Infective Endocarditis

INFECTIVE ENDOCARDITIS

Q. 1

Diagnostic criterion for infective endocarditis includes all EXCEPT:

 A Rheumatoid factor
 B

ESR

 C Positive blood culture
 D Positive ECG
Q. 1

Diagnostic criterion for infective endocarditis includes all EXCEPT:

 A Rheumatoid factor
 B

ESR

 C Positive blood culture
 D Positive ECG
Ans. B

Explanation:

ESR REF: Harrison’s 17th ed Chapter 118

The duke’s criteria for Infective endocarditis

Major Criteria

1. Positive blood culture

  • Typical microorganism for infective endocarditis from two separate blood cultures
  • Viridans streptococci, Streptococcus bovis, HACEK group, Staphylococcus aureus, or
  • Community-acquired enterococci in the absence of a primary focus, or
  • Persistently positive blood culture, defined as recovery of a microorganism consistent with infective endocarditis from: Blood cultures drawn >12 h apart; or
  • All of three or a majority of four or more separate blood cultures, with first and last drawn

at least 1 h apart

  • Single positive blood culture for Coxiella burnetii or phase 1 IgG antibody titer of >1:800 2. Evidence of endocardial involvement
  • Positive echocardiogram
  • Oscillating intracardiac mass on valve or supporting structures or in the path of regurgitant
    jets or in implanted material, in the absence of an alternative anatomic explanation, or
  • Abscess, or
  • New partial dehiscence of prosthetic valve, or
  • New valvular regurgitation (increase or change in preexisting murmur not sufficient)

Minor Criteria

  1. Predisposition: predisposing heart condition or injection drug use
  2. Fever 38.0°C (100.4°F)
  3. 3. Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, Janeway lesions
  4. Immunologic phenomena: glomerulonephritis, Osler’s nodes, Roth’s spots, rheumatoid L                                    factor
  5. Microbiologic evidence: positive blood culture but not meeting major criterion as noted previously or serologic evidence of active infection with organism consistent with infective endocarditis

Q. 2

Infective endocarditis due to pseudomonas is mostcommonly seen with

 A >Intravenous drug abuse of pentazocin
 B >HIV patient
 C >Chronic steroid therapy
 D >Elderly with community acquired pneumonia
Q. 2

Infective endocarditis due to pseudomonas is mostcommonly seen with

 A >Intravenous drug abuse of pentazocin
 B >HIV patient
 C >Chronic steroid therapy
 D >Elderly with community acquired pneumonia
Ans. A

Explanation:

intravenous drug abuse of pentazocin [Ref Harrison 1661/e p 891]

  • Psudomonas aeruginosa infects the native heart valves of intravenous drug users as well as prosthetic heart valves.
  • Foreign materials mixed with heroin or any other opioid may cause injury to valve leaflets or mural endocardium with resulting fibrosis and an increased risk for valve infection.

Note : Pentazocine is an opioid.


Q. 3

A 30-year-old woman with a history of intravenous drug abuse is admitted to a hospital for rapidly progressive malaise, fever, and chills. On physical examination, subungual splinter hemorrhages and a systolic murmur are detected. Blood cultures are positive for Staphylococcus aureus. She died of myocardial infarction on her third hospital day. Which of the following was the underlying condition leading to the patient’s demise?

 A

Acute infective endocarditis

 B

Carcinoid heart disease

 C

Libman-Sacks endocarditis

 D

Nonbacterial thrombotic endocarditis

Q. 3

A 30-year-old woman with a history of intravenous drug abuse is admitted to a hospital for rapidly progressive malaise, fever, and chills. On physical examination, subungual splinter hemorrhages and a systolic murmur are detected. Blood cultures are positive for Staphylococcus aureus. She died of myocardial infarction on her third hospital day. Which of the following was the underlying condition leading to the patient’s demise?

 A

Acute infective endocarditis

 B

Carcinoid heart disease

 C

Libman-Sacks endocarditis

 D

Nonbacterial thrombotic endocarditis

Ans. A

Explanation:

Infective endocarditis leads to formation of bulky and friable vegetations on the valvular leaflets.

The vegetations are composed of fibrin, neutrophils, and colonies of bacteria that cause erosion of underlying cardiac structures.

Fragments of infected vegetations may detach and cause pulmonary or systemic septic embolism.

Splinter hemorrhages in the nail bed and petechiae in skin and mucosae are also due to microscopic septic emboli.

In this case, myocardial infarction was probably due to a septic embolus in the coronary circulation.

If infective endocarditis is due to a virulent organism such as Staphylococcus aureus (a common cause of endocarditis in intravenous drug abusers), a tumultuous clinical course ensues, associated with high mortality.

With less virulent organisms, such as Streptococci viridans, Subacute infective endocarditis is the resultant clinical picture.

Subacute endocarditis arises in patients with previously malformed or damaged valves and is associated with a slower course and a better prognosis.

Also Know:
Carcinoid heart disease is caused by serotonin-producing carcinoids in the liver or lungs. Fibrosis of the endocardium ensues, affecting the right heart in the case of hepatic carcinoids and the left heart for pulmonary carcinoids. Thickening and rigidity of valvular leaflets are characteristic gross findings.
 
