Ambulatory Report – 12.20.16 – Stroke, Syphilis, and Endocarditis!

Thanks to LT who presented a case of a 50yo M from Japan without signif PMH, who presented with new L hemispheric stroke, and ultimately found to have syphilis endocarditis!
  • LT Pearl:  Stroke is never a stroke until you’ve given 50 of D50.
  • Stroke Basics: Standard large vessel stroke workup
    • CBC, coags, lipids, A1c
    • Cardioembolic: afib, clot in heart, paradoxical embolus
      • EKG, Tele
        • +/- outpatient holter/ziopatch to look for occult a-fib/flutter
        • Used to be 48 hours tele, recent UCSF study suggests longer tele with ziopatch better
      • TEE with bubble study
    • Aortic arch
      • TEE with bubble study
    • Carotids
      • CTA vs US vs MRA vs angio
      • Benefit of endarterectomy in pts w/ sx ipsilateral to 70-99% stenosis
    • Intracranial vessels
      • intracranial imaging (CTA, MRA, angio)
    • AND evaluate stroke risk factors
      • DM
      • Lipid panel
    • TEE vs TTE
      • Seminal study in Europe: 231 TIA/stroke patients had TTE AND TEE — 127 found to have cardiac source of emboli – 70% seen only on TEE and not TTE
      • What we do at UCSF
        • Age < 55 years old: straight to TEE because higher risk for cardioembolic source
        • Age > 55 years: surface TTE first, only if suspicion proceed to TEE
    • Can consider hypercoaguable workup in a young person if concern for APLS etc
  • Culture Negative Endocarditis
    • HACEK organisms are no longer as common b/c they can be cultured after 5d of incubation
    • Thank you to Rabih for his BBCCTT acronym (looks like we should at S to that for SYPHILIS!)
      • Bartonella
      • Brucella
      • Chlamydophila psittaci
      • Coxiella Burnetti (Q fever)
      • Tropheryma while
      • TB
      • Syphilis
  • Reminder about the Surgical Indications for Infective Endocarditis (from Hoen & Duval, NEJM 2013)
    • Heart Failure
      • Cardiogenic shock (emergent)
      • Severe regurg & poor hemodynamics (urgent)
      • Severe regurg & controlled HF (elective)
    • Uncontrolled Infection
      • local infection (ie. myocardial abscess) (urgent)
      • persistent fever/positive BCx for >5-7d (urgent)
      • Infection by fungi, pseudomonas, MDR organisms (elective)
    • Prevention of embolism
      • Veg > 1cm and >= embolic event despite ABx (especially < 2 wks) (urgent)
      • Veg > 1cm and other complications (CHF, persistent infection) (urgent)
      • Isolated Vegetation > 1.5m (urgent)

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