CVS PRC 1

Universiti Teknologi MARA

Faculty of Medicine

BACHELOR OF MEDICINE & BACHELOR OF SURGERY

(MBBS 240)

Session: 2021/22
Year 1
Semester 2

CARDIOVASCULAR SYSTEM MODULE

MICROBIOLOGY AND PARASITOLOGY

PRACTICAL & SGS

INFECTIVE ENDOCARDITIS

Date: 7th JULY (WEDNESDAY)

Time: 10.00 AM – 12:00 PM

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PRACTICAL: INFECTIVE ENDOCARDITIS

This practical session consists of THREE cases on infections of the cardiovascular system.

Part A 3 Cases

Part B Fixed learning resources

Part A

Case 1

A 20-year-old man was admitted to the ward with complaints of fever and malaise.
His problems started after he had dental abscess one month ago. On examination,
he had cardiac murmur and splinter haemorrhages. He has an underlying chronic
rheumatic heart disease. Blood was taken for culture and sensitivity.

Plate A (Blood agar): The plate showing the causative organism isolated on blood
agar.

1. Describe the colonial morphology of the organism isolated from the blood.

Alpha haemolysis with greenish colonies resistance to optochin

2. Perform a gram-stained smear of the organism isolated. Describe the microscopic

appearance of the organism seen in the gram stain smear.

Gram positive cocci arranged in short chain

3. What is the most likely causative organism? Give your reasons.

Viridans group streptococci because in blood agar, it resistance to optochin

4. How would you confirm the identity of this organism in the laboratory?

Blood culture, ELISA, PCR

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5. What is the most likely diagnosis?

IE

6. State the antibiotic/antibiotics to treat this infection.

Penicillin + gentamicin

7. How would you prevent the infection in this patient?

Improve oral hygiene especially to reduce bacteremia after tooth brushing

Case 2

A group of young men were caught in underground store of a supermarket. One of

them was brought to the hospital because he complained of weakness and
headache. On examination, he was found to have high temperature and multiple
puncture wounds over both of his cubital fossa. Blood was taken for culture and
sensitivity. An echocardiogram was also performed to help in the clinical diagnosis.

Plate B (Blood agar): The plate showing the causative organism isolated on blood
agar.

1. Describe the colonial morphology of the organism.

Round golden yellow colonies surrounded by wide zone of beta haemolysis

2. Perform a gram-stained smear of the organism isolated. Describe the microscopic

appearance of the organism seen in the gram stain smear.

Gram positive cocci arranges in grapelike clusters……………………………………………

3. What is the most likely causative organism?

Staphylococcus aureus…………………………………………………………………………….

4. What is the predisposing factor of this patient to acquire the infection?

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IDU – tricuspid valve, primarily a consequence of healthcare contact (eg:

intravascular catheters, surgical wounds, indwelling prosthetic devices, mainly left
sided)…………………………………………………………………………………………………..

5. What do you expect to see in the echocardiogram that helps to confirm the
diagnosis?

Vegetations on echocardiogram that lead to production of heart murmur…………..

6. Name ONE (1) other organism that is commonly associated in this group of patient.

Pseudomonas aeruginosa ___________________________________________________

7. State ONE (1) antibiotic that can be used to treat this infection.

Daptomycin _________________________________________________________________

Case 3

A 45-year-old farmer complained of fever and lethargy for 4 weeks. He has a

previous history of prosthetic valve replacement for chronic rheumatic heart
disease. On physical examination, he has a cardiac murmur. Further investigation
shows the vegetation seen on echocardiogram. A diagnosis of infective
endocarditis was made. Blood was taken for microbiological investigations.

Examine the table provided and answer the following questions.

Exhibit A: Table showing the results of blood culture and sensitivity.

Exhibit B: Table showing the results of the serological test.

Exhibit A Exhibit B

Blood culture results Serological test results

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Blood Culture of aerobic bottle: Coxiella burnetti antibody titre of 1:800 – positive
No growth after 5 days of incubation.
Brucella abortus antibody titre of 1:16 - negative
Blood culture of anaerobic bottle:
No growth after 5 days of incubation.

1. Interpret the blood culture results in relation with this patient’s diagnosis. (Exhibit A)
All blood cultures are negative at 5 days indicate there is more BCNIE or Fungal
IE

2. Interpret the serological results in relation with this patient’s diagnosis. (Exhibit B)

3. State ONE (1) reason for the negative blood culture in this patient.

Because of the infection with fastidious organisms or fungi or HACEK organisms

4. State TWO (2) risk factors that this patient has.

Undergoes a prosthetic valve replacement, have a chronic rheumatic disease

5. State the general principles of antibiotic treatment.

1. Parenteral antimicrobials in high dose to sustain antibacterial
concentrations for treatment success (intravenous not oral)
2. Bactericidal antimicrobials for effective treatment (combination of
antibiotics for synergistic effects)
3. Adequeate duration is required to prevent relapses and ensure killing of
bacteria (long term: 2- 6 weeks)

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PART B

Fixed learning resources

Exhibit B1: Track marks.

Exhibit B2: Blood culture bottles