Libman-Sacks endocarditis is a non-infective form of endocarditis associated with systemic lupus erythematosus (SLE). The vegetations are small and regularly aligned along the valvular margins.
 
Nonbacterial thrombotic endocarditis was previously known as marantic endocarditis, being associated with debilitating conditions such as disseminated neoplasms. Increased coagulability is probably the underlying pathogenesis. The lesions are small vegetations similar to Libman-Sacks endocarditis.
 
Clinical and Laboratory Features of Infective Endocarditis (Frequency,%)
 
Fever    80–90
Chills and sweats  40–75
Anorexia, weight loss, malaise   25–50
Myalgias, arthralgias      15–30
Back pain     7–15
Heart murmur    80–85
New/worsened regurgitant murmur   20–50
Arterial emboli    20–50
Splenomegaly      15–50
Clubbing   10–20
Neurologic manifestations      20–40
Peripheral manifestations (Osler’s nodes, subungual hemorrhages, Janeway lesions,
Roth’s spots)
2–15
Petechiae   10–40
Anemia  70–90
Leukocytosis  20–30
Microscopic hematuria 30–50
Elevated erythrocyte sedimentation rate  60–90
Elevated C Reactive protein level >90
Rheumatoid factor  50
Circulating immune complexes  65–100 

Ref: Karchmer A.W. (2012). Chapter 124. Infective Endocarditis. In D.L. Longo, A.S. Fauci, D.L. Kasper, S.L. Hauser, J.L. Jameson, J. Loscalzo (Eds), Harrison’s Principles of Internal Medicine, 18e.


Q. 4

Which of the following have most friable vegetation?

 A

Infective endocarditis

 B

Libman Sack’s endocarditis

 C

Rheumatic heart disease

 D

SLE

Q. 4

Which of the following have most friable vegetation?

 A

Infective endocarditis

 B

Libman Sack’s endocarditis

 C

Rheumatic heart disease

 D

SLE

Ans. A

Explanation:

The vegetations seen in Infective endocarditis begin as small excrescences, mostly solitary which later enlarge and form bulky friable lesions posing greatest risk of systemic emboli.
The vegetations seen in SLE (Libman Sack’s endocarditis) and Rheumatic Heart disease are verrucous.
 
Ref: Robbin’s Basic Pathology, 7th Edition, Pages 380, 381, 134, 376.

 


Q. 5

Which among the following is the most common cause of acute infective endocarditis?

 A

Staphylococcus aureus

 B

Streptococcus viridans

 C

Streptococcus intermedius

 D

Candida albicans

Q. 5

Which among the following is the most common cause of acute infective endocarditis?

 A

Staphylococcus aureus

 B

Streptococcus viridans

 C

Streptococcus intermedius

 D

Candida albicans

Ans. A

Explanation:

Streptococci and staphylococci are the cause of greater than 80% of infective endocarditis (IE) cases in which a responsible organism is identified.
Streptococcal species were historically the most common group of pathogens, but S. aureus as the most frequently isolated microbial agent worldwide.
 
Viridans group streptococci, or alpha-hemolytic streptococci, are a frequent cause of community-acquired native valve endocarditis (NVE).
 
Ref: O’Gara P.T., Haldar S.M. (2011). Chapter 86. Infective Endocarditis. In V. Fuster, R.A. Walsh, R.A. Harrington (Eds), Hurst’s The Heart, 13e.

Q. 6

In a hospital cardiac care unit, there are three patients with different cardiac conditions: a 52 year  old man with dilated cardiomyopathy, an 18 year old girl with mitral valve prolapse, and a 30 year old man with infective endocarditis of the mitral valve. Which of the following features do all these patients most likely share?

 A

Decreased compliance

 B

Depressed myocardial contractility

 C

Infectious etiology

 D

Risk of systemic thromboembolism

Q. 6

In a hospital cardiac care unit, there are three patients with different cardiac conditions: a 52 year  old man with dilated cardiomyopathy, an 18 year old girl with mitral valve prolapse, and a 30 year old man with infective endocarditis of the mitral valve. Which of the following features do all these patients most likely share?

 A

Decreased compliance

 B

Depressed myocardial contractility

 C

Infectious etiology

 D

Risk of systemic thromboembolism

Ans. D

Explanation:

Systemic thromboembolism may develop in each of these patients. Vegetations associated with infective endocarditis may undergo fragmentation and result in systemic thromboembolism. Stasis develops in dilated ventricles, which predisposes to formation of thrombi attached to the ventricular walls (mural thrombi). Mural thrombi may also form within the left atrium in the presence of mitral valve prolapse. Thromboemboli may originate from mural thrombi.
 
Decreased compliance is a pathophysiologic alteration present in a variety of cardiac disorders in which there is impediment to expansion or relaxation of ventricular walls, such as restrictive cardiomyopathy, hypertrophic cardiomyopathy, and constrictive pericarditis. This feature is not present in any of the conditions described in the question.
 
Depressed myocardial contractility results from conditions that impair myocardial inotropism, such as dilated cardiomyopathy and ischemic heart disease. Depressed inotropism is not present in infective endocarditis or mitral valve prolapse.
 
