Dr.Ch Venkat Kumar Raju, Dr Praveena N B, Dr. R Krishna Kumar, Dr.C Jayakumar
Department of Pediatric Cardiology and Pediatrics
Amrita Institute of Medical Sciences
17-year-old female from Malappuram was brought mother with complaints of fever for 4 months, cough for 2 months, blood tinged sputum, breathing difficulty and rashes on lower limbs from 2 weeks duration. Fever was low grade and intermittent in nature, was associated with chills and rigor. Cough was productive with scanty white color sputum was associated with blood since last 2 weeks. She had breathing difficulty initially during moderate exercise and later was present on doing daily activities, it was associated with abdominal distention and periorbital swellings. Rashes were initially noticed small pinpoint non itchy reddish lesions on extensor aspect of lower leg on right side. H/o loss of apetite and weight loss of 3 kg.
Treatment history- She was admitted thrice in last four months, received multiple antibiotics (Amox clav x 2times, doxycycline, ceftriaxone and linezolid), after discharge she would improve for a while.
Past History- at 3 months , she was incidentally detected to have a murmur, was diagnosed to have Double outlet right ventricle(DORV) ,Ventricular septal defect (VSD),Pulmonary stenosis (PS). At 7 months of age Bidirectional Glenn shunt was done. At 4 years of age child had right sided focal seizure lasting for 1 min, MRI done at that time revealed an infarct. She Corrective surgery done at 8years of age
Has an uneventful birth history, Normal development and vaccinated for age.
On examination she is tachypneic, pale, grade 2 clubbing on all 4 limbs and bilateral pitting edema
JVP measured was 4cm above sternal angle, multiple petechiae over lower limbs
On CVS examination Apical impulse at 6 ICS 2cm lateral to MCL, Normal S1 and S2, Wide variable split , 3/6 ESM at pulmonary area, 2/6 MDM at pulmonary area
GIT- Tender hepatomegaly, 11cm span, spleen +
At this point our D/Ds were
- Sub acute IE – H/o, heart disease, Surgery done, prolonged fever, features of CHF, petechiae, pallor, clubbing, splenomegaly
- SLE- Teenage female, Fever, weight loss, Pallor, Organomegaly, Rash, Edema
- SOJIA- Fever, rash , organomegaly, weight loss
- TB- Fever, weight loss, cough, hemoptysis
- IBD- weight loss, fever, No GI symptoms
- Malignancy
ECG showed Right axis deviation , RVH and RBBB
X ray showing scoliosis and rvh
ECHO- Case of DORV/VSD/PS
- S/P ICR + Conduit + Takedown of BDGS
- S/P VSD CLOSURE OF RESIDUAL VSD
- Infective endocarditis of the conduit (RV-PA), Gradient of 42mmhg
- Moderate TR, RVSP: 93mmhg + RAP
- RA/RV Dilated, Flattened septum
- Normal LV function
- Left arch, No coarcation
She was started on ceftriaxone
- Blood culture grew 3 cultures were taken peripherally with 30 min intervals
- All the cultures grew GPC
- Streptococcus Mitis
- Sensitive to Penicillin, Cefotaxime, Ofloxacin and Ceftriaxone
- Resistant to Erythromycin
Total 6 weeks of antibiotics were planned with replacement of pulmonary conduit
New IE Criteria (Dukes)
- Clinical Criteria ( 2 Major, 1 Major + 3 Minor and 5 minor)
Major Criteria (Microbiological, imaging and Surgical)
Microbiological Criteria
- Positive Blood culture
- Microorganisms that commonly cause IE, isolated from 2 or more separate blood cultures (Typical). OR
- Microorganisms that occasionally or rarely cause IE isolated from 3 or more separate blood culture (Atypical)
- Positive Lab tests
- Positive PCR for Coxiella Brunetii, Bartonella or Tropheryma whipplei from blood
- Coxiella Burnetii IgG >1:800 or isolated from single blood culture
- Indirect immunofluorescence assays(IFA) for IgM and IgG to bartonella henselae or quintana with IgG > 1:800
Imaging Criteria
- Echocardiography and cardiac CT imaging
- ECHO and/or CT showing vegetations, valvular/leaflet perforation, aneurysm or abscess or intracardiac fistula
- Significant new valvular regurgitation
- New partial dehiscence of prosthetic valve
- PET CT- abnormal metabolic activity involving native or prosthetic valve, ascending aortic graft, intracardiac device
Surgical Criteria
- Evidence of IE documented direct inspection during heart surgery
Minor Criteria
- Predisposition
- Fever >100.4
- Vascular phenomena
- Immunologic phenomena
- Microbiologic evidence
- Imaging criteria
- Physical examination criteria
Take Home Message – Always screen for Infective endocarditis in a patient with a conduit and ICR.