Endocarditis By : Mehrnoush. dianatkhah
Case 5.31, 31 years old woman CC : Fever, dyspnea, 3 days postpartum PMH : Mitral prolapse Fever 38.5 WBC : 8900 ESR : 84 CRP : 10.4 Cr : 0.6 NT Pro BNP: 5469 Physical examination: Jane-way on fingers PR : 100 BP : 100/70
Echocardiography LVEF-45%. Moderate LV dilation with mild systolic dysfunction. MR due to prolapse. A mass in arterial side of AMVL. Suspicious for prolapse or rupture of chordae. 2 hypermobile filamentous mass attached to ventricular side of aortic valve, highly suspicious of vegetation. Severe MR and severe AI. Plan: Surgery (valve replacment)
Duke Criteria 2 Major criteria or 1 Major criteria+ 3 Minor criteria or 5 Minor criteria
Management Emergency department: Meropenem Vancomycin Dentistry consultation before surgery: Amoxicillin 2 g
Prophylaxis Viridans streptococci bacteremia can result from any procedure that involves the manipulation of the gingival tissue or the periapical region of the teeth or perforation of the oral mucosa.
Blood culture 6/5 Streptococcus viridance Sensitive: Clindamycin, penicillin, Vancomycin Staphylococcus areus Sensitive: Cefoxitin, Cotrimoxazole, Clindamycin, Gentamycin, Penicillin, Vancomycin
Surgery 6.11 surgery Aortic and Mitral replacement (Metal) ASA, Pantoprazole,Lasix,Heparin (5000 stat then 1000u/h)) Carvedilol,Aldacton,Sertraline,Captopril Ampicillin 2g/4h Targocid 4.5g/6h
Rash 6.16 : Rash in all parts of the body (more than 2/3 of the body) Respiratory syndrome Mucosal lesions
Pharmacotherapy Consultation1 Ampicillin, Lasix, sertraline, ASA, Ranitidine, Levothyroxine, Heparin. Pharmacotherapy consultation 1: Ampicillin D/C Tab hydroxyzine 25 mg Qhs
Dermatology consultation: Dermatology consultation: Erythromato Macular popular rash mostly in extremities, and some in trunk. Dx : 1. Erythema multiform Order: Oint clobetazole Tab hydroxyzine 25 Qhs
Pharmacotherapy consultation 2 Pharmacotherapy consultation 2: Lasix D/C Sertraline D/C
Re-initiating AB therapy 6.29 Gentamycin 80mg BD Vancomycin 1g BD infusion over 3 hours Premedicate with 100 mg hydrocortisone Rash
Pharmacotherapy consultation 3 B/C : S. areus sensitive to cefoxitin Gentamycin 80mg BD 60mg TDS Vancomycin D/C Cloxacillin 2g QID Doxepin 25 mg Hs S. areus sensitive to cefoxitin
Re- initiating Sertraline Re- initiating Sertraline : Pruritus Sertraline D/C : Doxepin
Duration of therapy S. areus Cloxacilin 4 to 6 weeks Gentamycin 3 to 5 days If veg/culture is neg 4 to 6 weeks from first day of AB therapy. If veg/culture is positive 4 to 6 weeks from first day of surgery.
Erythema multiform As the name implies, erythema multiform(em) eruptions take on a varied spectrum of morphologic forms, ranging from the mildest with tiny maculovesicular lesions to more severe forms such as SJS and.
Stevens-Johnson syndrome Stevens-Johnson syndrome (SJS) is severe idiosyncratic reactions, most commonly triggered by medications, which are characterized by fever and mucocutaneous lesions leading to necrosis and sloughing of the epidermis.
Treatment of EM Mild disease For patients with only cutaneous involvement or limited oral mucosal involvement that is not disabling, management is focused on symptomatic relief. Topical corticosteroids and oral antihistamines can be used in patients who note itching and burning of cutaneous lesions. Severe oral mucosal involvement Extensive oral mucosal involvement may result in severe pain, leading to an inability to ingest foods or liquids. We suggest short courses of oral glucocorticoids only in patients with severe and debilitating EM with mucosal involvement. The usual starting dose is 40 to 60 mg/day of prednisolone tapered over 2 to 4 weeks.
Drug associated with SJS Anti-gout agents (especially allopurinol) Antibiotics (sulfonamides >> penicillins > cephalosporins) Antipsychotics and anti-epileptics (including carbamazepine, phenytoin, lamotrigine, and phenobarbital) Analgesics and non-steroidal anti-inflammatory agents (especially piroxicam)
Drugs associated with SJS
ACC/AHA guideline Antithrombotic therapy after valve replacement
ACCP evidence-based practice guidelines: Antithrombotic therapy in patients with mechanical heart valves
ACCP evidence-based practice guidelines: Antithrombotic therapy in patients with bioprosthetic heart valves ACC/AHA guideline summary: Antithrombotic therapy in patients with bioprosthetic heart valves
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