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Questions and Answers
What is the most common late manifestation of Lyme disease?
What is the most common late manifestation of Lyme disease?
Which organism is noted for producing FimA, facilitating adherence to the endocardium?
Which organism is noted for producing FimA, facilitating adherence to the endocardium?
What is a notable complication associated with Stage 2 Lyme disease?
What is a notable complication associated with Stage 2 Lyme disease?
Which feature of endocarditis-causing streptococci assists in binding to platelet-fibrin complexes?
Which feature of endocarditis-causing streptococci assists in binding to platelet-fibrin complexes?
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In Lyme disease, when is the optimal time for antibiotic therapy to clear the infection?
In Lyme disease, when is the optimal time for antibiotic therapy to clear the infection?
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What is a primary challenge in diagnosing Lyme disease?
What is a primary challenge in diagnosing Lyme disease?
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How does the exposure of fibronectin influence microbial adherence during endocarditis?
How does the exposure of fibronectin influence microbial adherence during endocarditis?
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What post-treatment effect is commonly observed in a significant proportion of Lyme disease patients?
What post-treatment effect is commonly observed in a significant proportion of Lyme disease patients?
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What is the primary composition of vegetations in acute bacterial endocarditis?
What is the primary composition of vegetations in acute bacterial endocarditis?
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Which organism is commonly associated with acute bacterial endocarditis?
Which organism is commonly associated with acute bacterial endocarditis?
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What symptom occurs in 80 – 90% of infective endocarditis cases?
What symptom occurs in 80 – 90% of infective endocarditis cases?
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What is a common peripheral manifestation of infective endocarditis?
What is a common peripheral manifestation of infective endocarditis?
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What describes the typical progression of subacute bacterial endocarditis?
What describes the typical progression of subacute bacterial endocarditis?
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What distinguishes Borrelia burgdorferi in terms of its biological needs?
What distinguishes Borrelia burgdorferi in terms of its biological needs?
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Which condition is NOT a risk factor for developing non-bacterial thrombotic endocarditis (NBTE)?
Which condition is NOT a risk factor for developing non-bacterial thrombotic endocarditis (NBTE)?
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What is the most common clinical feature of infective endocarditis?
What is the most common clinical feature of infective endocarditis?
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Which microbe is primarily responsible for myocarditis?
Which microbe is primarily responsible for myocarditis?
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Which feature of acute bacterial endocarditis relates to its physiological impacts?
Which feature of acute bacterial endocarditis relates to its physiological impacts?
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What is a characteristic feature of acute pericarditis that differentiates it from myocardial infarction?
What is a characteristic feature of acute pericarditis that differentiates it from myocardial infarction?
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Which treatment approach is typically used for managing idiopathic or viral pericarditis?
Which treatment approach is typically used for managing idiopathic or viral pericarditis?
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What is a common cause of constrictive pericarditis following acute pericarditis?
What is a common cause of constrictive pericarditis following acute pericarditis?
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Which statement correctly describes pericardial tamponade?
Which statement correctly describes pericardial tamponade?
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In myocarditis, which of the following outcomes is most commonly associated with severe inflammation of the myocardium?
In myocarditis, which of the following outcomes is most commonly associated with severe inflammation of the myocardium?
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Which of the following is rarely a cause of myocarditis but can have serious implications?
Which of the following is rarely a cause of myocarditis but can have serious implications?
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What is often observed in the ECG findings of acute pericarditis?
What is often observed in the ECG findings of acute pericarditis?
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Which scenario is most likely to result in cardiac tamponade?
Which scenario is most likely to result in cardiac tamponade?
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Which feature distinguishes constrictive pericarditis from other types of pericarditis?
Which feature distinguishes constrictive pericarditis from other types of pericarditis?
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Which statement accurately represents the presentation of acute pericarditis?
Which statement accurately represents the presentation of acute pericarditis?
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Which of the following statements about acute pericarditis is most accurate?
Which of the following statements about acute pericarditis is most accurate?
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What distinguishes constrictive pericarditis from acute and subacute pericarditis?
What distinguishes constrictive pericarditis from acute and subacute pericarditis?
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Which of the following is a major virulence factor of Coxsackie virus?
Which of the following is a major virulence factor of Coxsackie virus?
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What role does Staphylococcus epidermidis play in endocarditis?
