finger or toe nails. 27

28. Noncardiac Manifestations
Vasculitis

29. Clubbing. Seen in patients with chronic lung disease, cyanotic heart disease, cirrhosis and infective endocarditis.

30. Infective endocarditis: metastatic infections due to emboli.

31. Noncardiac Manifestations
Computed tomography of the abdomen showing large embolic infarcts in the spleen and left kidney of a patient with Bartonella endocarditis.

35. Activity of process: active, nonactive.
Classification of infective endocarditis due to recommendation of Ukranian society of cardiologists (confirmed by VI National Congress of Ukranian Cardiologists,
Activity of process: active, nonactive.
Native valvular endocarditis: primary, secondary (trauma, foreign body); prosthetic valve endocarditis.
Site: mitral valve, aortic valve, tricuspid valve, valve of the pulmonary artery, endocardium.
Etiology: Gram-positive bacilli, Gram-negative bacilli, L-forms, rickttsia, fungi
Stage of valvular disease, of cardiac insufficiency.
Complications.

36. Antibiotic Treatment for Infective Endocarditis Caused by Common Organisms
Streptococci Penicillin-susceptible streptococci, S. bovis
Penicillin G 2-3 million units IV q4h for 4 weeks
Penicillin G 2-3 million units IV q4h plus gentamicin 1 mg/kg IM or IV q8h, both for 2 weeks
Ceftriaxone 2 g/d IV as single dose for 4 weeks
Vancomycind 15 mg/kg IV q12h for 4 weeks

37. Antibiotic Treatment for Infective Endocarditis Caused by Common Organisms
Relatively penicillin-resistant streptococci
- Penicillin G 3 million units IV q4h for 4-6 weeks plus gentamicin 1 mg/kg IV q8h for 2 weeks
Penicillin-resistant streptococci, pyridoxal-requiring streptococci (Abiotrophia spp.)
- Penicillin G 3-4 million units IV q4h plus gentamicinc 1 mg/kg IV q8h, both for 4-6 weeks

38. Antibiotic Treatment for Infective Endocarditis Caused by Common Organisms
Enterococci
Penicillin G 3-4 million units IV q4h plus gentamicinc 1 mg/kg IV q8h, both for 4-6 weeks
Ampicillin 2 g IV q4h plus gentamicin 1 mg/kg IV q8h, both for 4-6 weeks
Vancomycin 15 mg/kg IV q12h plus gentamicin 1 mg/kg IV q8h, both for 4-6 weeks

39. Antibiotic Treatment for Infective Endocarditis Caused by Common Organisms
Methicillin-resistant, infecting prosthetic valves (Staphylococci)
Vancomycin 15 mg/kg IV q12h for 6-8 weeks plus gentamicin 1 mg/kg IM or IV q8h for 2 weeks plus rifampin 300 mg PO q8h for 6-8 weeks
HACEK organisms
Ceftriaxone 2 g/d IV as single dose for 4 weeks
Ampicillin 2 g IV q4h plus gentamicin 1 mg/kg IM or IV q8h, both for 4 weeks

40. Thank you for attention40