Of the three conditions in the question stem, only infective endocarditis is definitely related to an infectious etiology, usually bacteria. Recall that mitral valve prolapse is due to myxomatous degeneration of the mitral valve, sometimes associated with Marfan syndrome. The etiology of dilated cardiomyopathy is heterogeneous, and most cases are idiopathic. Of the remaining cases, viral infections, toxic insults (especially alcohol), metabolic disorders (hemochromatosis), pregnancy, and genetic influences are the underlying causes.
 
Ref: Levi M., Seligsohn U. (2010). Chapter 130. Disseminated Intravascular Coagulation. In J.T. Prchal, K. Kaushansky, M.A. Lichtman, T.J. Kipps, U. Seligsohn (Eds), Williams Hematology, 8e.

Q. 7

Which of the heart valve is most likely to be involved by infective endocarditis following a septic abortion?

 A

Aortic valve

 B

Mitral valve

 C

Tricuspid valve

 D

Pulmonary valve

Q. 7

Which of the heart valve is most likely to be involved by infective endocarditis following a septic abortion?

 A

Aortic valve

 B

Mitral valve

 C

Tricuspid valve

 D

Pulmonary valve

Ans. C

Explanation:

After septic abortion the bacteria spreads via the venous blood and enters the right side of the heart. So in such a case infective endocarditis of the tricuspid valve is more common.
 
Ref: Echocardiography By Petros Nihoyannopoulos, Page 217 ; Hurst’s The Heart, 13th Edition By Valentin Fuste, Chapter 86

 


Q. 8

Which of the following is least likely to cause infective endocarditis?

 A

Staphylococcus aureus

 B

Streptococcus facalis

 C

Salmonella typhi

 D

Pseudomonas aeruginosa

Q. 8

Which of the following is least likely to cause infective endocarditis?

 A

Staphylococcus aureus

 B

Streptococcus facalis

 C

Salmonella typhi

 D

Pseudomonas aeruginosa

Ans. C

Explanation:

Among the options provided salmonella typhi is the organism least likely to cause infective endocarditis. Endocarditis is a very rare complication of salmonella typhi infection.

Ref: Harrisons Principles of Internal Medicine, 16th Edition, Page 732.


Q. 9

Which among the following is the least common cause of infective endocarditis?

 A

ASD

 B

MS

 C

VSD

 D

AR

Q. 9

Which among the following is the least common cause of infective endocarditis?

 A

ASD

 B

MS

 C

VSD

 D

AR

Ans. A

Explanation:

Among the following, ASD is the least common cause of infective endocarditis. Here the low turbulence is responsible for decreased incidence of IE.


Q. 10

An IV drug user is diagnosed to have infective endocarditis involving the tricuspid valve. Which of the following is the most likely causative agent?

 A

Staphylococcus aureus

 B

Streptococcus gallolyticus

 C

Pseudomonas aeruginosa

 D

Streptococcus pyogens

Q. 10

An IV drug user is diagnosed to have infective endocarditis involving the tricuspid valve. Which of the following is the most likely causative agent?

 A

Staphylococcus aureus

 B

Streptococcus gallolyticus

 C

Pseudomonas aeruginosa

 D

Streptococcus pyogens

Ans. A

Explanation:

Prosthetic valve endocarditis is most commonly caused by Staphylococcus aureus. Many of these strains are resistant to methicillin. It usually involves the tricuspid valve. 
 
Prosthetic valve endocarditis usually occur within 2 months of valve surgery. It is usually due to an intraoperative contamination of prosthesis or due to a bacteremic postoperative complication. This type is usually caused by  S. aureus, Coagulase-negative staphylococci, facultative gram-negative bacilli, diphtheroids, and fungi. 
 
Ref: Karchmer A.W. (2012). Chapter 124. Infective Endocarditis. In D.L. Longo, A.S. Fauci, D.L. Kasper, S.L. Hauser, J.L. Jameson, J. Loscalzo (Eds),Harrison’s Principles of Internal Medicine, 18e.

Q. 11

Blood culture is positive in which infection of staph. aureus-

 A

TSS

 B

SSSS

 C

Infective endocarditis

 D

Impetigo

Q. 11

Blood culture is positive in which infection of staph. aureus-

 A

TSS

 B

SSSS

 C

Infective endocarditis

 D

Impetigo

Ans. C

Explanation:

Ans. is ‘c’ i.e., Infective endocarditis

.  Blood culture is positive when bacteria present in blood, i.e. when there is bacteremia.

.  Infective endocarditis is a complication of staphylococcal aureus bacteremia (SAB). Thus blood culture may be positive.

.  Staphylococcal scalded skin syndrome (SSSS) and impetigo do not have bacteremia.

.   In toxic shock syndrome (TSS) due to staphylococcus aureus, bacteremia is uncommon (in contrast, bacteremia is common in streptococcal TSS).


