Infective Endocarditis

ETIOLOGY
infective endocarditis is an infection on the endothelial surface of the heart, including the heart valves

ETIOLOGY
endothelial lesions, called
vegetations, usually occur on the valve leaflets(). These lesions are composed of microorganisms trapped in a fibrin mesh that extends into the bloodstream.

 Because antibiotics must reach

the organisms by passive diffusion through the fibrin, high doses of antibiotics are required for an extended period of treatment.

streptococci are the principal causes in children with congenital heart diseases without previous surgery.

coagulasemegative staphylococci are important causes of endocarditis that assume greater prominence after cardiac surgical procedures and with prosthetic cardiac and endovascular material

EPIDEMIOLOGY
Infective endocarditis among children is
primarily a complication of congenital heart disease High-risk cardiac lesions include : tetralogy of Fallot, ventricular septal defect, aortic stenosis, aortic regurgitation,patent ductus arteriosus, and transposition of the great vessels.

 The risk is increased after dental and

oral procedures or instrumentation or surgical procedures of the respiratory tract, genitourinary() tract, or gastrointestinal tract . Rheumatic heart disease is a rare risk factor.

 Neonatal endocarditis is associated with

the use of central vascular catheters() and surgery in neonates. In adults, there is a male preponderance() and association with social and behavioral factors, such as IV drug abuse and atherosclerotic( ) heart disease.

CLINICAL MANIFESTATIONS
The most common early symptoms of
infective endocarditis are nonspecific and include fever, malaise, and weight loss

 The subtle and nonspecific

findings underscore the need to obtain blood cultures if endocarditis is suspected, especially for children with congenital heart disease and for unexplained illness after dental or surgical procedures

LABORATORY STUDIES AND IMAGING

The key to diagnosis is showing
continuous bacteremia or less often fungemia() by culturing the blood. Multiple blood cultures are performed before initiating antibiotic therapy.

 Three separate venipunctures for

blood Multiplb blood cultures are performed before initiating antibiotic therapy.

 Patients who have been treated with

antibiotics recently or who are currently receiving antibiotics should have additional cultures performed.

 Despite adequate blood culture

techniques, 10% to 15% of cases of endocarditis are culturenegative.

DIFFERENTIAL DIAGNOSIS
Infective endocarditis must be
differentiated from other causes of bacteremia or other cardiac condition using the Duke criteria for categorizing the strength of the endocarditis diagnosis

 Prolonged bacteremia can be caused

by infectious endothelial foci outside of the heart, often associated with congenital malformations, vascular trauma, an infected venous thrombosis, and postvascular surgery.

TREATMENT
Severely iii patients must be'
stabilized with supportive therapies For cardiac failure, pulmonary edema, and low cardiac output Multiple blood cultures should be obtained before initiating antibiotic therapy

 Empirical antibiotic therapy may be

starred for acutely iii persons With subacute disease, it is recommended to await results of blood cultures to confirm the diagnosis and to treat according to the susceptibility of the isolate.

 Treatment ora culture-positive case

is directed against the particular bacterium using bactericidal antibiotics continued for 4 to 8 weeks

 Infective carditis from viridans

streptococci can be treated with traditional monotherapy with penicillin G for 4 weeks.

 A 2-week regimen of penicillin G plus

an aminoglycoside is effective in adults.

 an unusual pathogen (fungal

endocarditis), abscess of the valve annulus or of the myocardium, rupture of a valve leaflet, valvular insufficiency with refractory heart failure, recurrent serious embolic complications, or refractory prosthetic valve disease.

COMPLICATIONS
The major complications of infective
endocarditis are direct damage to the heart and heart valves and distant complications secondary to sterile and septic embolic from vegetations

 Damage to the heart and heart

valves may include regurgitation with vegetations or actual defects in the leaflets resulting from embolization of the leaflet tissue, abscess of the valve ring, or myocardial abscess

 These complications can be

monitored by physical examination and echocardiography. Cerebral abscesses or aneurysms can cause a strokelike picture.Splenic abscesses can cause fatal bleeding.

