Pediatric Examination and Board Review (12 page)

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FIGURE 4-4.
Selected peripheral manifestations of infective endocarditis.
A.
Splinter hemorrhages are linear hemorrhages under the nails that do not reach the nail margin. They are often red for the first two days and brownish thereafter.
B.
Conjunctival hemorrhages.
C.
Osler nodes are tender, erythematous nodules often occurring in the pulp of the fingers.
D.
Janeway lesions are small, flat, irregular spots found on the palms and soles. They are typically erythematous and nontender. (Reproduced, with permission, from Fuster V, O’Rourke RA, Walsh RA, et al. Hurst’s the Heart, 12th ed. New York: McGraw-Hill, Fig. 85-4.)

13.
(A)
The diagnosis of infective endocarditis can be determined by

1. Pathologic evidence either by surgery or embolectomy of an infected thrombus within the heart.

2. Two positive blood cultures with the same organism with no other source other than the heart.

3. A clinical course compatible with infective endocarditis.

Supportive evidence of endocarditis includes laboratory findings of anemia, increased white blood cell count, increased ESR or CRP, hematuria, decreased complement component C3, and increased bilirubinemia. The echocardiogram is useful for detecting intracardiac vegetations. The type of echocardiogram performed, whether it be transthoracic or transesophageal, depends on the age of the patient and the ability to achieve good acoustic windows.

14.
(A)
The most common organism causing infective endocarditis following dental procedures is
Streptococcus viridans
. However,
Staphylococcus aureus
and
Staphylococcus epidermidis
have become important causes of infective endocarditis.
Staphylococcus aureus
is now, overall, the leading cause.
Enterococcus
spp. is also a common cause of endocarditis, particularly in adults. Among patients with burns or IV drug abusers, staphylococci are the most common causative organisms. Infants with sepsis are also at higher risk for endocarditis with no underlying cardiac disease.

15.
(A)
Up to 10% of cases of endocarditis are culture negative. However, in 90% of cases, the causative agent may be identified by obtaining at least 3 blood cultures during the first 24 hours of hospitalization.

16.
(D)
Valvular heart lesions are most commonly associated with predisposition for the development of infective endocarditis; however, other forms of congenital heart disease, including tetralogy of Fallot, ventricular septal defect, patent ductus arteriosus, coarctation of the aorta, and pulmonary valve stenosis, have also been implicated. Congenital heart defects such as atrial septal defect, peripheral pulmonary stenosis, and mitral valve prolapse without mitral regurgitation are not considered to be highrisk lesions for development of infective endocarditis, and thus bacterial endocarditis prophylaxis is not indicated in these situations.

17.
(A)
In patients with suspected infective endocarditis, a course of either vancomycin or oxacillin and gentamicin is started because the most likely organisms include streptococci and staphylococci, depending on the rate of methicillin-resistant
S aureus
in the patient’s geographic area. Once the organism is identified, the antibiotic regimen can be adjusted. Surgical intervention is occasionally required for removal of foreign bodies that are difficult to sterilize with IV antibiotics or repair of valves that have been damaged by infection. Other complications associated with endocarditis include mycotic aneurysms, localized cardiac abscesses, and autoimmune phenomena such as nephritis and arthritis.

18.
(D)
Procedures in which there is a risk for significant bacteremia would require bacterial endocarditis prophylaxis. These procedures include dental procedures where bleeding is anticipated, tonsillectomy, cardiac surgery, incision of infected sites, urologic surgery, and Foley placement in the presence of a urinary tract infection. Endotracheal intubation is not associated with a high incidence of bacteremia and thus antibiotic prophylaxis is not required.

S
UGGESTED
R
EADING

Allen HD, Driscoll DJ, Shaddy RE, Feltes TF, eds.
Moss and
Adams Heart Disease in Infants, Children and Adolescents.
7th ed. Philadelphia, PA: Williams and Wilkins; 2007.

Braunwald E, Zipes DP, Libbey P, eds.
Braunwald: Heart Disease: A Textbook of Cardiovascular Medicine.
7th ed. Philadelphia, PA: WB Saunders; 2004.

Keane JF, Fyler DC, Lock JE, eds.
Nadas’ Pediatric Cardiology.
2nd ed. Philadelphia, PA: Hanley and Belfus; 2006.

Newburger J, Takahashi M, Gerber M, et al. Diagnosis, treatment and long-term management of Kawasaki disease. A statement for health professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association.
Pediatrics.
2004;114:1708-1733.

Park M, ed.
Pediatric Cardiology for Practitioners.
5th ed. St. Louis, MO: Mosby; 2007.

CASE 5: A 10-YEAR-OLD BOY WITH ELEVATED BLOOD PRESSURE ASCERTAINED AT A ROUTINE PHYSICAL EXAMINATION

A 10-year-old boy presents for a preparticipation sports physical examination. He has previously been well with no significant past medical history. His vital signs indicate a heart rate of 101 bpm and a blood pressure of 130/85 mm Hg (greater than the 95th percentile for age). The remainder of his examination is normal.

SELECT THE ONE BEST ANSWER

1.
What is the most appropriate next step?

(A) recheck the blood pressure with a smaller blood pressure cuff

(B) recheck the blood pressure on at least 2 other separate occasions before beginning further evaluation

(C) begin medical therapy with antihypertensive medications

(D) order a renal ultrasound

(E) check serum catecholamine levels

2.
At this age, what is the most common cause of hypertension?

(A) primary familial or idiopathic hypertension

(B) coarctation of the aorta

(C) renal artery thrombosis

(D) renal parenchymal disease

(E) adrenal hyperplasia

3.
Renal parenchymal hypertension is caused by all except which of the following mechanisms?

(A) salt retention

(B) water retention

(C) increased renin levels

(D) excess levels of catecholamines

(E) none of the above cause renal parenchymal hypertension

4.
On the third visit, the patient continues to demonstrate evidence of systemic hypertension with elevated blood pressure recordings. Of the following, which is the most appropriate testing at this time?

(A) urinalysis

(B) serum catecholamine levels.

(C) renal CT scan

(D) urine 17-hydroxy steroids or 17-ketosteroids

(E) all of the above

5.
Which of the following interventions would not be recommended at this time?

(A) stop all exercise

(B) weight reduction

(C) stop tobacco use

(D) salt reduction

(E) all of the above should be recommended

6.
Beta-blockers are useful for treatment of hypertension but are contraindicated in all but which of the following?

(A) patients with asthma

(B) patients with diabetes

(C) hyperthyroidism

(D) bradycardia

(E) severe bee sting allergy

7.
The patient returns with a hypertensive crisis with a systolic blood pressure greater than 180 mm Hg and a diastolic blood pressure greater than 110 mm Hg associated with headache, vomiting, and pulmonary edema. What is the most commonly used medication in this setting?

(A) nitroprusside sodium

(B) captopril

(C) phentolamine

(D) Aldactone

(E) clonidine

8.
A 10-year-old child presents for a sports physical examination. The examination and blood pressure are completely normal. There is a family history of hypercholesterolemia in his mother. What is the most appropriate advice for this patient?