Cardiovascular Slideshow

Case 1:
A. All the results are above normal parameters

B. Streptococcus Pyogenes(B-hemolytic/ Group A Strep)

C. Type II (antigen-antibody)

D. 1 st line: Penicillin (Allergic: Erythromycin), Pain and fever: analgesia, Steroids for anti-
inflammatory, Bed rest

NB look at prophylaxis (primary and secondary)

Case 2:
A. Septicaemia: Invasion of bloodstream by microorganisms producing clinical signs and
symptoms e.g. fever, rigor, tachycardia, hypotension, mental confusion etc.

Bacteraemia: Presence of bacteria in blood; can be transient and asymptomatic e.g. chewing
food or incubation of infectious disease

B. Look at vitals eg. Blood pressure, temp, pulse and resp

Blood: WBC count, CRP and ESR

C. Gram + : Staph A, Staph E, Enterococci, pneumococci

Gram -: E. Coli, Pseudomonas, Klebsiella spp.

Others: Fungi, anaerobes and mycobacteria

D. Find the cause of infection and treat accordingly with susceptible antimicrobials (Send for
M, C, and S)

Case 3:
A. Classical PUO:

 Symptoms: fever >38˚C on several occasions more than three weeks

 Diagnosis: Uncertain origin despite appropriate investigations after at least three
outpatient visits or three days in hospital

B. Travel history, Insect bites, occupation and positive contacts with any other sick
individual.

C. History guide you: septic screen, bloods for microscopy.

D. Neoplasm, Collagen vascular disease, drugs and usually infections.

For infections:

 Bacterial (TB, Salmonella typhi, Staph A, H. Influenza etc)

 Parasites ( Plasmodium spp., Trypanosoma brucei, E. Histolytica)
 Fungi (C. Neoformans, H. Capsulatum)
 Virus (EBV, Hep and CMV)

E. Treat the underlying cause with susceptible treatment eg. Cancer with chemo or radiation
or Infections treat the aetiological agent.

Case 4:
A. Infective endocarditis

B. Streptococcus viridians

C. Pathogenesis of IE

1. Valvular endothelium damage (Trauma eg RHD or inflammation)

2. “Sterile” platelet-fibrin thrombi formation on damaged valve (NBTE)
3. Transient bacteraemia during tooth extraction
1. 4.Adherence of bacteria to NBTE
4. Colonization and bacterial division
5. More fibrin deposition, platelet aggregation, extracellular protease, protection form
neutrophils
6. Mature vegetation: meshwork of thrombotic platelets, fibrin and inflammatory cells

D. Clinical:

 Look at modified Duke’s criteria: look for presence of major and minor criteria,
 Peripheral vascular manifestations ( Janeways lesion and emboli infarcts)
 Hyperglobulinemia and splenomegaly
 Circulationg rheumatoid factor
 Circulating anti-nuclear antibody (Osler’s nodes and Roth spots)

Blood Culture:

 2 or 3 sets of culture must be positive

 Bacteraemia must be continuous, 80% low grade
 90%- the first two positives, 91% even if antibiotics for 2/52
 Special cultures for rare and fastidious organisms e.g. fungi

Serology
  Clotted blood serum used
 Q fever- Coxiella burnetii
 Murine Typhus (Rickettsia typhi)
 Pstittacosis (Chlamydia psittaci)
 Brucellosis

Hematology

 Often abnormal but not diagnostic

 Anaemia- iron deficiency
 ESR
 Hypergammaglobulinaemia
 Rh factor
 Circulation immune complexes

Urine

 Proteinuria
 Microscopic hematuria
 RBC casts

E. Look at Principles of IE management

Empirical treatment:

 Native valve: Benzylpenicilllin and Gentamycin (look specifically at S. Viridnas and S.

Aureus details)
 Prosthetic valve: Benzylpenicilllin, Gentamycin AND Cloxacilin (Look at Enterococci,
GNB and Pseudomonas)

Prophylaxis

Dental site

 Iodine containing mouthwash

 Irrigate dental sulci with iodinated glycerol solution
 Local antibacterial solution

Surgery

 3g Amoxicilin orally 1 hour before + 1,5 g 6 hours after procedure

 Penicillin allergy- Erythromycin or Clindamycin
 Increased risk and GIT and GUT procedures use: IV Ampicillin + Gentamycin or
 IV Gentamycin + Vancomycin


Case 5:
A. 2 or 3 sets

B. Prevent introduction of bacteria of surrounding skin into injection site: Alcohol swab twice, wipe
away from injection site and let it airdry before introducing needle into skin.

C. Child: 5 ml and Adult 10 ml

D. FAN (fasitidious antimicrobial neutralization): Activated Charcoal in solution for patients currently
on anti-microbials. Charcoal binds to antimicrobials to inactivate it which then allows bacteria to
grow.

Case 6:
A. Infective Endocarditis

B.Staph Aureus

 Group D Streptococcus
 Enterobacteriae
 Pseudomonas
 Fungi

C. History of IV drug abuse.

D. Look at previous work for more detail e.g. Staph Aureus- Gram +, Grape like clusters, Coagulase +,
Catalase +, DNAase etc.

