Disclosures. Native Valve Endocarditis and its Complications. Outline. Outline. Basics. Basics 3/23/2017
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1 Native Valve Endocarditis and its Complications SCVP and Binford Dammin Society of Infectious Disease Pathologists Shared Companion Meeting USCAP 2017 Annual Meeting Disclosures Relevant financial relationships None Off label usage None Mathieu C. Castonguay, MD, FRCP(C) March 5, 2017 Definition bacterial or fungal infection of the endocardium usually valvular native (NVE) or prosthetic (PVE) valves Historical overview ( We cannot escape history ) A. Lincoln, 1862 first description (1646, Lazare Rivière) round carbuncles resembled a cluster of hazelnuts and filled the opening of the aorta 1
2 Historical overview valvular vegetation (1806, Jean Nicolas Corvisart) Historical overview valvular vegetation (1806, Jean Nicolas Corvisart) perfect resemblance to venereal nodules and cauliflowers that their nature may be syphilitic Historical overview endocarditis (1835, Jean Baptiste Bouillaud) Historical overview emboli (1852, William Senhouse Kirkes) Coined the word endocardium Historical overview emboli (1852, William Senhouse Kirkes) Historical overview parasitic disease (1869, Emanuel Winge) Endocarditis as a disease with multi systemic manifestations filaments entangled with micro organisms short round beads or tiny sticks 2
3 Historical overview acute and chronic forms (1885, William Osler) Historical overview effective treatments (1940 s onward) Pathogenesis bacteremia mucosal or cutaneous entry points Pathogenesis bacteremia adhesion adhesins pre existing microthombi (microtrauma) Pathogenesis bacteremia adhesion colonization proliferation thrombosis inflammation biofilm 3
4 General (developed world) annual incidence 3 10/100,000 M : F > 2 : % in hospital mortality ~ 40% one year mortality > 25% healthcare acquired > $120,000/patient (US) Predisposing conditions structural abnormalities rheumatic disease congenital heart disease unrepaired cyanotic congenitally myxomatous mitral valve disease degenerative fibrocalcific aortic valve disease Predisposing conditions structural abnormalities intracardiac devices coexisting conditions diabetes mellitus HIV infection hemodialysis IVDU Predisposing conditions structural abnormalities intracardiac devices coexisting conditions recent invasive procedure previous endocarditis Predisposing conditions 50% none identified 4
5 Sites of involvement (clinical) Sites of involvement (surgical pathology) left sided IE (75 80%) right sided IE (10 15%) left sided IE (90 95%) right sided IE (5%) bilateral (1%) Modified from Arch Intern Med 2009; 169: Modified from Cardiovasc Pathol 2013; 22: Microbiology Staphylococcus S. aureus 30% of cases (stable) aggressive disease healthcare related infections IVDU Microbiology Staphylococcus S. aureus coagulase negative staphylococci 10% (increasing) antibiotic resistance aggressive disease healthcare related infections, IVDU Microbiology Staphylococcus Streptococcus oral (viridans) streptococci 20% (decreasing) invasive dental procedures Microbiology Staphylococcus Streptococcus oral (viridans) streptococci other streptococci 10% group D (S. gallolyticus) colorectal ca 5
6 Microbiology Staphylococcus Streptococcus Enterococcus 10% GU/GI Microbiology Staphylococcus Streptococcus Enterococcus HACEK organisms zoonoses fungal others 5 10% Microbiology polymicrobial 1 2% Microbiology polymicrobial culture negative 10 20% recent antibiotic use fastidious organism may decrease with better identification methods Changes Houston, TX, 1943 Mayo Clin Proc 2010; 85 (5):
7 Changes Changes Mayo Clin Proc 2010; 85 (5): BMC Infect Dis 2011; 11: 48 Changes BMC Infect Dis 2011; 11: 48 Clinical Features Presentation protean constitutional features of infection fever, sweats fatigue anorexia weight loss joint pain 7
