Pediatric Acquired Heart Disease - PowerPoint PPT Presentation

Loading...

PPT – Pediatric Acquired Heart Disease PowerPoint presentation | free to view - id: 6baf0a-ZmVlZ



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Pediatric Acquired Heart Disease

Description:

Pediatric Acquired Heart Disease Dr Sagui Gavri Pediatric Cardiology Hadassah Hebrew University Hospital ... – PowerPoint PPT presentation

Number of Views:221
Avg rating:3.0/5.0
Slides: 47
Provided by: Ornaan
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Pediatric Acquired Heart Disease


1
Pediatric Acquired Heart Disease
  • Dr Sagui Gavri
  • Pediatric Cardiology
  • Hadassah Hebrew University Hospital

2
Pediatric Acquired Heart Disease
3
Pediatric Acquired Heart Disease
  • 3 y/o healthy male
  • Looks ill
  • Prolonged High Fever gt 39.5 C
  • Red Rush
  • Bilateral Conjunctivitis

4
Pediatric Acquired Heart Disease
5
Pediatric Acquired Heart Disease
6
Pediatric Acquired Heart Disease
7
Pediatric Acquired Heart Disease
8
Pediatric Acquired Heart Disease
9
Pediatric Acquired Heart Disease
10
Kawasaki Disease - Mucocutaneous Lymph Node
Syndrome
11
Kawasaki Disease - Epidemiology
  • 9/100000 for the white American population
  • Boys Girls 1.51
  • 80 under 5y and over 1 year
  • Increase risk for coronary aneurism under 1y/o
    and over 8y/o
  • Clusters in winter and spring.

12
Kawasaki Clinical Criteria
13
Kawasaki Disease Stages of Cardiovascular
Pathology
  • Stage 1 (09 days)   Microvascular
    angiitis   Acute endoarteritis and
    perivasculitis of major coronary
    arteries   Pericarditis, valvulitis, and
    endocarditis   Myocarditis including
    atrioventricular conduction system   Causes of
    death heart failure and dysrhythmiaStage 2
    (1225 days)   Panvasculitis of major coronary
    arteries with aneurysms and thrombus
  • formation   Intimal proliferation of
    coronary arteries   Myocarditis, endocarditis,
    and pericarditis   Causes of death same as in
    stage 1 also myocardial infarction, aneurysm
  • ruptureStage 3 (2831
    days)   Granulation of coronary
    arteries   Marked intimal thickening   Disappear
    ance of microvascular angiitis   Cause of death
    myocardial infarctionStage 4 (40 days to 4
    years)   Scarring, stenosis, calcification, and
    recanalization of major coronary
  • arteries   Fibrosis of myocardium and
    endocardium   Cause of death myocardial
    infarction

14
Kawasaki Coronary Pathology
15
Kawasaki - Treatment
  • Acute phase High dose IVIG with high dose
    Aspirin (50-100 mg/kg)
  • Subsequent treatment Antiplatelet dose of
    Aspirin 3-5 mg/kg.
  • Steroids only in IVIG resistant cases.
  • Anticoagulation - Warfarin if aneurismatic
    changes occur.

16
Pediatric Acquired Heart Disease
  • 7 y/o male
  • Fever up to 38.8 c
  • Right ankle and later left knee arthritis.
  • New systolic murmur
  • s/p Partially treated sterp A tonsilitis 1 month
    ago.

17
Pediatric Acquired Heart Disease
18
Pediatric Acquired Heart Disease
19
Pediatric Acquired Heart Disease
  • Acute phase reactant ESR, CRP
  • Evidence of recent Strp A infection ASLO,
    throat culture, rapid antigen test, Anti DNAase
    b.
  • ECG prolong PR interval
  • Echocardiography Valvulitis, Myo/pericarditis,
    Functional heart assessment.

20
Rheumatic Fever 1st Deg AVB
21
Acute Rheumatic Fever
  • Most Common acquired heart disease in developing
    countries 300-500/100000.
  • Rate in the Developed world dropped to nearly o
    at the 1980s with improved life quality and
    penicillin treatment and came up to 0.5-3/100000.

22
Acute Rheumatic Fever
  • Patients 5-14 years consist of 72 of the cases.
  • Mortality dropped from 8-30 to zero.
  • Acute Rheumatic Fever licks the joint and bites
    the heart.

23
Acute Rheumatic Fever Diagnostic Criteria
60-90
70
10-30
0-5
0-5
24
Acute Rheumatic Fever Carditis
  • Found in 60-90 of cases
  • Mainly Valvulitis
  • 30-70 long term morbidity
  • Mitral Valve most commonly affected
  • Aortic Valve more specific for diagnosis.
  • Acute heart damage is not influenced by the
    treatment.

