BOF: 2.54
A 63-year-old male is admitted with a history of
low-grade fever and feeling generally unwell.
He had had an endoscopy two months ago and was found to
be Helicobacter pylori positive and was given a course of eradication
treatment.
As he was having fever his general practitioner also gave
him a weeks course of ciprofloxacin but this did not settle his fever .The
course of antibiotics was completed a week prior to admission.
On examination he has a
temperature of 38.4º C. On examination of his hands there are erythematous
macules on his palms and tender erythematous nodules in the pulp of his
fingers. His pulse rate is 70 beats per minute, regular with a slow rising
pulse. There is brachio-radial delay of the pulse.
The JVP is not elevated, the apex
beat is in the 5th intercostal space in the mid-clavicular line and
it is heaving in nature. The second heart sound is soft and single and there
is an ejection systolic murmur in the aortic area conducted to the neck.
On examination of his abdomen the
spleen tip is palpable.
Investigations reveal normocytic,
normochromic anaemia, elevated CRP and he has microscopic haematuria.
In this patient your next line of
management would be to take blood cultures and:
a) Treat with
penicillin 1.2 g 4-hourly with gentamicin 80 mgs 12-hourly
b) Treat with
vancomycin 1 g 12- hourly with gentamicin 80 mgs 12- hourly
c) Treat with
ampicillin 2 g 4-hourly with gentamicin 80 mgs 12-hourly
d) Treat with
flucloxacillin 2g 4-hourly with gentamicin 80 mgs 12-hourly
e) Await
results of blood cultures
Answer:
e)
The clinical features suggest the
patient has aortic stenosis and together with the rest of the history,
examination and investigations you would suspect infective endocarditis.
However, to conclusively prove a
patient has infective endocarditis, Duke’s criteria should be fulfilled and in
this case they have not yet been fulfilled.
In addition, this patient has had
two courses of antibiotics recently. Hence, one would delay antibiotic
treatment until cultures are available. This is possible, as the patient does
not have haemodynamic instability.
Duke’s Criteria
Infective endocarditis (IE) may be
diagnosed if one of the following conditions is fulfilled:
·
2 major criteria
·
1 major and 3 minor
·
5 minor criteria
Summary of major and minor
criteria
Major criteria
·
Positive blood cultures:
Expected organisms
Blood cultures > 12 hours apart
3/3 or 3/ 4 positive with
> 60 mins between 1st and last
·
Echocardiographic support:
Oscillating mass
Abscess
New partial dehiscence of valve
New valve regurgitation
Minor criteria
·
Fever
·
Predisposition to IE (heart condition or IVDA intravenous drug
abuse)
·
Echocardiogram consistent with IE
·
Immune phenomena: Roth spots, Osler’s nodes, glomerulonephritis,
rheumatoid factor
·
Microbiological evidence of IE (positive blood culture but do
not meet major criteria, serological support for infection)
·
Vascular phenomena (emboli, mycotic aneurysm, septic pulmonary
infarcts, conjunctival haemorrhage, intracranial haemorrhage, Janeway lesions)