Q. 12

A patient of RHD developed infective endocarditis after dental extraction. Most likely organism causing this is –

 A

Streptococcus viridans

 B

Streptococcus pneumoniae

 C

Streptococcus pyogenes

 D

Staphylococcus aureus

Q. 12

A patient of RHD developed infective endocarditis after dental extraction. Most likely organism causing this is –

 A

Streptococcus viridans

 B

Streptococcus pneumoniae

 C

Streptococcus pyogenes

 D

Staphylococcus aureus

Ans. A

Explanation:

Ans. is ‘a’ i.e., Streptococcus viridans

Viridans streptococci are normally resident in the mouth and upper respiratory tract. They cause transient bacteremia following tooth extraction or other dental procedures; and get implanted on damaged or prosthetic valves or in a congenitally diseased heart, and grow to form vegetations.


Q. 13

The group of organism HACEK , causing infective endocarditis include following except – 

 A

Haemophilus

 B

Actionobacillus

 C

Corynebacterium

 D

Eikenella

Q. 13

The group of organism HACEK , causing infective endocarditis include following except – 

 A

Haemophilus

 B

Actionobacillus

 C

Corynebacterium

 D

Eikenella

Ans. C

Explanation:

Ans. is ‘c’ i.e., Cornebacterium 

.  HACEK group includes Haemophilus species, Actinobacillus, Cardiobacterium hominis, Eikenella corrodens and Kingella kingae.


Q. 14

Infective endocarditis is common in –

 A

MR

 B

Coarctation of aorta

 C

AR

 D

a and c

Q. 14

Infective endocarditis is common in –

 A

MR

 B

Coarctation of aorta

 C

AR

 D

a and c

Ans. D

Explanation:

Ans. is ‘a’ i.e., MR; ‘c’ i.e., AR

.   Infective Endocarditis is common in AR, AS, MR, V SD and complex congenital heart disease.


Q. 15

The risk of developing infective endocarditis is the least in patient with –

 A

Small VSD

 B

Severe aortic regurgitation

 C

Severe mitral regurgitation

 D

Large ASD

Q. 15

The risk of developing infective endocarditis is the least in patient with –

 A

Small VSD

 B

Severe aortic regurgitation

 C

Severe mitral regurgitation

 D

Large ASD

Ans. D

Explanation:

Ans. is ‘d’ i.e., Large ASD

Pathogenesis of infective endocarditis (IE)

        Infective endocarditis may develop on previously normal valve, but a variety of cardiac and vascular abnormalities predispose to infective endocarditis.

o Two most common cardiac abnormalities that predispose to infective endocarditis are –

1.Rheumatic carditis

o Rheumatic carditis causes damage to heart valve.

o Damaged part of heart may be covered with platelets and fibrin, upon which bacteria can take hold. 2. Congenital heart diseases (CHDs)

o IE occurs in CHDs where blood flow occurs due to high pressure gradient, e.g. VSD or AS. o The high pressure of jet of blood hits the endocardium and damages it.

o Infection generally starts at this lesion.

High Risk                                         Moderate Risk                                                 Low Risk

Prosthetic heart valve                      MVP + M. R.                     Mitral valve prolapse without mitral Regurgitation.

Tetralogy of fallot                                 T.S.                                                                     ASD

PDA

AR                                                            P.S.

AS                                                            M.S. Coarctation of Aorta

VSD

MR


Q. 16

Non-sterile vegetations are seen in –

 A

Rheumatic fever

 B

Infective endocarditis

 C

Non bacterial thrombotic endocarditis

 D

Libman sack’s endocarditis

Q. 16

Non-sterile vegetations are seen in –

 A

Rheumatic fever

 B

Infective endocarditis

 C

Non bacterial thrombotic endocarditis

 D

Libman sack’s endocarditis

Ans. B

Explanation:

Ans. is ‘b’ i.e., Infective endocarditis

o As the name suggests, non-sterile means presense of organism in the vegetation that is the characteristic feature of infective endocarditis.

o Vegetation of infective endocarditis has following characteristics

         Large, bulky, friable and irregular

       Multiple

         Present on upper surface of the cusps.

o Vegetation is a mass of platelets, fibrin, microcolonies of microorganisms (non-sterile) and scant inflammatory cells.

o Aortic and mitral valves are the most common sites of infection.

o In intravenous drug users, valves of right side are involved.

o Vegetations sometimes erode into the underlying myocardium to produce an abscess cavity —> Ring abscess. Why heart valve is the most common site of infective endocarditis ? Lets see

o As the valves of heart do not actually receive any supply of their own, defensive immune mechanism (such as WBCs) cannot approach the valves.

o So, if an organisms (such as bacteria) establishes a hold on the valve forming a vegetation, the body cannot get rid of them.


Q. 17

Which of these statements is FALSE about infective endocarditis in I.V. drug abusers-

 A

Candida is a common cause.

 B

Pulmonary valve is commonly involved

 C

Staphylococeus aureus is commonest organism

 D

Tricuspid valve is most commonly involved

Q. 17

Which of these statements is FALSE about infective endocarditis in I.V. drug abusers-

 A

Candida is a common cause.

 B

Pulmonary valve is commonly involved

 C

Staphylococeus aureus is commonest organism

 D

Tricuspid valve is most commonly involved

Ans. B

Explanation:

Ans. is ‘b’ i.e., Pulmonary valve is commonly involved

Infective endocarditis in I.V. drug abusers usually involves the right side of the heart.

        Tricuspid valve is most commonly involved.

