Muscle :

Myocarditis and
Pericarditis

Efrida Warganegara

Aetiology and
Transmission

Group B, and to a lesser extend

group A coxsackieviruses and
certain enteroviruses, are the
main viral causes of
myocarditis & pericarditis

Both

condition are seen

principally in adult male and
are important because they
can be mistaken for
myocardial infarction, yet the

Aetiology and
Transmission
Spread

by fecal-oral and
occasionally from pharyngeal
sectretion

Mumps

and influenzae are

less common causes of
myocarditis or pericarditis

Rubella

can causes
myocardiris and associated

Clinical Features and

Pahogenesis

Ingested

coxsackievirus spread
from the pharynx or gut wall to
the lymphatics and then to the
blood

Invasion

of heart or pericardium
takes place across blood vessels
and result in acute inflamation.

In

the heart and pericardium this

gives rise to dyspnoe, pain in the
chest, and sometimes mimics a

Diagnosis, treatment and

prevention
Coxsackievirus

may be isolated
from throat swab, fecal specimens
or pericardial fluid

Rising

titres of neutralizing
antibody may be demonstrable, or
the presence of IgM antibodies in
ELISA test

There

are no spesific

JOINT AND BONE INFECTIONS :

1. Reactive Arthritis,
Arthralgia,
and Septic Arthritis
2. Osteomyelitis

Reactive Arthritis, Arthralgia,

and Septic Arthritis
Aetiology, pathogenesis, diagnosis, and
treatment
Joints

and bones will be considered separately

for convinience, but joint lesions often spread
to involved neighbouring bone, and vice versa
Joints can become infected by the
hematogenous route or directly following
trauma or surgery, but in many cases the
condition is immunologically mediated rather
than due to microbial invasion of the joints
The microbe responsible is at a distant site in the
body, and it is a reactive arthritis

Aetiology, pathogenesis, diagnosis, and

treatment
Arthritis and Arthralgia occur after
certain enteric bacterial infections, and
Arthralgia in rubella & hepatitis B infection is of
similar origin
In this type of arthritis more than one joints is
usually affected
Ankylosing Spondylitis is ssociated with Klebsiella
infection
There is no evidence that rheumatoid arthritis is
caused by either viruses or mikrobes.
Circulating bacteria sometimes localized in joints,
especially following trauma can cause
supurative (septic) arthritis generally a single
joint is involved
Reactive

Aetiology, pathogenesis, diagnosis, and

treatment
Joints

are very susceptible, particularly if they

are already damaged for instance by
rheumatoid arthritis, or if prothesis has
been inserted
Knee are most commonly affected, followed by
hips, ankle and elbows
Patients show fever, joint paint, limitation of
movement, swelling, and usually a joint
effusion.
Bacteria can be isolated from the joint fluid
(seen in the centrifuged deposites), and the
commonest organism is Stapylococcus aureus.
`

Osteomyelitis
Aetiology & Pathogenesis
As

with Joint, infection can be by direct route (from

a nearby focus of infection, after fracture, after
orthopedic surgery) or from circulating microbes
The commonest cause of hematogenous
osteomyelitis is Staphylococcus aureus, but when
infection is from a neighbouring site it is generally
mixed with Gram (-) rod and occasionally
anaerobes also present
Accute osteomyelitis typically involves the growing
end of a long bone, where sprouting capillary loops
adjacent to epiphysial growth plates promote the
localization of circulating bacteria tends to be a
disease of children and adolescent

Osteomyelitis

Clinical features, diagnosis, and

treatment
There is a painful tender bone lesion and
generally febril illness.
Diagnosis is from blood cultute taken before
sytart of antimicrobial therapy or when
there is an open lesion, from a bone biopsi
Periosteal reaction and bone loss maybe
visible radiologically
Treatment is begun on a most likely basis
cloxacillin for penicillinase-producing S.
aureus, as soos as microbiological sample
have been taken

Osteomyelitis

Clinical features, diagnosis, and

treatment
Osteomyelitis become chronic, especially
when there are necrotic bone fragments to act
as a continued source of infection
Surgical intervention fot the debridement and
drainage, as well as prolonged courses of
antibiotics may be necessary
Tuberculosis may affect the spine, the hop, the
knee, or the bones of the hands and feet
Constitutional disturbances are often absent,
but the site is generally painful and pressure
from a tuberculous abscess in the spine can
cause paraplegi.

INFECTIVE
ENDOCARDITIS

EFRIDA WARGANEGARA

INTRODUCTION

Infective endocarditis is an uncommon

disease that often present as a Pyrexia
of Unknown Origin (PUO), and is fatal if
untreated

Infection involves the endothelial lining

of the heart, including the heart valves

Occurs as an acute, rapidly progressive

disease or subaccute form

Introduction - continue
In

about 1/3 of patient, there is a

pre-existing : - heart defect
(congenital; acquired : result of
rheumatic fever) or a prosthetic
heart valve insitu

However,

the patient may be

unaware of any defect prior to
the infection

Etioloic Agent in Infective Endocarditis

Percentage of
Agent
Cases
Streptococci
60-80
Viridans streptococci
30-40
Enterococci
5-18
Other streptococci
15-25
Staphylococci
20-35
Coagulase-positive
10-27
Coagulase-negattive
1-3
Gram-negative aerobic bacilli
1.5-13
Fungi
2-4
Miscellaneous bacteria
<5
Mixed-infection
1-2
"culture negative"
<5-24