8 Clinical Features Presentation protean constitutional features of infection cardiac findings new/changed murmur heart failure new conduction abnormality Clinical Features Presentation protean constitutional features of infection cardiac findings vascular phenomena emboli Clinical Features Clinical Features Presentation protean constitutional features of infection cardiac findings vascular phenomena immunologic phenomena glomerulonephritis Osler nodes, Roth spots Diagnostic criteria modified Duke Major criteria Blood cultures Endocardial involvement Echocardiographic New regurgitation Minor criteria Predisposing condition Fever Vascular phenomenon Immunologic phenomenon Microbiological evidence Clin Infect Dis 2000; 30: Clinical Features Diagnostic criteria modified Duke definite IE (clinical criteria) 3 major 1 major + 3 minor 5 minor Clinical Features Diagnostic criteria modified Duke definite IE (pathologic criteria) micro organism by culture or histology pathologic lesion confirmed by histology Clin Infect Dis 2000; 30: Clin Infect Dis 2000; 30:
9 Source: dreamicus.com/vegetation.html a growth or excrescence of any sort specifically, a clot, composed largely of fused blood platelets, fibrin, and sometimes microorganisms, adherent to a diseased heart orifice or valve, and often initiated by infection of the structures involved 71, M Steadman s Medical Dictionary, 27 th Edition 9
10 H&E, 1X Elastic, 1X 56, M Prev MV annuloplasty (IHD) H&E, 10X H&E, 10X Viridans streptococcus S. mitis H&E, 20X Gram, 100X Elastic, 2X Gram, 40X healing 51, M MV prolapse H&E, 1X 10
11 healing 44, M H&E, 10X Staphylococcus aureus S. mitis H&E, 4X H&E, 20X Gram, 40X vegetation 69, M Urosepsis 31, M Aerococcus urinae Gram, 40X vegetation vegetation 31, M 31, M Aggregatibacter aphrophilus (HACEK) Gram, 100X 11
12 vegetation frequently submitted to microbiology first cultures, molecular studies may not get infected material in surg path lab 54, M perforation 82, M * Degen AV integration of all available data is key * S. aureus S. mitis 27, M perforation healed Shone syndrome perforation * (69%) (46%) H&E, 4X Modified from Cardiovasc Pathol 2013; 22: , F valve aneurysm valve aneurysm (5%) (8%) viridans streptococcus Modified from Cardiovasc Pathol 2013; 22:
13 effect on valve function regurgitation stenosis combined effect on valve function Modified from Cardiovasc Pathol 2013; 22: Complications Cardiac abscess (may progress to fistula) abscess Complications (25%) (13%) Courtesy of Dr. W. D. Edwards Modified from Cardiovasc Pathol 2013; 22:
14 Complications Complications Cardiac Cardiac rupture (cord or papillary muscle) cusp prolapse 47, F Recent ERCP 68, F Cirrhosis H&E, 1X S. aureus C. albicans H&E, 4X Gram, 100X H&E, 2X GMS, 40X Complications Complications Cardiac Cardiac septic myocarditis/vasculitis myocardial infarction (embolic) 52, M 70, F H&E, 20X S. aureus H&E, 10X H&E, 2X Complications Complications Cardiac Systemic pericarditis emboli 52, M S. aureus H&E, 10X H&E 14
15 Non bacterial thrombotic endocarditis (NBTE) sterile valve thrombi risk factors structurally abnormal valves hypercoagulable states endothelial damage Non bacterial thrombotic endocarditis (NBTE) 69, M Degen AV AV MV Non bacterial thrombotic endocarditis (NBTE) Fenestrations age related degenerative change (semilunar valves) no functional significance H&E, 4X Elastic, 4X MV 15
16 Fenestrations Valvular dysplasia congenitally abnormal valves * Valvular dysplasia Valvular dysplasia 23, M Unicuspid AV Hyperbilirubinemia Valvular dysplasia Traumatic perforation iatrogenic other 16
17 Traumatic perforation Traumatic perforation 52, M Conjoined cusp? NBTE * * Traumatic perforation Traumatic perforation Conjoined cusp? NBTE 52, M * *? 17
18 Selected References 1. Cahill TJ, et al. Challenges in Infective Endocarditis. J Am Coll Cardiol 2017; 69 (3): Correa de Sa DD, et al. Epidemiological Trends in Infective Endocarditis: A Population Based Study in Olmsted County, Minnesota. Mayo Clin Proc 2010; 85 (5): Murdoch DR, et al. Clinical Presentation, Etiology, and Outcome of Infective Endocarditis in the 21 st Century. Arch Intern Med 2009; 169 (5): Fedeli U, et al. Increasing Incidence and Mortality of Infective Endocarditis: A Population Based Study Through a Record Linkage System. BMC Infect Dis 2011; 11: Castonguay MC, et al. Surgical Pathology of Native Valve Endocarditis in 310 Specimens from 287 Patients ( ). Cardiovasc Pathol 2013; 22: Native Valve Endocarditis and its Complications SCVP and Binford Dammin Society of Infectious Disease Pathologists Shared Companion Meeting USCAP 2017 Annual Meeting Mathieu C. Castonguay, MD, FRCP(C) March 5,
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