What role does Staphylococcus epidermidis play in endocarditis?
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In postural-tachycardia syndrome (POTS), which physiological change is most characteristic?
In postural-tachycardia syndrome (POTS), which physiological change is most characteristic?
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Which stage of the Ixodes tick lifecycle is most associated with the transmission of Lyme borreliae to humans?
Which stage of the Ixodes tick lifecycle is most associated with the transmission of Lyme borreliae to humans?
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What characteristic of Borrelia burgdorferi allows it to evade the immune system effectively?
What characteristic of Borrelia burgdorferi allows it to evade the immune system effectively?
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When do nymphal ticks primarily feed on infected rodents to facilitate the transmission cycle of Lyme disease?
When do nymphal ticks primarily feed on infected rodents to facilitate the transmission cycle of Lyme disease?
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In which environment do Borrelia burgdorferi tend to hide and multiply within the host?
In which environment do Borrelia burgdorferi tend to hide and multiply within the host?
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What is one of the primary functions of the pericardium?
What is one of the primary functions of the pericardium?
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What is the primary method of Lyme borreliae transmission from ticks to the next generation of ticks?
What is the primary method of Lyme borreliae transmission from ticks to the next generation of ticks?
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Which type of inflammation is characterized by a shaggy-looking inflammatory exudate on the heart's surface?
Which type of inflammation is characterized by a shaggy-looking inflammatory exudate on the heart's surface?
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Acute pericarditis is most commonly caused by which of the following?
Acute pericarditis is most commonly caused by which of the following?
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What is a distinguishing feature of pericardial effusion compared to acute pericarditis?
What is a distinguishing feature of pericardial effusion compared to acute pericarditis?
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Which condition is least likely to be a direct cause of acute pericarditis?
Which condition is least likely to be a direct cause of acute pericarditis?
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The clinical feature of chest pain in acute pericarditis is often characterized as what?
The clinical feature of chest pain in acute pericarditis is often characterized as what?
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In which age group is acute pericarditis more likely to occur?
In which age group is acute pericarditis more likely to occur?
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Which type of fluid accumulates in the pericardium as a result of acute pericarditis?
Which type of fluid accumulates in the pericardium as a result of acute pericarditis?
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What is one of the common accompanying symptoms of the erythema migrans rash in Lyme disease?
What is one of the common accompanying symptoms of the erythema migrans rash in Lyme disease?
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Which organ system is least likely to be affected during Stage 2 Lyme disease?
Which organ system is least likely to be affected during Stage 2 Lyme disease?
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What is a characteristic of post-treatment Lyme disease syndrome?
What is a characteristic of post-treatment Lyme disease syndrome?
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Which of the following statements about the virulence factors of streptococci causing endocarditis is true?
Which of the following statements about the virulence factors of streptococci causing endocarditis is true?
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What is a major challenge when diagnosing Lyme disease in patients?
What is a major challenge when diagnosing Lyme disease in patients?
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What anatomical feature facilitates the adherence of endocarditis-causing streptococci to thrombotic vegetations?
What anatomical feature facilitates the adherence of endocarditis-causing streptococci to thrombotic vegetations?
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Which symptom is associated with Stage 3 Lyme disease?
Which symptom is associated with Stage 3 Lyme disease?
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Which factor contributes to the difficulty in diagnosing Lyme disease using serologic tests?
Which factor contributes to the difficulty in diagnosing Lyme disease using serologic tests?
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Which symptom is most characteristic of acute pericarditis compared to myocardial infarction?
Which symptom is most characteristic of acute pericarditis compared to myocardial infarction?
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What is the primary diagnostic method used for acute pericarditis?
What is the primary diagnostic method used for acute pericarditis?
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Which complication is most commonly associated with untreated acute pericarditis?
Which complication is most commonly associated with untreated acute pericarditis?
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Which statement about pericardial fluid accumulation is correct?
Which statement about pericardial fluid accumulation is correct?
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In acute pericarditis, which pattern of ECG findings is typically unexpected for myocardial infarction?
In acute pericarditis, which pattern of ECG findings is typically unexpected for myocardial infarction?
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What is a common infectious cause of myocarditis?
What is a common infectious cause of myocarditis?
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Which drug class is NOT typically used for managing idiopathic or viral pericarditis?
