OTHER INFECTIONS OF CVS
Myocarditis
Inflammation of the myocardium,
Clinical manifestation: Chest pain, arrhythmias, or congestive heart failure.
Progression: Rapidly progressive and often fatal.
Cause: Infectious and non-infectious etiology.
Etiology
Infectious Non-Infectious
- Viruses - Most common agents - Most common being Coxsackievirus
B, followed by adenoviruses, parvovirus B19, human herpesvirus 6, and
dengue viruses
-Parasitic agent such as Trypanosoma cruzi, the agent of Chagas’
disease
- Bacterial agent: Rarely caused by bacteria, as a result of bacteremia,
direct extension from a contiguous focus, or a bacterial toxin.
Laboratory Diagnosis:
Endomyocardial biopsy - Provide a definitive diagnosis.
Evidence of viral infection by detection in peripheral samples or by serology
provides only circumstantial evidence of possible etiology.
Pericarditis
Inflammation of the pericardium
Clinical presentation: Chest pain, pericardial friction rub, and pericardial efusion.
Etiology: Both infectious and non-infectious etiology.
Infectious etiologic agents:
Viruses: Most common agents; such as Coxsackievirus B (most common
cause), Echovirus, Adenovirus, HIV and others
Bacteria: Rarely cause purulent pericarditis, usually as a complication of
pneumonia due to S. aureus, H. infuenzae, meningococcus and pneumococcus
M. tuberculosis can cause pericarditis, usually as a complication of pulmonary
tuberculosis.
Laboratory Diagnosis:
Percutaneous pericardial biopsy or pericardiotomy with biopsy and drainage
provide a definite diagnosis.
Evidence of coincident viral infection, either by culture or serology, is
circumstantial.
Pericardial Effusion:
Excess fluid production in pericardial sac, usually secondary to pericarditis or other
causes such as malignant, or autoimmune processes within the pericardium.
Infections of Blood Vessels:
Mycotic Aneurysm
Aneurysm: Infammatory damage and weakening of an arterial wall; leading to
a bulging of the arterial wall, that can eventually rupture.
Aneurysms of any infectious etiology except syphilitic aortitis.
The etiologic agents are similar to those that cause endocarditis such as
streptococci and staphylococci.
Infective Endarteritis
Inflammation of the arterial wall, which may occur with or without coexistent
aneurysmal dilation.
Device-related Infections:
Includes infections of various devices inserted in the blood vessels such as
central line (central venous catheters) and peripheral IV cannula
CRBSI (Catheter-related Bloodstream Infection):
o Severely-ill patients in ICUs are often put on central line for
administration of medications and parenteral nutrition.
o Central lines may get infected due to mishandling during insertion or
during daily maintenance which leads to development of CRBSI.
o Major healthcare associated infection
Suppurative Thrombophlebitis
o Inflammation of a vein wall.
o Occurs secondary to either dermal infection or use of indwelling
intravenous catheters; the latter being the most common cause.
o IV cannulation: STP occurs frequently in hospitalized patients after 3-
4 days of IV cannulation (e.g. veinfam), which gets colonized by the
organisms present on patient’s skin or hands (as normal skin flora) of
the healthcare workers
o Etiology: S. aureus, members of Enterobacteriaceae, and yeasts
(Candida and Malassezia)
o Lemierre's syndrome: It is a condition characterized by
thrombophlebitis of the internal jugular vein and bacteremia—caused
primarily by anaerobic organism Fusobacterium necrophorum,
following a recent oropharyngeal infection
ACUTE RHEUMATIC FEVER:
Multisystem disease that occurs in people previously affected with streptococcal
(group A) sore throat, as a result of an autoimmune reaction.
Although ARF may involve many parts of the body, almost all the manifestations
resolve completely; except the cardiac valvular damage, which is called as rheumatic
heart disease (RHD).
Group A Streptococcus (S. pyogenes) principally causes infections of skin and soft
tissues
Etiology:
Age: Primary ARF - Mainly a disease of children age 5–14 years - Rare in persons
aged more than 30 years.
However, recurrent episodes of ARF are more common in adolescents and young
adults.
Gender: No clear gender association – But, more commonly affects females.
ARF results following upper respiratory tract infection with group A streptococci
(usually by M-serotypes 1, 3, 5, 6, 14, 18, 19, 24, 27, and 29).
Genetic predisposition may play a role; people with HLA-DR7 and HLA-DR4 appear
to be more susceptible as compared to others.
Pathogenesis
Pathogenesis is unclear.
It may be due to:
Autoimmune theory:
o Based on theory of molecular mimicry—the antibodies targeted
against streptococcal antigens (M protein) cross react with human
tissue antigens (e.g. heart and joint).
o Cross reactive antibodies bind to valvular endothelium, leading to
damage of the heart valves
Cytotoxic theory: Streptococcal toxins (e.g. streptococcal pyrogenic toxin) and
enzymes (streptolysin O) are directly toxic to human heart.
Clinical Manifestations
Usually appear after period of ~3 weeks following precipitating group A streptococcal
infection. The prior streptococcal infection may be either subclinical (more common)
or presents as sore throat.
Acute rheumatic fever affects heart, joints, skin and brain.
The common manifestations in the order of frequency include:
Migrating polyarthritis: Most common manifestation
o Pain in joint (hot, swollen, red, and/or tender joints) - Moves from one
joint to another over a period of hours.
o Asymmetric
o Afects the large joints—most commonly the knees, ankles, hips, and
elbows
Pancarditis:
o Affects endocardium, pericardium, or myocardium
o Valvular damage: Hallmark - Leading to mitral regurgitation (most
common) and aortic regurgitation
o Myocardial inflammation - May affect electrical conduction pathways,
leading to P-R interval prolongation.
Subcutaneous nodules: Occur as painless, small, mobile lumps beneath the
skin overlying bony prominences, particularly of the hands, feet, and elbows
Chorea (Sydenham’s): Abnormal involuntary movement disorder, mainly
affecting head and limbs
Erythema marginatum: Pink macular rashes that appear and disappear before
the examiner’s eyes.
Diagnosis:
Supportive evidence:
Elevated ASO titre—which
will be much higher in patients
with ARF than that seen in patients
with GAS infections without ARF
A positive throat cultures
Rapid antigen test for GAS
Recent scarlet fever.
Primary Prevention
Includes timely and complete treatment of group A streptococcal sore throat with
antibiotics (penicillin) within 9 days of sore throat onset, which will prevent almost all
cases of ARF
Secondary Prevention:
Patients with ARF are at much higher risk of developing recurrent ARF - Therefore,
long-term penicillin prophylaxis is indicated to prevent recurrences.
Drug of choice for secondary prophylaxis: Intramuscular benzathine penicillin G given
every 4 weeks.
In case of penicillin allergy, erythromycin (250 mg, twice a day) can be given as an
alternative.
Duration depends upon underlying carditis
ARF without carditis: For 5 years after the last attack or 21 years of age
(whichever is longer
ARF with carditis but no residual valvular disease: For 10 years after the last
attack, or 21 years of age (whichever is longer)
ARF with persistent valvular disease: For 10 years after the last attack, or 40
years of age (whichever is longer) or sometimes lifelong prophylaxis