VEGETATION NEGATIVE INFECTIVE ENDOCARDITIS A VIEW POINT... Mumbai Dec 2005 Annual scientific sessions

Transcription

1 VEGETATION NEGATIVE INFECTIVE ENDOCARDITIS A VIEW POINT... Mumbai Dec 2005 Annual scientific sessions S.Venkatesan,G.Gnanavelu,G.Karthikeyan,V.Jaganathan,R.Alagesan M.Annamalai,S.Shanmugasundaram, S.Geetha,A.Balaguru.G.Anuradha Madras Medical College. Chennai.India

2 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

3 Many diagnostic criteria has been advanced. None had withstood the test of time. Currently Dukes criteria standard. is considered as de facto

4 IE is a Criteria syndrome Von Reyn 1981 Clinical,Autopsy Duke 1994 Stressed Echo evidence Modified Duke (Li 2000) TEE included

5 Major criteria Positive blood culture (BC) 2 separate positive BCs consistent with IE (V. streptococci, Streptococcus bovis, HACEK group, S. aureus, and enterococci) in the absence of a primary focus 2 positive BCs drawn >12 hours apart or 4 positive BCs irrespective of the timing 1 positive BC for C. brunetii or antiphase-i immunoglobulin G antibody titer >1:800 Evidence of endocardial involvement Positive echocardiogram (TEE recommended in prosthetic valves, rated at least possible IE by clinical criteria, or complicated IE; TTE as the first test in other patients): Vegetation on valve or supporting structure Abscess New partial dehiscence of prosthetic valve New valvular regurgitation

6 Minor criteria Predisposition Fever Vascular phenomena Immunologic phenomena Microbiological evidence: positive BC that does not meet major criteria or serological evidence of infection Echocardiographic minor criteria eliminated

7 Which comes first? Clinical Microbial Echocardiography

8 Adhesion Colonisation Invasion Vegetation

9 It needs of Millions of bacteria and debri to form 3mm sized vegetation that is detected by Echo

10 Back ground It has been our observation some of the patients with RHD, and severe regurgitant lesions with febrile spells that indicated high degree of suspicion of IE but without documentation of vegetation.

11 In this context we report our analysis of patients with IE without vegetations. Out of 24 patients admitted between in our hospital with the diagnosis of IE 4 patients failed to show vegetations

12 Baseline data Patient Lesion Function al class CHF M 18 MR/MS/TR Class 4 Yes M 22 MR/AR Class 3 Yes F 20 MR/AR Class 2 No M 18 MR/TR Class 3 No

13 Clinical features Patient Fever Immunological vascu lar M 18 + Nil Yes M 22 + Nil No F 20 + Nil Yes M 18 + Nil No

14 Microbiology Blood culture 1 Blood culture 2 Blood culture 3 1 Streptococcus Viridans - Streptococcus viridans 2 Staph aureus Staph auerus - 3 Staph aureus Staph auerus Staph auerus 4 Staph aureus Pseudomonas -

15 TTE Vegetation Base line Echo Echo-1 w Echo- 2 w Echo 4 w 1 No vegetation No vegetation No vegetation No vegetation 2 No vegetation No vegetation No vegetation No vegetation mm 12mm 4 No vegetation No vegetation No vegetation No vegetation

16 Echocardiography Valve lesion Jet Morphology Flail valve Echo Geneic mass Worsening MR/AR LV dysfunction 1 MR/MS/ TR Severe Eccentric yes nil yes yes 2 MR/AR Both severe Yes nil MR/AR severe/mod erate - nil yes yes 4 MR/AR both severe - nil yes

17 Trans Esophageal echocardiography done at least once in all patients Failed to detect vegetations

18 Therapy Standard therapy first week Followed by Culture guided therapy Drugs used Ceftrixone, Amikacin, Vancomycin

19 Course & complications One patient developed cerebral vasculits and another renal insufficiency during the course of treatment. Two patients stabilized with medical management. One expired. Other had refractory cardiac failure and was referred for emergency surgery

20 Nomenclature of the syndrome

21 How do you call IE without Culture positivity? Culture negative endocarditis How shall we label IE without vegetation? Vegetation negative endocardits

22 Incidence of Vegetation Negative IE

23 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

24 Mechanisms for absence of visible vegetation

25 Resolution of power Ultrasound TTE vs TEE 5mm /2mm 65 % - 90% Negative TEE Does not exclude IE if suspicion is high

26 Temporal dissociation between appearance of vegetation and the clinical syndrome. Vigorous antimicrobial treatment might have prevented the formation of vegetation

27 Classical Endo luminal,mobile Layered Intramural boroughing

28 Chordal rupture as a Sole manifestation of IE.

29 Is diffuse Endocardial involvement possible? Some think CHF by itself is a evidence for endocarditis

30 Conclusion Even though vegetations are considered sine qua non of IE in many clinical situations IE occurs with out vegetation. The incidence is 16% in our series. The mechanisms are varied.

31 IMPLICATIONS Echocardiography per se has significant limitation in ruling out Infective endocarditis Over reliance on ECHO to rule out IE has the potential to delay in starting therapy And Could have adverse outcome One should attempt to diagnose IE in the pre vegetation phase itself

32 Good judgement comes from experience... Experience comes from bad judgement.