25
Acute Rheumatic Fever Arthritis
  • 2-5 weeks latent period s/p group A streptococcus
    infection.
  • Large joint migratory polyarthritis
  • Rapid response to anti inflammatory treatment.
  • No long term morbidity.

26
Acute Rheumatic Fever Sydenham Chorea (st.
Vitus Dance)
  • Inflammation involving the basal ganglia,
    cerebral cortex and cerebellum.
  • Diagnostic as single criteria.
  • Self limited disease.

27
Acute Rheumatic Fever Subcutaneous Nodules
  • Not pathognomonic (could appear in SLE, RA)
  • Last 1-10 days, associated with carditis.

28
Acute Rheumatic Fever Erythema Marginatum
  • Will appear in less then 5 of cases.
  • Associated with carditis

29
Acute Rheumatic Fever Primary Treatment
  • 10 days penicillin to eradicate GAS.
  • High dose Aspirin (50-100 mg/kg/day) until
    clinical and laboratory evidence of inflammation
    resolve.
  • If severe carditis Steroid (prednisone
    2mg/kg/day for 2 weeks and taper down)

30
Acute Rheumatic Fever Secondary Prophylaxis
  • Benzathine penicillin G   1.2 million units
    intramuscularly every 34 weeks
  • Or
  • Phenoxymethylpenicillin (penicillin V)   250
    mg orally BID
  • Or
  • Sulfadiazine Or sulfisoxazole   0.5 g orally
    daily for patients 27 kg   1 g orally daily for
    patients gt27 kg
  • Penicillin- and sulfa-allergic patientsErythromyc
    in   250 mg orally BID
  • Category Duration
  • RHD (clinical or echo) 10 y since
    last episode and at least until age 40 y
    possibly lifelong
  • RF with carditis, but no RHD 10 y or well
    into adulthooda
  • RF without carditis 5 y or
    until age 21 y

31
Pediatric Acquired Heart Disease
  • 12 y/o healthy female
  • Fever up to 38.8 c
  • Pallor, Weakness, Red urine
  • Right ankle and later left knee arthralgia.
  • New systolic murmur.
  • Known small restrictive VSD.

32
Pediatric Acquired Heart Disease
33
Pediatric Acquired Heart Disease
  • 3/6 Systolic Murmur over the precordium,
    radiating to the axilla.
  • Splinter hemorrhages are seen at the tip of the
    nails.

34
Pediatric Acquired Heart Disease
35
Pediatric Acquired Heart Disease
  • Laboratory test
  • CBC Leukocytosis, Anemia
  • ESR, CRP Elevated
  • Blood Cultures At least 3 different sets over
    24h
  • Hematuria

36
Pediatric Acquired Heart Disease
Roth spots
37
Pediatric Acquired Heart Disease
38
Infective Endocarditis - Epidemiology
  • 0.3/100000 children/year.
  • Mortality 11.6
  • Increase in number of cases with previous
    congenital heart disease in the developed
    countries. (VSD, TOF, PDA, AS are the major)

39
Infective Endocarditis Diagnostic Criteria -
Duke
  • Definite infective endocarditis (IE)
  • Pathologic criteria
  • Micro-organisms demonstrated by culture or
    histologic examination of a vegetation, a
    vegetation that has embolized, or an intracardiac
    abscess specimen or
  • Pathological lesions vegetation or intracardiac
    abscess confirmed by histologic examination
    showing active endocarditis
  • Clinical criteria
  • 2 major criteria or
  • 1 major criterion and 3 minor criteria or
  • 5 minor criteria
  • Possible IE
  • 1 major criterion and 1 minor criterion or
  • 3 minor criteria
  • Rejected IE
  • Firm alternative diagnosis explaining evidence of
    IE or
  • Resolution of IE syndrome with antibiotic therapy
    for 4 days or
  • No pathologic evidence of IE at surgery or
    autopsy, with antibiotic therapy for 4
  • days or does not meet criteria for possible IE
    as above