        Pulmonary valve is involved in fewer cases only.

        Most common organism causing endocarditis in I.V. drug abusers is =>staphylococcus aureus.

        Other common organisms are —> Candida, Enterococcus fecalis, Pseudomonas, Serratia marcescens


Q. 18

Which of the following is not a complication of infective endocarditis –

 A

Myocardial ring abscess

 B

Suppurative pericarditis

 C

Myocardial infarction

 D

Focal and diffuse glomerulonephritis

Q. 18

Which of the following is not a complication of infective endocarditis –

 A

Myocardial ring abscess

 B

Suppurative pericarditis

 C

Myocardial infarction

 D

Focal and diffuse glomerulonephritis

Ans. B

Explanation:

Ans. is none or ‘b’ i.e., Suppurative Pericarditis

Complications of Endocarditis

o Valvular insufficiency or stenosis with cardiac failure

  • Myocardial ring abscess with possible perforation of aorta, interventricular septum or free wall.
  • Suppurative pericarditis with endocarditis on artificial valves, partial dehiscense with paravalvular leak. o Embolic complications
  • With left sided lesions

(a)      Brain (cerebral infarct or abscess, meningitis)

(b)     Heart (Myocardial infarction)

(c)      Spleen (abscesses)

(d)     Kidney (abscesses), other sites.

o With Right sided lesions

(a) Lung (infarcts, abscess, pneumonia)

o Renal complications

                Embolic phenomenon

                Focal and diffuse glomerulonephritis due to trapping of antigen – antibody complexes which may lead to hematuria, albuminuria or renal failure.

                Multiple abscesses : especially with acute staphylococcal endocarditis.

  • So according to Robbins all of the given options can be seen. Even Braunwald’s Heart disease mentions all the four options as complications of infective endocarditis.

o If we have to go for one we will prefer suppurative pericarditis as the answer because in infective endocarditis mostly autouimmune pericarditis occurs.


Q. 19

In which of the following vegetation are friable and easily detachable from the cardiac valves –

 A

Rheumatic fever

 B

Rheumatoid heart

 C

SLE

 D

Infective endocarditis

Q. 19

In which of the following vegetation are friable and easily detachable from the cardiac valves –

 A

Rheumatic fever

 B

Rheumatoid heart

 C

SLE

 D

Infective endocarditis

Ans. D

Explanation:

Ans. is ‘d’ i.e., Infective endocarditis

o The hallmark of infective endocarditis is the presence of large, friable, bulky, potentially destructive vegetation containing fibrin, inflammatory cell, and bacteria.

o Emboli may be shed from vegetation at any time because of detachment.

Also know

o Vegetations of NBTE may also be friable and detachable to produce emboli. But they are small and non-destructive.


Q. 20

Which of the following is associated with destruction of valves ?

 A

Acute infective endocarditis

 B

Libman sach’s endocarditis

 C

Rheumatic Heart disease

 D

All

Q. 20

Which of the following is associated with destruction of valves ?

 A

Acute infective endocarditis

 B

Libman sach’s endocarditis

 C

Rheumatic Heart disease

 D

All

Ans. A

Explanation:

Ans. is ‘a’ i.e., Acute infective endocarditis

Note : Amongst the given options infective endocarditis is most destructive.


Q. 21

Infective endocarditis is not seen in ‑

 A

ASD

 B

TOF

 C

VSD

 D

MR

Q. 21

Infective endocarditis is not seen in ‑

 A

ASD

 B

TOF

 C

VSD

 D

MR

Ans. A

Explanation:

Ans. is ‘a’ i.e., ASD

o Endocarditis tends to occur in :

 High pressure areas (left side of heart)

 Downstream from sites where blood flows at a high velocity through a narrow orifice from a high to low-pressure chamber (distal to constriction in Coarctation of aorta)

  • Endocarditis is unusual in sites with a small pressure gradient as ASD -Harrison
  • Infective endocarditis is very rare in patients of ASD                -Ghai
  • Endocarditis occurs more frequently in patients with valvular incompetence than in those with pure stenosis.

Q. 22

Infective endocarditis least common in ?

 A

Sever MR

 B

Severe AR

 C

Small VSD

 D

Small ASD

Q. 22

Infective endocarditis least common in ?

 A

Sever MR

 B

Severe AR

 C

Small VSD

 D

Small ASD

Ans. D

Explanation:

Ans. is `d’ i.e., Small ASD

o Infective endocarditis is rare in secundum ASD, unless associated with mitral valve prolapse.


Q. 23

In infective endocarditis which of the following is not immune mediated –

 A

Roth spots

 B

Osiers nodes

 C

Glomerulonephritis

 D

None

Q. 23

In infective endocarditis which of the following is not immune mediated –

 A

Roth spots

 B

Osiers nodes

 C

Glomerulonephritis

 D

None

Ans. D

Explanation:

Ans. is ‘None’


Q. 24

Diagnostic criterion for Infective Endocarditis include all, Except:

 A

Positive Echocardiogram

 B

Positive Blood culture

 C

Raised ESR

 D

Positive Rheumatoid Factor

Q. 24

Diagnostic criterion for Infective Endocarditis include all, Except:

 A

Positive Echocardiogram

 B

Positive Blood culture

 C

Raised ESR

 D

Positive Rheumatoid Factor

Ans. C

Explanation:

Answer is C (Raised ESR)

Raised ESR is not part of diagnostic criterion for infective endocarditis. Positive Rheumatoid Factor (immunogenic phenomen) is a minor criteria while positive blood culture and positive echocardiogram are both major criterion for diagnosis of Infective Endocarditis.