Which drug class is NOT typically used for managing idiopathic or viral pericarditis?
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Which symptom is commonly associated with pericardial tamponade?
Which symptom is commonly associated with pericardial tamponade?
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In which scenario would pericardiocentesis be indicated?
In which scenario would pericardiocentesis be indicated?
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What results from prolonged or untreated inflammation of the pericardium?
What results from prolonged or untreated inflammation of the pericardium?
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What distinguishes the types of infectious agents in bacterial endocarditis regarding their presentation?
What distinguishes the types of infectious agents in bacterial endocarditis regarding their presentation?
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What is a common feature shared by vegetations in acute bacterial endocarditis?
What is a common feature shared by vegetations in acute bacterial endocarditis?
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Which of the following clinical features is most strongly associated with acute bacterial endocarditis?
Which of the following clinical features is most strongly associated with acute bacterial endocarditis?
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Which condition is most likely to lead to the development of non-bacterial thrombotic endocarditis (NBTE)?
Which condition is most likely to lead to the development of non-bacterial thrombotic endocarditis (NBTE)?
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What are Osler nodes in the context of infective endocarditis?
What are Osler nodes in the context of infective endocarditis?
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Which group of organisms is associated with endocarditis but is less virulent than staphylococcus aureus or streptococcal species?
Which group of organisms is associated with endocarditis but is less virulent than staphylococcus aureus or streptococcal species?
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Which neurological manifestation is likely to occur with infective endocarditis due to arterial emboli?
Which neurological manifestation is likely to occur with infective endocarditis due to arterial emboli?
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What is a characteristic sign of the acute phase of bacterial endocarditis?
What is a characteristic sign of the acute phase of bacterial endocarditis?
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Which of the following statements correctly summarizes the characteristics of the HACEK group of organisms?
Which of the following statements correctly summarizes the characteristics of the HACEK group of organisms?
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In a patient with congenitally defective heart structures, what is a likely complication they may develop?
In a patient with congenitally defective heart structures, what is a likely complication they may develop?
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What defines orthostatic intolerance in relation to POTS?
What defines orthostatic intolerance in relation to POTS?
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Which physiological mechanism primarily contributes to the pathophysiology of POTS?
Which physiological mechanism primarily contributes to the pathophysiology of POTS?
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Which clinical feature must be present to meet the diagnostic criteria for POTS?
Which clinical feature must be present to meet the diagnostic criteria for POTS?
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Which statement best describes the clinical implications of orthostatic intolerance in POTS patients?
Which statement best describes the clinical implications of orthostatic intolerance in POTS patients?
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What distinguishes POTS from other dysautonomias?
What distinguishes POTS from other dysautonomias?
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Which of the following factors is significant in diagnosing POTS?
Which of the following factors is significant in diagnosing POTS?
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In the context of POTS, how is a normal blood pressure response defined when standing?
In the context of POTS, how is a normal blood pressure response defined when standing?
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What primary symptom must patients with POTS report when transitioning to standing?
What primary symptom must patients with POTS report when transitioning to standing?
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Which symptom is commonly associated with orthostatic intolerance?
Which symptom is commonly associated with orthostatic intolerance?
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What physiological change occurs in the lower limbs in patients with neuropathic POTS?
What physiological change occurs in the lower limbs in patients with neuropathic POTS?
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Which factor is hypothesized to lead to hypovolemic POTS?
Which factor is hypothesized to lead to hypovolemic POTS?
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What defines the complexity in diagnosing POTS?
What defines the complexity in diagnosing POTS?
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Which demographic is more frequently affected by POTS?
Which demographic is more frequently affected by POTS?
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What is one proposed mechanism for blood pooling in patients with POTS?
What is one proposed mechanism for blood pooling in patients with POTS?
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Which testing method is typically required to diagnose POTS?
Which testing method is typically required to diagnose POTS?
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Which statement reflects the current understanding of POTS subtypes?
Which statement reflects the current understanding of POTS subtypes?
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What does a low aldosterone:renin ratio in POTS patients suggest?
What does a low aldosterone:renin ratio in POTS patients suggest?
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Which physiological change is commonly observed in POTS patients upon standing?
Which physiological change is commonly observed in POTS patients upon standing?
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Which factor is associated with the reduction of blood volume in deconditioned POTS patients?