40
Infective Endocarditis Diagnostic Criteria -
Duke
  • Major criteria
  • Blood culture positive for infective endocarditis
    (IE)
  • Typical micro-organisms consistent with IE from 2
    separate blood cultures
  • Viridans streptococci, Streptococcus bovis, HACEK
    group, Staphylococcus aureus or
  • Community-acquired enterococci in the absence of
    a primary focus or
  • Micro-organisms consistent with IE from
    persistently positive blood cultures defined as
    follows
  • At least 2 positive cultures of blood samples
    drawn gt12 h apart or
  • All of 3 or a majority of 4 separate cultures of
    blood (with first and last sample drawn 1 h
    apart)
  • Single positive blood culture for Coxiella
    burnetii or antiphase-1 IgG antibody titer
    gt1800
  • Evidence of endocardial involvement
  • Echocardiogram positive for IE (TEE recommended
    for patients with prosthetic valves, rated at
    least possible IE by clinical criteria, or
    complicated IE paravalvular abscess TTE as
    first test in other patients) defined as follows
  • Oscillating intracardiac mass on valve or
    supporting structures, in the path of regurgitant
    jets, or on implanted material in the absence of
    an alternative anatomic explanation or
  • Abscess or
  • New partial dehiscence of prosthetic valve
  • New valvular regurgitation (worsening or changing
    or pre-existing murmur not sufficient)

41
Infective Endocarditis Diagnostic Criteria -
Duke
  • Minor
    criteria
  • Predisposition, predisposing heart condition, or
    injection drug use
  • Fever, temperature gt38C
  • Vascular phenomena, major arterial emboli, septic
    pulmonary infarcts, mycotic aneurysm,
    intracranial hemorrhage, conjunctival
    hemorrhages, and Janeway lesions
  • Immunologic phenomena glomerulonephritis, Osler
    nodes, Roth spots, and rheumatoid factor
  • Microbiologic evidence positive blood culture,
    but does not meet a major criterion as noted
    above or serologic evidence of active infection
    with organism consistent with IE
  • Echocardiographic minor criteria eliminated

42
Infective Endocarditis Etiologic Agents
  • Agent
    Frequency
  • Streptococci
  • a-Hemolytic
    Most common
  • ß-Hemolytic
    Uncommon
  • Enterococci
    Rare
  • Pneumococci
    Rare
  • Others
    Uncommon
  • Staphylococci
  • S. aureus Second
    most common
  • Coagulase-negative
    Uncommon, but increasing
  • Gram-negative agents
  • Enterics
    Rare
  • Pseudomonas species
    Rare
  • HACEKa
    Rare
  • Neisseria species
    Rare
  • Fungi
  • Candida species
    Uncommon
  • Others
    Rare

43
Infective Endocarditis Treatment
  • Prolong antibiotic treatment 4-6 w
  • Bactericidal rather than bacteriostatic.
  • Parenteral treatment.
  • Consider surgical treatment for
  • a. Significant embolic events
  • b. Progressive heart failure
  • c. Failure of antibiotic treatment

44
Infective Endocarditis Treatment
  • Start empiric treatment with wide range
    antibiotic.
  • Change antibiotic coverage by blood culture and
    sensitivity of the organism

45
Infective Endocarditis Treatment Native Valve -
Strep
  • Highly penicillin-susceptible viridans group
    streptococci and Streptococcus bovis (MIC 0.12
    µg/mL)
  • Regimen Dosagea
    Route Duration,
    weeks
  • Aqueous crystalline penicillin G 200,000 U/kg
    per 24 h IV in 46 doses 4
  • sodium
  • Or
  • Ceftriaxone sodium 100 mg/kg
    per 24 h IV/IM in 1 dose 4
  • Aqueous crystalline penicillin G 200,000
    U/kg per 24 h IV in 46 doses
    2
  • sodium
  • Or
  • Ceftriaxone sodium 100
    mg/kg per 24 h IV/IM in 1 dose
    2
  • Plus Gentamicin sulfatec 3
    mg/kg per 24 h IV/IM in 3 doses
    2
  • Vancomycin hydrochlorided 40 mg/kg
    per 24 h IV in 23 doses 4
  • Strains of viridans group streptococci and S.
    bovis relatively resistant to penicillin (MIC
    gt0.12 to 0.5 µg/mL)
  • Regimen Dosagea
    Route Duration, weeks
  • Aqueous crystalline penicillin G 300,000 U/24
    h IV in 46 doses 4
  • Sodium
  • Or
  • Ceftriaxone sodium 100 mg/kg
    per 24 h IV/IM in 1 dose 4
  • Plus Gentamicin sulfatec 3
    mg/kg per 24 h IV/IM in 3 doses
    2

46
Pediatric Acquired Heart Disease - Summery
  • Less Common then congenital heart disease.
  • Variable clinical appearance
  • High index of suspicion
  • Early treatment can change the outcome.
  • THANK YOU
About PowerShow.com