The Duke Criteria for the Clinical Diagnosis of Infective Endocarditis:

Major Criteria

1.    Positive blood culture

•    Typical microorganism for infective endocarditis from two separate blood cultures

•    Viridans streptococci, Streptococcus gallolyticus, HACEK group, Staphylococcus aureus, or

•    Community-acquired enterococci in the absence of a primary focus, or

•    Persistently positive blood culture, defined as recovery of a microorganism consistent with infective endocarditis from:

•    Blood cultures drawn >12 h apart; or

•    All of 3 or a majority of 4 separate blood cultures, with first and last drawn at least 1 h apart

•    Single positive blood culture for Coxiella burnetii or phase I IgG antibody titer of >1:800

2. Evidence of endocardial involvement

•    Positive echocardiogram”

•    Oscillating intracardiac mass on valve or supporting structures or in the path of regurgitant jets or in implanted material, in the absence of an alternative anatomic explanation, or

•    Abscess, or

•    New partial dehiscence of prosthetic valve, or

•    New valvular regurgitation (increase or change in preexisting murmur not sufficient)

Minor Criteria

1.   Predisposition: predisposing heart condition or injection drug use

2.   Fever 38.0°C (100.4°F)

3.   Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage,

conjunctival hemorrhages, Janeway lesions

4.   Immunologic phenomena: glomerulonephritis, Osler’s nodes, Roth’s spots, rheumatoid factor

5.    Microbiologic evidence: positive blood culture but not meeting major criterion as noted previously’ or serologic

evidence of active infection with organism consistent with infective endocarditis

‘Definite endocarditis is defined by documentation of two major criteria, of one major criterion and three minor criteria, or of five minor criteria.

Transesophageal echocardiography is recommended for assessing possible prosthetic valve endocarditis or complicated endocarditis.

`Excluding single positive cultures for coagulase-negative staphylococci and diphtheroids, which are common culture contaminants, and organisms that do not cause endocarditis frequently, such as gram-negative bacilli.

Note: HACEK, Haemophilus spp., Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella spp.


Q. 25

Infective endocarditis is least likely to occur in:

 A

Atrial septal defect

 B

Small ventricular septal defect

 C

Mitral valve prolapse

 D

Tetrology of Fallot’s

Q. 25

Infective endocarditis is least likely to occur in:

 A

Atrial septal defect

 B

Small ventricular septal defect

 C

Mitral valve prolapse

 D

Tetrology of Fallot’s

Ans. A

Explanation:

Answer is A (ASD)

Endocarditis is unusual in sites with a small pressure gradient as in – ASD – Harrison


Q. 26

Which of the following is least likely to be associated with Infective Endocarditis:

 A

Small ASD

 B

Small VSD

 C

Mild MR

 D

Mild MS

Q. 26

Which of the following is least likely to be associated with Infective Endocarditis:

 A

Small ASD

 B

Small VSD

 C

Mild MR

 D

Mild MS

Ans. A

Explanation:

Answer is A (Small ASD)

Endocarditis is unusual in sites with a small pressure gradient as in – ASD – Harrison


Q. 27

Infective endocarditis is commonly seen in all except

 A

Small VSD

 B

Tetralogy of fallot

 C

PDA

 D

ASD

Q. 27

Infective endocarditis is commonly seen in all except

 A

Small VSD

 B

Tetralogy of fallot

 C

PDA

 D

ASD

Ans. D

Explanation:

Answer is D (ASD)

Endocarditis is unusual in sites with a small pressure gradient as in ASD

ASD is low risk lesion for the development of infective endocarditis and the single best answer amongst the options provided


Q. 28

Infective endocarditis is least common in‑

 A

Mitral stenosis

 B

Aortic stenosis

 C

VSD

 D

ASD

Q. 28

Infective endocarditis is least common in‑

 A

Mitral stenosis

 B

Aortic stenosis

 C

VSD

 D

ASD

Ans. D

Explanation:

Answer is D (ASD)

Endocarditis is unusual in sites with a small pressure gradient as in ASD

ASD is low risk lesion for the development of infective endocarditis and the single best answer amongst the options provided.


Q. 29

Infective endocarditis is most commonly seen in:

 A

ASD

 B

VSD

 C

PDA

 D

Pulmonary stenosis

Q. 29

Infective endocarditis is most commonly seen in:

 A

ASD

 B

VSD

 C

PDA

 D

Pulmonary stenosis

Ans. B

Explanation:

Answer is B (VSD)

VSD is the most common congenital lesion to be complicated by infective endocarditis


Q. 30

Roth’s spots are seen in:

 A

Infective Endocarditis

 B

Rheumatic Endocarditis

 C

Central Retinal Arterial Occlusion (CRAO)

 D

Typhoid

Q. 30

Roth’s spots are seen in:

 A

Infective Endocarditis

 B

Rheumatic Endocarditis

 C

Central Retinal Arterial Occlusion (CRAO)

 D

Typhoid

Ans. A

Explanation:

Answer is A (Infective Endocarditis)

Roth’s spots (lesions) are oval retinal haemorrhages with a clear pale center that are typically seen in patients with subacute bacterial endocarditis. They are believed to be caused by immune complex deposition and are included as a minor criterion amongst Duke’s criteria for clinical diagnosis of Infective Endocarditis.


