vegetation negative infective endocarditis a … · vegetation negative infective endocarditis a...
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VEGETATION NEGATIVE INFECTIVE ENDOCARDITIS
A VIEW POINT . . .
S.Venkatesan,G.Gnanavelu,G.Karthikeyan,V.Jaganathan,R.AlagesanM.Annamalai,S.Shanmugasundaram, S.Geetha,A.Balaguru .G.Anuradha
Madras Medical College. Chennai.India
Mumbai Dec 2005
Annual scientificsessions
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Infective endocarditis
Still a dreaded clinical entity
Mortality & morbidity is more than MI or UA
Equals that of a malignancy if not diagnosed &treated early
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Many diagnostic criteria has been advanced .
None had withstood the test of time.
Currently Dukes criteria is considered as de factostandard.
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Von Reyn 1981 Clinical ,Autopsy
Duke 1994 Stressed Echo evidence
Modified Duke (Li 2000) TEE included
IE is a Criteria syndrome
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New valvular regurgitation
New partial dehiscence of prosthetic valve
Abscess
Vegetation on valve or supporting structure
Positive echocardiogram (TEE recommended in prosthetic valves, rated atleast possible IE by clinical criteria, or complicated IE; TTE as the first test inother patients):
Evidence of endocardial involvement
1 positive BC for C. brunetii or antiphase-I immunoglobulin G antibody titer>1:800
2 positive BCs drawn >12 hours apart or 4 positive BCs irrespective of thetiming
2 separate positive BCs consistent with IE (V. streptococci, Streptococcus bovis,HACEK group, S. aureus, and enterococci) in the absence of a primary focus
Positive blood culture (BC)Majorcriteria
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Echocardiographic minor criteria eliminated
Microbiological evidence: positive BC that does not meetmajor criteria or serological evidence of infection
Immunologic phenomena
Vascular phenomena
Fever
PredispositionMinorcriteria
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Which comes first ?
Echocardiography
Microbial
Clinical
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Colonisation
Adhesion
Vegetation
Invasion
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It needs of Millions of bacteria anddebri to form 3mm sized vegetation that is detectedby Echo
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It has been our observation some ofthe patients with RHD , and severe regurgitantlesions with febrile spells that indicated highdegree of suspicion of IE but withoutdocumentation of vegetation .
Back ground
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“In this context we report our analysis of patientswith IE without vegetations. Out of 24 patientsadmitted between 2004-2005 in our hospital with thediagnosis of IE 4 patients failed to showvegetations”
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NoClass 3MR/TRM 18
NoClass 2MR/ARF 20
YesClass 3MR/ARM 22
YesClass 4MR/MS/TRM 18
CHFFunctional class
LesionPatient
Baseline data
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Clinical features
NoNil+M 18
YesNil+F 20
NoNil+M 22
YesNil+M 18
vascular
ImmunologicalFeverPatient
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Microbiology
-PseudomonasStaph aureus4
Staph auerusStaph auerusStaph aureus3
-Staph auerusStaph aureus2
Streptococcusviridans
-StreptococcusViridans
1
Blood culture 3Blood culture 2Blood culture 1
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No vegetationNo vegetationNo vegetationNo vegetation4
12mm11mm--3
No vegetationNo vegetationNo vegetationNo vegetation2
No vegetationNo vegetationNo vegetationNo vegetation1
Echo 4 wEcho- 2 wEcho-1 wBase lineEcho
TTE Vegetation
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Echocardiography
yesnil-both severeMR/AR4
yesyesnil-severe/moderate
MR/AR3
--nilYesBoth severeMR/AR2
yesyesnilyesSevereEccentric
MR/MS/TR
1
LVdysfunction
WorseningMR/AR
Echo Geneicmass
Flailvalve
JetMorphology
Valvelesion
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Trans Esophageal echocardiography done
at least once in all patients
Failed to detect vegetations
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Therapy
Standard therapy first week
Followed by Culture guided therapy
Drugs used Ceftrixone , Amikacin , Vancomycin
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Course & complications
One patient developed cerebral vasculits andanother renal insufficiency during the course oftreatment.
Two patients stabilized with medical management.
One expired .
Other had refractory cardiac failure and was referredfor emergency surgery
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Nomenclature of the syndrome
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How do you call IE without Culture positivity ?
How shall we label IE without vegetation ?
Culture negative endocarditis
Vegetation negative endocardits
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Incidence of Vegetation Negative IE
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Vegetation Negative Vs vegetation positive
Comparison not possible due to small series
But trend towards more staphylo coccal
infection in veg negative IE
Mortality 1 out of 4
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Mechanisms for absenceof visible vegetation
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Resolution of power Ultrasound
TTE vs TEE5mm /2mm
65 % - 90%
Negative TEE Does notexclude IE if suspicion is high
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Temporal dissociation between appearance ofvegetation and the clinical syndrome.
Vigorous antimicrobial treatment might haveprevented the formation of vegetation
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Classical Endoluminal ,Mobile
Intramuralboroughing
Layered
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Chordal rupture as a
Sole manifestation
of IE.
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Is diffuse Endocardial involvement possible ?
Some think CHF by itself is a evidence forendocarditis
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Conclusion
•Even though vegetations are considered sine quanon of IE in many clinical situations IE occurs without vegetation.
•The incidence is 16% in our series.
•The mechanisms are varied.
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Echocardiography per se has significantlimitation in ruling out Infectiveendocarditis
Over reliance on ECHO to rule out IE hasthe potential to delay in starting therapyAnd Could have adverse outcome
One should attempt to diagnose IE in thepre vegetation phase itself
IMPLICATIONS
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Good judgement comes fromexperience . . .
Experience comes from badjudgement.