USMLE Forum Archives - USMLE Step 2 CK - Name that disease
Name that disease
mosaabma - 09-30-06 04:18
A 54-year-old woman with a history of valve replacement visits her dentist for a routine cleaning. Two days later, she develops a severe fever, has small hemorrhages on her fingers, and funduscopic evaluation reveals the presence of retinal hemorrhages. She becomes hypotensive and is rushed to the emergency department. Which of the following is the most diagnosis?
(A) Acute bacterial endocarditis
(B) Acute rheumatic fever
(C) Libman-Sacks endocarditis
(D) Nonbacterial thrombotic endocarditis
(E) Subacute bacterial endocarditis
mosaabma - 09-30-06 04:18
A 54-year-old woman with a history of valve replacement visits her dentist for a routine cleaning. Two days later, she develops a severe fever, has small hemorrhages on her fingers, and funduscopic evaluation reveals the presence of retinal hemorrhages. She becomes hypotensive and is rushed to the emergency department. Which of the following is the most diagnosis?
(A) Acute bacterial endocarditis
(B) Acute rheumatic fever
(C) Libman-Sacks endocarditis
(D) Nonbacterial thrombotic endocarditis
(E) Subacute bacterial endocarditis
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#1
It can only be acute docraj - 10-01-06 01:05 sub acute bacteremic endocarditis affects previously healthy heart valves. If it is a diseased heart valve or prosthetic valve then it is always acute.
#2
Re: Name that disease TheOne - 10-01-06 15:13 The Answer is A,
Acute Bacterial Endocarditis or "Inflamation of Heart Valves",
Causative agent in this woman: Mostly Staph. aureus.
Reason: History of Valve Replacement + Dental Procedure.
Common Symptoms: Fever, rigors, heart failure "from valve destuction" and symptoms related to systemic emboli (neurologic impairment, back pain, pulmonary symptoms).
P/E: New murmur, small skin infarctions small hemorrhages on her fingers (Janeway lesions), deep-seated, painful nodules in fingers & toes (Osler's nodes = "Ouch"ler's nodes), and Retinal exudates funduscopic evaluation reveals the presence of retinal hemorrhages (Roth's spots).
Diagnosis: Combination of lab and clinical data, 3 sets of blood culture + Thoracic Echocardiogram (Vegitations).
If the Thoracic Echocardiogram is -ve, proceed to TransEsophageal Echocardiogram (TEE).
+ve Blood Culture and Echocardiogram findings diagnose Endocarditis.
Rx: Prolonged Antibiotics, generally (4-6 wks), start empirically with Gentamicin + Oxacillin or Nafcillin.
If there's risk of MRSA, use Vancomycin instead of Oxacillin/Nafcillin.
In case of heart failure (due to valve destruction), valve ring abcess, or systemic emboli despite Antibiotic therapy then go for Valve Replacement.
Note: Following Rx for infectious endocarditis, patients should receive endocarditis prophylaxis.
Complications: Valve destruction and Heart Failure, Spinal Osteomyelitis, Embolic Stroke.
Prevention: give Endocarditis Prophylaxis for high risk patients (Prosthetic valve, prior Bacterial endocarditis, congenital heart abnormalities, Hypertrophic Cardiomyopathy, and Mitral Valve Prolapse with Mitral Regurgitation).
Amoxicillin (Clindamycin if Penicillin Allergy) 1 hour before any Dental, Pulmonary, GI, or GU procedures.
Note: In GI & GU procedures, cover Enterococcus with IV Ampicillin and Gentamicin.
P.S. the patients hypotension is due to Bacteremic "or Septic" shock, Treat That First.
#3
Excellent !!!!
mosaabma - 10-01-06 15:38 A: CORRECT: Previously damaged heart valves or prosthetic valves are susceptible to infection. Bacteria seed the valves in this case after dental work. The rapid decline of the patient and the peripheral and retinal hemorrhages reveal the likely diagnosis as acute bacterial endocarditis. In mechanical valves, if there is infection around the valve, it can lead to its possible dislodgement.
B: Acute rheumatic fever may lead to fever. If the myocardium is affected, conduction abnormalities may result. Repeated bouts affecting the myocardium lead to its scarring.
C: Libman-Sacks endocarditis presents as sterile vegetations on both sides of the heart valves. Fever and peripheral hemorrhage are not seen. These vegetations are seen in systemic lupus erythematosus.
D: As the name implies, nonbacterial thrombotic endocarditis is characterized by accumulation of small thrombotic emboli on the heart valves. This condition is associated with chronic diseases such as cancers.
E: While a normal heart valve is not usually susceptible to the less virulent organisms that give rise to subacute bacterial endocarditis, those with a prosthesis are. The important distinction is rapidity of the onset of symptoms.
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