Q. 31

Not a feature of infective endocarditis is :

 A

Myocardial abscess

 B

Vegetations along cusps

 C

Thrombus in left atria

 D

Perforation of cusp

Q. 31

Not a feature of infective endocarditis is :

 A

Myocardial abscess

 B

Vegetations along cusps

 C

Thrombus in left atria

 D

Perforation of cusp

Ans. C

Explanation:

Answer is C (Thrombus in left atria)

Infective endocarditis does not lead to formation of thrombi within the left atrial. It may however lead to formation of friable vegetations that may embolize to the systemic circulation as infective emboli.

Infective endocarditis is characterized by colonization or invasion of the heart valves or mural endocardium by a microbiological agent, leading to the formation of bulky, friable vegetations laden with organisms.


Q. 32

Which of the following is least likely to cause infective endocarditis :

 A

Staphylococcus albus

 B

Streptococcus faecalis

 C

Salmonella typhi

 D

Pseudomonas aeruginosa

Q. 32

Which of the following is least likely to cause infective endocarditis :

 A

Staphylococcus albus

 B

Streptococcus faecalis

 C

Salmonella typhi

 D

Pseudomonas aeruginosa

Ans. C

Explanation:

Answer is C (Salmonella Typhi)

Endocarditis is common with staphylococcus albus,.streptococcus fecalis and pseadontonas aeruginosa. Endocarditis has only been mentioned as rare complication of salmonella typhi infection. —

The least likely organism to infective endocarditis amongst the options provided is salmonella typhi. Other options

 

Staphylococcus albus (Staph. epidermis) (Coagulase Negative staph.)

 treptococcus fecalis (Enterococci)

Pseudomonas Aeroginosa Gram negative bacilli

•   S. epidermis (albus) is the most

•   Streptococci fecalis is the most

•  Common agent in endocarditis among

Common coagulase negative

common cause of enterococcal

infection drug users

staphylococii

infective endocarditis

•   P. aerug inosa infects the native heart

•   Coagulase negative staph (S.

•   These organism account for 10 – 20%

valves of intravenous drug users as

epidermidis/alba) are the most common cause of ‘Prosthetic  valve endocarditis’

of cases of bacterial endocarditis

well as prosthetic heart valves


Q. 33

Acute Infective Endocarditis with abscess formation is most commonly associated with

 A

Listeria

 B

Staphylococcus

 C

Streptococcus

 D

Enterococcus

Q. 33

Acute Infective Endocarditis with abscess formation is most commonly associated with

 A

Listeria

 B

Staphylococcus

 C

Streptococcus

 D

Enterococcus

Ans. B

Explanation:

Answer is B (Staphylococcus)

Acute Infective Endocarditis with abscess formation is most commonly associated with staphylococcus.

`The most common organism causing acute infective endocarditis overall is staphylococcus aureus. Staphylococcus aureus endocarditis is particularly virulent and associated with annular and myocardial abscess formation and a higher mortality’


Q. 34

Which of the following is recommended for culture sampling in Infective Endocarditis:

 A

2 culture sets separated by at-least 1 hour over 24 hours

 B

2 culture sets separated by at-least 2 hours over 24 hours

 C

3 culture sets separated by at-least 1 hour over 24 hours

 D

3 culture sets separated by at-least 2 hours over 24 hours

Q. 34

Which of the following is recommended for culture sampling in Infective Endocarditis:

 A

2 culture sets separated by at-least 1 hour over 24 hours

 B

2 culture sets separated by at-least 2 hours over 24 hours

 C

3 culture sets separated by at-least 1 hour over 24 hours

 D

3 culture sets separated by at-least 2 hours over 24 hours

Ans. C

Explanation:

Answer is C (3 culture sets separated by at-least 1 hour over 24 hours)

Three culture sets separated from one another by at-least I hour should he obtained over 24 hours.

in the absence of prior antibiotic therapy three (2-bottled) culture sets separated from one another by at-least 1 hour should be obtained from different venepuncture sites over 24 hours. If the cultures remain negative 48 to 72 hours, two or three additional blood culture sets should be obtained’


Q. 35

Antiboiotic Prophylaxis for infective endocarditis is indicated in:

 A

Isolated secundum ASD

 B

Mitral valve prolapse without regurgitation

 C

Prior coronary artery bypass graft

 D

Coarctation of aorta

Q. 35

Antiboiotic Prophylaxis for infective endocarditis is indicated in:

 A

Isolated secundum ASD

 B

Mitral valve prolapse without regurgitation

 C

Prior coronary artery bypass graft

 D

Coarctation of aorta

Ans. D

Explanation:

Answer is D (Coarctation of Aorta)

Coarctation of Aorta is a high risk cardiac lesion fior the development of infective endocarditis and an indication fir antibiotic prophyloxis.