Which factor is associated with the reduction of blood volume in deconditioned POTS patients?
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What underlying mechanism may lead to excessive norepinephrine secretion in some individuals with hyper-adrenergic POTS?
What underlying mechanism may lead to excessive norepinephrine secretion in some individuals with hyper-adrenergic POTS?
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How might activating auto-antibodies to adrenoreceptors affect patients with hyper-adrenergic POTS?
How might activating auto-antibodies to adrenoreceptors affect patients with hyper-adrenergic POTS?
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What is one common non-pharmacological recommendation for managing POTS symptoms?
What is one common non-pharmacological recommendation for managing POTS symptoms?
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What is a potential therapeutic approach for patients with hypovolemic POTS?
What is a potential therapeutic approach for patients with hypovolemic POTS?
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Which condition may reveal inadequate aldosterone secretion in predisposed individuals suffering from POTS?
Which condition may reveal inadequate aldosterone secretion in predisposed individuals suffering from POTS?
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Study Notes
BMS 200 - Cardiology 9
- Course covers pericarditis, myocarditis, endocarditis, orthostatic, and vasovagal syndromes.
- Outcomes include describing pathogenesis, major clinical features, and prognosis for various heart conditions.
- Specific topics include acute, subacute, and constrictive pericarditis; infectious and non-infectious myocarditis; acute and subacute bacterial endocarditis; and the biology, life cycle, virulence factors, diagnosis, and clinical manifestations of Borrelia burgdorferi, trypanosoma cruzi, and ehrlichia chaffeensis.
- Additional topics include coxsackie virus and echovirus, COVID19 cardiac complications, HACEK group bacteria, Staphylococcus epidermidis and viridans streptococci, and postural tachycardia syndrome (POTS).
Inflammation of Heart Structures
- Pericarditis: Acute, subacute, and constrictive forms.
- Myocarditis: Infectious and non-infectious causes, and an overview of inflammatory causes.
- Endocarditis: Acute and subacute bacterial endocarditis.
Pericardium Recall
- Double-walled sac containing the heart and great vessels.
- Fibrous layer: Tough, inelastic, dense irregular connective tissue.
- Serous layer: Thinner, more delicate, composed of mesothelium with visceral and parietal layers (aka epicardium).
- Functions: Anchors and protects the heart; prevents overfilling; allows friction-free operation.
- Note: Epicardium also contains coronary vessels, nerves, and fat.
- Normal pericardial fluid: 15–50 mL.
Acute Pericarditis
- Most common pathologic process impacting the pericardium, often affecting younger patients.
- Major causes: Viral (Coxsackie A & B, echovirus), bacterial (extensions from pneumonia), fungal (opportunistic), rheumatic fever, autoimmune disorders (RA, SLE, AS), cancer (invasion of pericardium), CKD (increased filtration, excess pericardial fluid), cardiac injury (traumatic/post-infarction), and idiopathic (likely viral).
- General pathogenesis: Excessive extracellular fluid (CHF, CKD) can limit inflammation, resulting in pericardial effusion rather than inflammation. Inflammation can be fibrinous type.
- Clinical features: Severe, sharp chest pain (pleuritic), often better when sitting up and leaning forward, possibly radiating to ischemic chest pain, troponin/ECG changes, pericardial friction rub (raspy, scratchy sound).
- ECG & auscultatory findings (FYI): Note "everywhere" ST elevation, not common in MI.
- Diagnosis: Echocardiography primary method. CT/MRI can provide more detail about pericardial thickening.
- Treatment: High-dose aspirin, NSAIDs, colchicine, steroids.
- Prognosis: Most idiopathic or viral cases self-resolve, with recurrences possible depending on cause. Potential complications: Constrictive pericarditis, recurrences, cardiac tamponade.
- Additional Info: Most cases viral, often occurring 10-12 days after infection; symptoms usually include fever, sharp chest pain; may transition to subacute or constrictive pericarditis (symptoms lasting more than 4-6 weeks). Increased pericardial fluid (up to 2 liters) can be tolerated, while significant pericardial effusions may require pericardiotomy.
Constrictive Pericarditis
- Scarring of pericardium after acute pericarditis.
- Often obliterates the pericardial cavity.
- Can greatly restrict cardiac filling.
