Infective endocarditis

This week we reviewed a case of infective endocarditis. Check out our past blog post that highlight the Modified Duke's Criteria, also found in the American Heart Association guidelines

Guidelines for surgery include:
1) Valvular dysfunction
       -Valvular perforation or rupture
       -Congestive heart failure
2) Perivalvular extension 
       -Valvular dehiscence, rupture or fistula
       -Conduction abnormalities ie. heart block
       -Abscess
3) Vegetation/Bacteremia
       -Invasive infections ie. fungal IE
       -Persistent embolic events or bacteremia despite adequate treatment
       -Size of vegetation and persistent vegetation (controversial) 

Risk factors for endocarditis include an abnormal valve (ie. mechanical or past valvular disease), or an increased risk of bacteremia (immunocompromised states, IV drug use, permanent lines, hemodialysis etc.)


On a related topic here is an interesting NEJM article - a review on the approach and management of bacterial infections in patients who use illicit drugs

Pulmonary hemorrhage

- Hemoptysis can be from a bronchial or pulmonary artery source. 'Massive' hemoptysis is usually from an erosion into a bronchial artery, and is often seen in chronic inflammatory states (bronchiectasis, TB, aspergilloma etc.)

- Pulmonary artery hemorrhage has a broad differential. Don't miss systemic vasculitis or connective tissue disease, meds/toxins or high pulmonary pressures such as PE or mitral stenosis

- Remember to ask about drug use: cocaine can cause diffuse alveolar damage and hemorrhage within 48 hours. The treatment is primarily supportive

- Treatment? Always start with the ABCs, with a focus on airway. The patient should be placed in a lateral position with the affected lung down. This helps stop the bleeding and protect the unaffected lung from aspiration. Specific management depends on the underlying cause. For example, systemic vasculitis is treated with high dose methylprednisolone, cyclophosphamide and plasma exchange