Rosen & Barkin's 5-Minute Emergency Medicine Consult (242 page)

• Identify risk factors for endocarditis in patients with fever of unknown etiology.
  
• Blood cultures
  
• ECG is needed to confirm the diagnosis.
  

• CBC:
  
  • Anemia (sometimes hemolytic)
    
  • Leukocytosis (with granulocytosis and bandemia)
    
• Blood cultures:
  
  • Multiple sets (3 sets over a time period) should be obtained before antibiotic administration:
    
    • 5–10% with endocarditis have false-negative cultures
      
    • Consider culture of catheter device
      
• Elevated sedimentation rate and C-reactive protein (lacks specificity)
  
• Urinalysis:
  
  • Microscopic hematuria
    

• CXR:
  
  • CHF
    
  • Septic pulmonic emboli, which may be seen in right-sided endocarditis
    
• EKG
  
  • Arrhythmia, new heart block
    
• Echocardiogram
  
  • Acute valvular pathology
    
  • Abscess
    
  • Vegetations
    
  • Transesophageal echo provides greater sensitivity.
    
• CT scan
  
  • May provide comprehensive information and valvular abnormalities
    

• Rheumatic fever
  
• Atrial myxoma
  
• Acute pericarditis
  
• MI
  
• Aortic dissection with regurgitant valve
  
• Thrombotic thrombocytopenic purpura
  
• Systemic lupus erythematosus
  
• Occult neoplasm with metastasis
  
• Septicemia
  
• Cotton fever
  

TREATMENT

• Monitor for signs of heart failure.
  
• Operative repair if:
  
  • Severe valvular dysfunction causing failure
    
  • Unstable prosthesis
    
  • Perivalvular extension with intracardiac abscess
    
  • Antimicrobial therapy failure
    
  • Large or fungal vegetations
    
• Antibiotic therapy:
  
  • IV, bactericidal, and empiric, pending culture results
    
  • Native valve or congenital abnormality:
    
    • Penicillin G + nafcillin + gentamicin
      
    • Vancomycin + gentamicin
      
  • Prosthetic valve or history of IVDA:
    
    • Vancomycin + gentamicin + rifampin
      
    • Nafcillin + gentamicin + rifampin (if methicillin-resistant
      S. aureus
      [MRSA] is not suspected)
      
    • If MRSA vancomycin failure/intolerant consider daptomycin or quinupristin–dalfopristin
      
    • Vancomycin resistant
      
    • Enterococcus faecium
      consider quinupristin–dalfopristin
      
    • Enterococcal: Penicillin G + gentamicin; vancomycin + gentamicin
      
    • Enterococcal (gentamicin resistant): Penicillin G + streptomycin
      
  • Fungal:
    
    • Amphotericin B
      
  • HACEK:
    
    • Ceftriaxone
      

• Amphotericin B:
  
  • Test dose 0.1 mg/kg up to 1 mg slow IV
    
  • Wait 2–4 hr.
    
  • If tolerated, begin 0.25 mg/kg IV and advance to 0.6 mg/kg IV QID
    
• Ceftriaxone: 2 g/d IV (peds: 100 mg/kg/24h)
  
• Daptomycin: 4 mg/kg/d U IV
  
• Gentamicin: 1 mg/kg IV q8h (peds: 3 mg/kg/24h in 3 equally div. doses)
  
• Nafcillin: 2 g IV q4h
  
• Penicillin G: 4 million IU IV q4h (peds: 300,000 U/kg/d div. into 4 equal doses)
  
• Quinupristin–dalfopristin: 7.5 mg/kg IV q8h (peds: 7.5 mg/kg/12h)
  
• Rifampin: 600 mg PO QID
  
• Streptomycin: 15 mg/kg/24h IV/IM in 2 equally div. doses (peds: 20 mg/kg/24h IV in 2 equally div. doses)
  
• Vancomycin: 15 mg/kg IV q12h (peds: 40 mg/kg/24h in 2–3 equally div. doses)
  

FOLLOW-UP

• Patients with risk factors who exhibit pathologic criteria or clinical findings
  
• All IV drug users with fever
  
• Admit patients with cardiovascular instability to an intensive care unit/monitored setting.
  

None

• Expected course:
  
  • Most patients will defervesce within 1 wk.
    
• Complications:
  
  • Cardiac: CHF, valve abscess, pericarditis, fistula
    
  • Neurologic: Embolic stroke, abscess, hemorrhage
    
  • Embolization: CNS, pulmonary, ischemic extremities
    
  • Mycotic aneurysms: Cerebral or systemic
    
  • Renal: Infarction, nephritis, abscess
    
  • Metastatic abscess: Kidney, spleen, tissue
    

• Fever, new or changing murmur
  
• 50% of cases occur in patients with no known history of valve disease
  
• Recent health care exposure/device consider as risk factor
  
• Common complications; watch for stroke, embolization, heart failure, intracardiac abscess
  
• Admit IV drug abusers presenting with fever to rule out endocarditis.
  
• Empiric therapy for acutely ill after 2–3 sets of blood cultures from separate venipuncture sites.
  

• Chen RS, Bivens MJ, Grossman SA. Diagnosis and management of valvular heart disease in emergency medicine.
  Emerg Med Clin North Am
  . 2011;29(4):801–810.
  
• Hoen B, Duval X. Clinical practice. Infective endocarditis.
  N Engl J Med.
  2013;368(15):1425–1433.
  
• Keynan Y, Rubinstein E. Pathophysiology of infective endocarditis.
  Curr Infect Dis Rep
  . 2013;15(4):342–346.
  
• Murdoch DR, Corey GR, Hoen B, et al. Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century: The International Collaboration on Endocarditis-Prospective Cohort Study.
  Arch Intern Med
  . 2009;169(5):463–473.
  
• Selton-Suty C, Célard M, Le Moing V, et al. Preeminence of Staphylococcus aureus in infective endocarditis: A 1-year population-based survey.
  Clin Infect Dis
  . 2012;54(9):1230–1239.
  

CODES

• 421.0 Acute and subacute bacterial endocarditis
  
• 424.90 Endocarditis, valve unspecified, unspecified cause
  
• 996.61 Infection and inflammatory reaction due to cardiac device, implant, and graft
  

BASICS

• Presence of endometrial tissue and glands outside uterus
  
• An estrogen-dependent chronic inflammatory disease
  
• Affects 6–10% of women of reproductive age and 50–60% of women/teenage girls with pelvic pain
  
• Endometrial tissue found anywhere in pelvic cavity, on ovaries, uterine ligament (due to retrograde menstruation) and distant sites, including bowel and lungs
  

• Unknown
  

Not prior to menarche

• Anatomic obstruction of menstrual outflow
  
• Early menarche
  
• Short menstrual cycles
  
• Genetic component suggested by twin and family studies
  

DIAGNOSIS

• Dysmenorrhea (50–90%)
  
• Deep pelvic pain
  
• Dyspareunia
  
• Dysfunctional uterine bleeding
  
• Lower abdominal pain
  
• Nausea, abdominal distention
  
• Infertility (30–50%)
  

• Focal pain or tenderness on pelvic exam
  
• Tenderness along uterosacral ligament
  
• Retroverted uterus
  
• Rectovaginal nodularity
  
• Pelvic mass
  
• Physical exam can vary depending on location of endometrial tissue
  
• Catamenial pneumothorax occurs during menses due to pleural endometriosis