- Causes: TB pericarditis, post-traumatic/surgical/radiation pericarditis, neoplastic disease, CKD, or idiopathic.
- Clinical presentation: Often resembles restrictive cardiomyopathy (congestion; typically preserved stroke volume but lower EDV); fatigue, distended neck veins, hepatosplenomegaly.
- Diagnosis: US or MRI.
- Treatment: Pericardial resection.
Pericardial Tamponade
- Severe pericardial fluid accumulation obstructing blood flow into ventricles.
- Causes: Ruptured ventricular aneurysm, severe acute pericarditis, cardiac trauma, aortic dissection.
- Clinical features: Hypotension, muffled heart sounds, distended neck veins, shock.
- Treatment: Urgent pericardiocentesis (fluid removal).
Myocarditis
- Heart inflammation, sometimes causing dilated cardiomyopathy, conduction block, or predisposition to ventricular tachycardia; rarely sudden cardiac death.
- Etiologic agents: Common include viral (echovirus & Coxsackie virus), Lyme disease, trypanosomiasis cruzi (South America), Ricketsia ricketsii, ehrlichia chaffeensis (uncommon but potentially deadly).
- Pathogenesis: Viral invasion of myocytes, cytokine release, and adaptive immune responses can damage heart tissue. Granuloma formation, prolonged cytokine release, and possible immune-mediated attack can cause fibrosis and damage to the extracellular matrix (ECM).
- Clinical Features & Diagnosis: Symptoms and signs of acutely developing heart failure; chest pain; ECG changes (suggestive of pericarditis); atrial or ventricular tachyarrhythmias; progressive dyspnea, weakness; and myalgias. Standard diagnostic tools include ECG, echocardiogram, and troponin. MRI is often useful.
Bacterial Endocarditis
- Infection of the endocardium, often initiated by damaged endocardium, a thrombus, and bacteria.
- The resulting inflammatory mass can damage heart valves, break off and cause strokes, interfere with flow through blood vessels, and cause unique hemorrhagic/ischemic findings (like retinal hemorrhages).
- Typical sequence: Damaged endocardium or abnormal heart surface forms a thrombus; bacteria with virulence factors invade and colonize the thrombus.
- Most common causes: Large bacterial loads (e.g., dental/gingival disease, IV drug use); valvular damage/recent surgery; and congenital heart disease (particularly VSD).
- Types: Acute bacterial/NBTE; infections have immediate/life threatening valve damage, or a less severe subacute presentation.
- Clinical features: Fever, chills, sweats (acute or subacute); anorexia, weight loss; myalgias, arthralgias, back pain; heart murmur (may not be present immediately); arterial emboli; splenomegaly; nail clubbing; neurologic manifestations (and peripheral manifestations); use of Duke criteria to diagnose.
Endocarditis Microbes - General Virulence Factors
-
Streptococci: Extracellular dextrans to adhere to inflamed endothelium.
-
S. aureus: Tissue factor to build clots that may help them get to and stay in the heart,
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HACEK: Gram-negative bugs often found in oral cavity. Fastidious (difficult to grow)bugs.
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Other microbes causing endocarditis, Myocarditis have various virulence mechanisms.
Lyme Disease
- Caused by Borrelia burgdorferi (tickborne spirochete, common in Northern Hemisphere).
- 30,000 new cases in the US.
- Structure: Inner membrane with peptidoglycan layer, outer membrane.
- Infectious process: Larvae transmit to nymphs, nymphs to adults. Humans are not required.
- Virulence factors: Attachment to complement regulatory proteins and variable antigenic surface proteins.
- Life cycle & Virulence: Ticks transmit to rodents. Nymphs and adults also can feed on humans. Important to understand the stages.
- Clinical stages: Stage 1=Erythema migrans rash (often accompanied by fever). Stage 2 involves systemic problems (sometimes months or weeks later); stage 3=arthritis.
- Additional Clinical Details: Post-treatment Lyme disease syndrome is sometimes seen after treatment with antibiotics. Diagnosis is complex.
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Description
Test your knowledge on cardiology topics such as pericarditis, myocarditis, and endocarditis. This quiz covers the pathogenesis, clinical features, and prognosis of various heart conditions, including the impacts of specific pathogens. Review essential details on acute and subacute cases along with emerging complications related to COVID-19.