Acute Gastroenteritis

ETIOLOGY AND EPIDEMIOLOGY

Acute enteritis or acute gastroenteritis refers to diarrhea, which is abnormal frequency and liquidity of fecal( discharges

Diarrhea is caused by many different infectious or inflammatory processes in the intestine. These processes directly affect enterocyte secretory and absorptive functions

 Some of these processes act by increasing

cyclic AMP levels Other processes (Shigella toxin, congenital chloridorrhea) cause secretory diarrhea by affecting ion channels or by unknown mechanisms. Enteritis has many viral, bacterial, and parasitic causes

Diarrhea is the leading cause of morbidity and the second most common disease in children in the U.S. In the developing world, it is a major cause of childhood mortality. The epidemiology of gastroenteritis depends on the specific organisms

Some organisms are spread person to person, others are spread via contaminated food or water, and some are spread from animal to human. Many organisms spread by multiple routes..

The ability of an organism to infect relates to its mode of spread, its ability to colonize the gastrointestinal tract, and the number of organisms required to cause disease

 Rotavirus invades the epithelium and

damages villi of the upper small intestine and in severe cases involves the entire small bowel and colon

 Rotavirus is the most

frequent cause of diarrhea during the winter months. Vomiting may last 3 to 4 days, and diarrhea may last 7 to 10 days. Dehydration is common in younger children.

 Primary infection with rotavirus in

infancy may cause moderate to severe disease but is less severe later in life.

Typhoid fever is caused by Salmonella

typhi and occasionally Salmonella paratyphi

 These infections are distinguished by their

potential for prolonged fever, inconsistent presence of diarrhea, and extraintestinal manifestations. approximately 400 cases of typhoid fever occur each year. The incubation period of typhoid fever is usually 7 to 14 days

Most cases are imported from other countries. Worldwide there are an estimated 16 million cases of typhoid fever annually, resulting in 600,000 deaths. The typhoid bacillus infects humans only, and chronic carriers are responsible for new cases.

 Nontyphoidal Salmonella produce diarrhea

by invading the intestinal mucosa. The organisms are transmitted through contact with infected animals

or from contaminated food products, such

as dairy products, eggs, and poultry.

 Shigella( dysenteriae may cause

disease by producing Shiga toxin, either alone or combined with tissue invasion. The incubation period is 1 to 7 days, and infected adults may shed organisms for 1 month

Infection is spread by person-to-person contact or by the ingestion of contaminated food with 10 to 100 organisms. The colon is selectively affected. High fever and seizures may occur, in addition to diarrhea.

CLINICAL MANIFESTATIONS
Gastroenteritis may be accohapanied by
systemic findings, such as fever, lethargy, and abdominal pain.

 Patients with diarrhea and possible

dehydration should be evaluated to assess the degree of dehydration as evident from clinical signs and symptoms, ongoing losses, and daily requirements

 Viral diarrhea is characterized by watery

stools, with no blood or mucus. Vomiting may be present, and dehydration may be prominent Fever, when present, is 10w grade.

 There is fever, headache, and abdominal

pain that worsen over 48 to 72 hours with nausea, decreased appetite, and constipation over the first week. Ifuntreated, the disease persists for 2 to 3 weeks marked by significant weight loss and occasionally hematochezia or melena

 Bowel perforation is a common

complication in adults, but is rare in children. Dysentery( is diarrhea involving the colon and rectum, with blood and mucus, possibly foul smelling, and fever

 Gastrointestinal bleeding and blood loss

may be significant. Enterotoxigenic disease is caused by agents that produce enterotoxins,

 Fever is absent or only low grade.

Diarrhea usually involves the ileum with watery stools without blood or mucus and usually lasts 3 to 4 days with four to five loose stools per day.

Insidious onset 0f progressive anorexia, nausea, gaseousness, abdominal distention, watery diarrhea, secondary lactose intolerance, and weight loss is characteristic of giardiasis. A chief consideration in management or a child with diarrhea is to assess the degree of dehydration

 The degree of dehydration dictates the urgency

of the situation and the volume of fluid needed for rehydration.

Mild dehydration (3% to 5%) is characterized by

normal pulse rate or minimal tachycardia, decreased urine output, thirst, and normal physical examination

 Moderate dehydration (5% to 10%) is

characterized by tachycardia, little or no urine output, irritability or lethargy, sunken eyes and fontanel, decreased tears, dry mucous membranes, mild tenting of the skin, and delayed capillary refill (<2 seconds) with cool and pale skin.

 Severe dehydration (10% to 15%) is

characterized by tachycardia with a weak pulse, hypotension and widened pulse pressure, no urine output, extremely sunken eyes and fontanel, no tears, parched mucous membranes, tenting of the skin, and extremely delayed capillary refill (>3 seconds) with cold and mottled skin.