Aetiology
Almost

any organism can cause

endocarditis, but infection of native
valves is caused most commonly by
species of Oral Streptococci :
Viridans streptococcus (Strep.
sanguis, Strept. oralis, Strept. mitis)

Alfa-hemolytic

(but they may be

nonhemolytic), most prevalent
members of the normal flora of the
URT and important for the healthy

About

1/4 - 1/3 of cases are

caused by Staphylococcus,
alhough this fraction is higher in
intravenous drug abusers.
have a higher incidence of Gram
(-) and fungal endocarditis
arising from m.o. that they inject
into themeselves

Coagulase-negative

Staphylococcus are common

causes of early prostheticvalves endocarditis and are
probably acquired at the time of
surgery
The

species causing late infection

(>3 months) after cardiac
surgery resemble more closely

Pathogenesis
Endocarditis

is an endogenous infection
acquired when m.o. entering the
bloodstream establish themselves on
the heart valves. Thus any bacteriemia
may potentially result in endocarditis

Most

commonly streptococcus from the

oral flora enter the bloodstream (during
dental procedure or vigourus teeth
cleaning or flossing), and adhere to
damaged heart valves

In

the course of the bacteriemia,

viridans streptococci, penumococci, or
enterococci may settle on normal or
previously deformed heart valves
producing Accute Endocarditis
endocarditis often
involves abnormal valves
(congenital deformities and rheumatic,
or atherosclerotic lesion).
Subaccute endocarditis, most
frequently due to members of the

Subaccute

Subaccute Bacterial Endocarditis (SBE)

Viridans

streptococcus ordinarily the most

prevalen members of the upper resp trac
flora, are also the most frequent cause of
SBE

Group

D streptococcus (enterococcus and

S. bovis) also are common causes SBE,
that 5-10% cases are due to enterococcus
originating in the gut or urinary trac.

The

lesion is slowly progressive,

and a certain amount of healing
accompanies the active
inflammation : vegetation
consist of fibrin, platelet, blood
cells, and bacteria adherent to
the valve leaflets
multiplication attract further
deposition of fibrin and platelet
they are protected from the host
defences and vegetation can
grow to several centimeters in

The

clinical course is gradual,

quite slow process and
correspondingly the time period
between the initial bacteriemia
and the onset of symptom is
around 5 weeks

The

disease is variably fatal in

untreated cases

Clinical Feature
The

patient almost always has a fever,

anemia, weakness, a heart murmur,
embolic phenomena, and enlarged
spleen and renal lesion

Also

complain of nonspesific sympyom :

anorexia, weight loss, malaise, chills,
nausea, vomiting, and night sweats

Periheral

manifestation may also be

evident in the form of splinter
haemorrhages and Oslers nodes

Diagnosis
The

blood culture is he single

most important laboratory test.

Ideally

3 separate samples of
blood should be collected within a
24-hour periode and before
antimicrobial therapy

Isolation

of the causative is
essentially to enable antibiotic
susceptibility test to be

Treatment and Prevention

To

complete eradication takes

several weeks
Penicillin for susceptibility
streptococcus is a choice, if
allergy erythromycin
For enterococus : combination
penicillin/ampicillin with
aminoglycoside
For staphylococcus : b-lactamase
stable penicillin (oxacillin, may be

Treatment and Prevention

Prevention

: people with
known heart defect should be
given prophylactic antibiotic
to protec them during dental
surgery and any other
invasive procedure that is
likely to cause a transient
bacteriemia

Rheumatic Fever and

Rheumatic Heart
Disease

Efrida Warganegara

Rheumatic Fever
This

is an indirect complication,
most serious sequele of Strep.
Pyogenes because it result in
damage to heart muscle and
valves

Pharyngeal

infection with Bhemolytic group A streptococci is

followed frequently by the
development of antistreptococcal
antibodies, and if there is a

Rheumatic Fever
Antibodies

are formed to antigens in

the streptococcal cell wall which
cross-react with the sarcolemma of
human heart, and with tissues
elsewhere

The

onset of rheumatic fever is often

preceded by S. pyogenes infection 14 weeks earlier, although the
infection may be mild and may not
detected

In

general, however, patients with

Symptom and Sign

Typical

symptom and sign RF include

fever, malaise, a migratory
nonsuppurative polyarthritis, and
evidence of inflamation of all parts of
the heart (endo-, myo-, peri-cardium)

The

carditis characteristically leads to

thickened and deformed valves and to
small perivascular granulomas in the
myocardium (Ashoffs bodies) that are
finally replaced by scar tissues

Symptom and Sign

Granuloma

are formed in the heart

(Aschoffs nodule) and 2-4 weeks
after the sore throat the patient
(usually children) develops
myocarditis or pericarditis

Perhaps

subcutanous nodules,
polyarthritis and rarely chorea, a
disease of the central nervous
system (CNS) that can be caused

Symptom and Sign

Erythrocyte

sedimentation rates,
serum transminase levels, ECG,
and other test are use to estimate
rheumatic activity

Rheumatic

fever has a marked

tendency to be reactivated by
recurrent streptococcal infections.

The

first attack of RF usually

produces only slight cardiac

Rheumatic Heart
Disease

Repeated attacks of Strep. pyogenes

with different M type can result in
damage to the heart valves

Certain

children have a genetic

predisposition to this immune-mediated
disease.

If

a primary attack is accompanied by

rising or high antistreptolysin O (ASO)
antibody levels, future attacks must be
prevented by penicillin prophylaxis
throughout chilhood.

Terima Kasih