Q. 36

Which of the following have most friable vegetation:

 A

Infective endocarditis

 B

Libman Sack’s endocarditis

 C

Rheumatic heart disease

 D

SLE

Q. 36

Which of the following have most friable vegetation:

 A

Infective endocarditis

 B

Libman Sack’s endocarditis

 C

Rheumatic heart disease

 D

SLE

Ans. A

Explanation:

Answer is A (Infective endocarditis)

Most friable vegetations with the highest risk of embolization are seen in infective endocarditis.

Friability of Vegetation and risk of embolization

Infective Endocarditis > NBTE (Marantic) > Rheumatic endocarditis and Libman Sack’s endocarditis

 

Rheumatic Fever

Non bacterial Thrombotic

Libman Sack’s Endocarditis

Infective Endocarditis

 

(Marantic Endocarditis)

(SLE)

 

•  Small

•  Small (but larger than those

•  Medium sized(small)

•  Large, Bulky

•  Warty, verrucous

of rheumatic)

•  Flat, Verrucous,lrregular

•  Irregular

•  Usually Firm

•  Friable

•  Usually Firm; occasionally friable

•  Friable (most friable)Q

May be friable (but less

than those of NBTE)

(embolization rare)

(embolization common)

(embolization rare)

(embolization common)

.

•  Along lines of closure

•  Along lines of closure

•  On surface of cusps

Both surfaces may be involved

most common being the

undersurface, less often on mural

endocardium

•  In pockets of valves

•  Irregular vegetations on

valve cusps that can

extend onto the

chordae.

•  Less often on mural

endocardium

•  Sterile (no organisms)

•   Sterile

•  Sterile

•  Non-sterile (bacteria)

•  Non destructive

•  Non destructive

•  Destructive

•  Destructive

Valve perforation : no

Valve perforation : no

Valve perforation : no

Ulcerates or perforates

Mural involvement: rare

Mural involvement: rare

Mural involvement: common

underlying valve (or

myocardium)

•  Seen in Rheumatic fever

•   Seen in hyper coagulable

states e.g. cancer,

promyelocytic leukemia

increased estrogenic state

•  Seen in SLE

•  Seen in Infective

endocarditis

 Most common site:

  • Most common site for vegetations in Libman Sack’s endocarditis are the A-V values, mitral and tricuspid.
  • Most common site for vegetations in NBTE is mitral and less often aortic and Tricuspid.
  • Most common site for vegetations of RF is mitral followed by combined mitral and aortic.

Q. 37

Infective endocarditis after tooth extraction is probably due to ‑

 A

Streptococcus viridans

 B

Streptococcus pneumoniae

 C

Streptococcus pyogenes

 D

Staphylococcus aureus

Q. 37

Infective endocarditis after tooth extraction is probably due to ‑

 A

Streptococcus viridans

 B

Streptococcus pneumoniae

 C

Streptococcus pyogenes

 D

Staphylococcus aureus

Ans. A

Explanation:

Ans. is ‘a’ i.e., Streptococcus viridans

  • Viridans streptococci are normally resident in the mouth and upper respiratory tract. They cause transient bacteremia following tooth extraction or other dental procedures; and get implanted on damaged or prosthetic valves or in a congenitally diseased heart, and grow to form vegetations.
  • They are ordinarily nonpathogenic but can on occasion cause disease. In persons with preexisting cardiac lesions, they may cause bacterial endocarditis, Str. sanguis being most often responsible.
  • Str. mutans is important in causation of dental caries.
  • The transient viridans streptococcal bacteremia induced by eating, tooth-brushing, flossing and other source of minor trauma, together with adherence to biological surfaces, is thought to account for the predilection of these organisms to cause endocarditis.
  • Viridans streptococci are also isolated, often as a part of a mixed flora, from sites of sinusitis, brain abscess and liver abscess.
  • Viridans streptococcal bacteremia occurs relatively frequently in neutropenic patients, particularly after bone marrow transplantation or high dose chemotherapy for cancer.

Treatment of varidans streptococcal infections include :-

  1. Bacteremia in neutropenic patients → Vancomycin.
  2. Other infection → Penicillin.

Q. 38

Images of vegetations in major forms of Endocarditis is shown in the image.Identify ‘B’.

 A

Rheumatic Heart Disease

 B

Infective Endocarditis

 C

Non Bacterial Thrombotic Endocarditis

 D

Libman Sack Endocarditis

Q. 38

Images of vegetations in major forms of Endocarditis is shown in the image.Identify ‘B’.

 A

Rheumatic Heart Disease

 B

Infective Endocarditis

 C

Non Bacterial Thrombotic Endocarditis

 D

Libman Sack Endocarditis

Ans. B

Explanation:

Ans:B.)Infective Endocarditis

Image shows:

  • A:Rheumatic Heart Disease
  • B:Infective Endocarditis
  • C:Non Bacterial Thrombotic Endocarditis
  • D:Libman Sack Endocarditis

DISTINGUISHING FEATURES OF VEGETATIONS IN MAJOR FORMS OF ENDOCARDITIS



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