LABORATORY AND IMAGING STUDIES

includes a complete blood count,
electrolytes,BUN, creatinine(, and urinalysis for specific gravity as an indicator of hydration Stool specimens should be examined for mucus, blood, and leukocytes, which indicate colitis.

 Fecal leukocytes are present in response

to bacteria that diffusely invade the colonic mucosa. A positive fecal leukocyte examination indicates the presence of an invasive or cytotoxin-producing organism,such as Shigella, Salmonella, C. jejuni,

 A rapid diagnostic test for rotavirus in

stool should be performed, especially during the winter. Stool cultures are recommended for patients with fever, profuse diarrhea,

 there is no history to suggest

contaminated food ingestion, a viral etiology is most likely. Stool evaluation for parasitic agents should be considered for acute dysenteric illness or in protracted cases of diarrhea in which no bacterial agent is identified.

 Positive blood cultures are uncommon

with bacterial enteritis except for S. typhi (typhoid fever) and for nontyphoidal Salmonella and E. coli enteritis in very young infants

 In typhoid fever, blood cultures are positive early in the disease, whereas stool cultures become positive only after the secondary bacteremia.

DIFFERENTIAL DIAGNOSIS
Diarrhea can be caused by infection,
toxins, gastrointestinal allergy including allergy to milk or its components, malabsorption defects, inflammatory bowel disease, celiac disease, or any injury to enterocytes

 Specific infections are differentiated from

each other by the use of stool cultures and ELISA or PCR tests, when necessary Acute enteritis may mimic other acute diseases, such as intussusception and acute appendicitis

 Persistent or chronic diarrhea may require

tests for malabsorption or invasive studies, including endoscopy and small bowel biopsy Common-source diarrhea usually is associated with ingestion of contaminated food

 Common-source diarrhea also includes

ingestion of preformed enterotoxins produced by bacteria, such as S. aureus and Bacillus cereus, which multiply in contaminated foods, and nonbacterial toxins, such as from fish, shellfish, and mushrooms.

 After a short incubation period, vomiting

and cramps are prominent symptoms, and diarrhea may or may not be present. Heavy metals that leach into canned food or drinks causing gastric irritation and emetic syndromes may mimic symptoms of acute infectious enteritis.

TREATMENT
Most infectious causes of diarrhea in
children are self-limited. Management of viral and most bacterial causes of diarrhea is primarily supportive and consists of correcting dehydration and ongoing fluid and electrolyte deficits and managing secondary complications resulting from mucosal injury.

 Antibiotic treatment is recommended for

only some bacterial and parasitic causes of diarrhea Treatment of fluid deficits requires an estimation of the degree of dehydration and the determination of any electrolyte imbalance.

 Hyponatremia is common,

and hypernatremia is less common. Metabolic acidosis results from losses of bicarbonate in stool, lactic acidosis resulting from malabsorption or shock, and phosphate retention resulting from transient prerenal-renal insufficiency

 Traditionally, therapy for 24 hours with

oral rehydration solutions alone is effective for viral diarrhea. Therapy for severe fluid and electrolyte losses involves IV hydration, whereas less severe degrees of dehydration

 children without excessive vomiting or shock

may be managed with oral rehydration solutions containing glucose and electrolytes The World Health Organization oral rehydration solution contains 90 mEq/L of sodium, 20 mEq/L of potassium chloride, and 111 mEq/L of glucose.

 Antibiotic treatment of mild illness with

Salmonella does not shorten the clinical course, but does prolong bacterial excretion. Antibiotic treatment of Shigella produces a bacteriologic cure in 80% of patients after 48 hours, reducing the spread of the disease

 Many Shtgella sonnei isolates,

the predominant strain affecting children, are resistant to amoxicillin and TMP-SMZ. Recommended treatment for children is an oral third-generation cephalosporin(

 Treatment

with erythromycin, azithromycin, or ciprofloxacin (for persons >18 years old)

 The course of Y. enterocolitica usually is

self-limited,lasting 3 days to 3 weeks. The efficacy of antibiotic treatment is questionable, but children with septicemia or focal infection, such as mesenteric lymphadenopathy, should be treated with cefotaxime

COMPLICATIONS
The major complication of gastroenteritis
is dehydration and the cardiovascular compromise that can occur with severe hypovolemia

 In disease caused by Shigella,

high fever and seizures may occur. Intestinal abscesses can form with Shigella and Salmonella infections, especially typhoid fever, leading to intestinal perforation

 which is a life-threatening complication.

Severe vomiting associated with gastroenteritis can cause esophageal tears or aspiration