Cardiology Series: Case 4

ANSWERS WILL BE POSTED TOMORROW 3/5/17 by 18:00 CET

A 49-year old man presents with high-grade fever and generalized fatigue and discomfort. He also complained of night sweats and rigors.

On inspection of the hands you note the following:

The patient complains of pain over these red and raised lesions that are visible on both of his hands.

1. What are the described lesions called ? 

2. What is the most likely diagnosis ? 

3. List three other lesions that may be present on the hands or feet in patients with this disease.

You order Routine blood tests and note that this patient has normochromic normocytic anaemia, high neutrophils and raised ESR and CRP.

You also request an ECG and the result below was obtained.
Image result for prolonged pr interval on ecg

Source : http://lifeinthefastlane.com/ecg-library/basics/pr-interval/

4. Describe the ECG findings.

5. How would you investigate even further ?

6. What is the major criteria for this condition ?

7. What are the risk factors associated with this condition ? 

8. How would you manage this patient ?

9. What are the complications that may arise ?

Source: http://www.gponline.com/clinical-review-infective-endocarditis-diagnosis-management/cardiovascular-system/article/1299394


ANSWERS

1. Osler’s nodes

2. Infective endocarditis

3. Three other physical signs on hands or feet

  • Janeway’s lesions (painless hemorrhagic cutaneous lesions on the palms and soles)
  • Splinter Haemorrhages on nails
  • Clubbing with endocarditis

Note: Also Roth spots visible as boat shaped retinal hemorrhage with a pale center.

4. First degree heart block showing a prolonged PR interval (>0.20s)

5. Use the Duke’s criteria discussed in question no.6

Routine Blood investigations
Full Blood Count: Hgb (L) normochromic normocytic, Neutrophils (H), ESR and CRP (H)
Renal Function Test: U&E, Creatinine and eGFR.
Liver Function Test
Urinalysis 
for microscopic haematuria

Blood Cultures
Do three sets at different times from different sites at peak of fever.

Echocardiogram
Transthoracic echocardiogram to show vegetations, but only if >2mm.
Transesophageal echocardiogram more sensitive for mitral lesions and possible development of aortic root abscess.

Chest X-ray
Shows evidence of cardiomegaly.

6. Duke criteria for infective endocarditis

Positive blood culture: typical organism in 2 seperate cultures or persistently positive blood cultures.
Endocardium involvement: positive echocardiogram seen as vegetation, abscess or dehiscence of prosthetic valve or new valvar regurgitation.

7. Risk Factors
Artificial heart valves
Intracardiac devices, such as Implantable cardioverter-defibrillators (ICDs).
Unrepaired cyanotic congenital heart defects
History of infective endocarditis
Chronic rheumatic heart disease due to recurrent Strep Pyogenes infection
Age-related degenerative valvular lesions
Hemodialysis
Coexisting Conditions: Diabetes mellitus, alcohol abuse, HIV/AIDS, and intravenous drug use all fall in this category

8. Management of Acute endocarditis

  • Empirical antibiotic therapy is commenced immediately after blood is drawn for culture. This usually involves vancomycin and ceftriaxone intravenous infusions until results from the blood culture are obtained.
  • High dose antibiotics are administered via the intravenous route. These are routinely continued for 2-6 weeks depending on the targeted infection at question.
  • Consider surgery if evidence of heart failure, valvular obstruction, repeated emboli, fungal endocarditis, persistent bacteraemia, myocardial abscess and unstable infected prosthetic valve.

9. Complications of Infective Endocarditis

  • Congestive Heart Failure
  • Extravalvular cardiac manifestations
  • Systemic and Pulmonary embolism
  • Mycotic aneuysm
  • Neurologic- stroke and neuropsychiatric syndromes
  • Glomerulonephritis and renal infarcts
  • Anaemia and TTP

 

 

 

 

 

 

 

 

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4 thoughts on “Cardiology Series: Case 4

  1. Hello Sir!
    I think they are Janeway Lesions and the work diagnosis would be endokarditis
    In the ecg sinusrhythmus with av-block first degree
    I would do bloodcultures and echocardiographie( first TTE then TEE)

    Liked by 1 person

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