E. Inject into unsterile skin and introduce organisms into skin. Look at complete pathogenesis of IE.

Case 7:
A. Infective endocarditis

B. Yes, especially during prophylaxis are recommended during surgery procedures

C. GUT procedures use: IV Ampicillin + Gentamycin or IV Gentamycin + Vancomycin

D.Commonly: Staph epidermidis, Staph Aureus , Candida spp and Aspergillus spp. Others:Enterobac
and Pseudomonas, Diphtheroids

E. Look at previous work for more detail e.g. Staph Aureus- Gram +, Grape like clusters, Coagulase +,
Catalase +, DNAase etc

Case 8:
A. Group D Streptococci (Enterococcus)
B. Gram + cocci in chains etc look at previous work for more detail.

C.Yes, instrumentation and extreme ages increases the risk of septicaemia.

D. Septicaemia: Invasion of bloodstream by microorganisms producing clinical signs and

symptoms e.g. fever, rigor, tachycardia, hypotension, mental confusion etc.

Bacteraemia: Presence of bacteria in blood; can be transient and asymptomatic e.g. chewing
food or incubation of infectious disease

E.Investigate the underlying cause to treat it firstly (Blood MCS and serology) treat the rest
symptomatically. Closely monitor patient and do spectic screening to prevent septic shock.

Case 9:
A. Streptococcus viridans

B.Look at previous work for detail e.g. Coagulase negative etc

C.Instrumentation 2 months earlier involving heart valves. Early prosthetic infection. Prosthetic valve
is regared as foreign and thus a riks for IE. For full pathogenesis refer to previous questions.

D.Prosthetic Mitral valve

E.Aim is to completely irradicate the source of infection (look at principles)

 Empiric: Benzylpenicillin+Gentamycin+Cloxacillin
 Enterococci: PenG or Ampicillin + Gentamycin for 6 weeks
 GNB (Enterbacteriae): Cefotaxime/ Ceftriaxone for 6 weeks
 Pseudomonas: Pipercillin or Ceftazidime + Tobramycin for 6 weeks

Case 10:
A. Viruses are most common, but most common bacterial is Strep Pyogenes

B. Suppurative Complications

 Otitis media
 Sinusitis
 Necrotising fasciitis
 Tonsillopharyngeal cellulitis or abcess

Non-supparative complications

 Acute rheumatic fever

 Scarlet fever
 Streptocococcal toxic shock syndrome
 Acute glomerulonephritis
 PANDAS syndrome
C. Streptolysins: lyse RBC’s, Streptokinase A and B: proteolytic enzymes, Erythrogenic toxin which is
responsible for rash in scarlet fever. (look at Intro Bacteriology on pg 27)

D.Penicillin is drug of choice. Erythormycin in allergic patients.

E.Throat swab of surface of both tonsils and posterior pharyngeal wall and Blood: serum for ASOT
and anti-DNAase

F. Look at General rules for specimen collection at Lab diagnosis (Prof. Nchabaleng)

 Collected before starting antibiotics

 Specimen must be representative of site of infection
 Wash hands thoroughly before and after collecting specimen
 Strict aseptic techniques
 Appropriate sterile container, transport media and secure container and lid airtightly sealed

Case 11:
A.Pseudomona Aeruginosa

B.Gram – rod, motile by means of single flagella, use biofilm for adherence, opportunistic infection,
adapted to live in harsh conditions but prefer mosit conditions (soil and water)

C.Pipercillin or Ceftadizine + Tobramycin (sensitivity to all except tobramycin not indicated)

D.6 weeks

Case 12:
A.Reasons for culture negative endocarditis

 Prior antibiotic treatment

 Fastidious, nutritionally variant, cell wall deficient organisms and anaerobes
 Obligate intracellular parasites e.g. Coxiella burnetii, Chlamydiae and Bartonella
 Fungi
 Viruses
 Non-infective causes e.g. uraemia

B. Look at intro into bacteriology for more info into each specie mentioned above

C. Fungi eg. Candida and Aspergillus, Viral eg. HIV

D. HACEK group (small, fastidious gram – bacilli)

 Haemophilus spp
 Aggregatibacter actinomycetmcomintans
 Cardiobacterium hominis
 Eikenella corrodens
 Kingella kingae
E.Diptheroids, Candida and Aspergillus

F. Try another approach e.g. do not only test for bacterial causes; investigate viral, fungal and
neoplastic causes. Do not stop to investigate until the cause is identified

Case 13:
A.Staphylococcus Aureus

B. Bloods for MCS and FBC for septic screening (CRP ESR). Monitor vital signs.

C.Predisposing factors for septicaemia

 Extremities of age
 Underlying disease e.g. malignancies, chronic diseases
 Instrumentation e.g. catheters, line sepsis
 Prior drug therapy e.g. broad spectrum antibiotics alter normal body flora and increase
incidence of opportunistic infections.

D.Septic shock associated with hypotension, DIC and acute renal failure

Case 14:
A. Nosocomial PUO: uncertain after three days despite appropriate investigations incl at least two
days of incubation of microbiological cultures

Symptoms: Fever exceeding 38.3˚C on several occasions in a hospitalized patient receiving acute
care; infection not present or incubating on admission

B. Differentials of PUO:

 Bacterial: extrapulmonary TB, Staph Aureus, Shigella

 Viral: EBV, HepB, CMV
 Parasitic: Plasmodium spp, Trypanosoma brucei
 Fungal: Cryptococcus neoformans, Histoplasma capsulatum

C. Please look at Intro Bacteriology

D. Please look at Intro Bacteriology