Ovarian vein thrombosis

Ovarian vein thrombosis
Presentation by:Rekha Mody, M.D.

* Post partum Ovarian vein thrombosis
* Pathophysiology-venous stasis and hypercoagulability; recent surgery, malignancy, Crohn’s disease increases probability
* Frequency- diagnosed on the right side in 80-90% of the affected postpartum patients; 1/2000 deliveries; usually within 1 week of birth
* Treatment-anticoagulation and IV antibiotics
* Why it occurs-
o in the immediate post partum period there is retrograde flow in the left ovarian vein and anterograde flow in the right ovarian vein
o The right ovarian vein is longer than the left ovarian vein
o Right ovarian vein many valves that may attract thrombosis
o Ovarian veins enlarge during pregnancy
o Period of stasis after birth
* Complications-
o Ovarian vein thrombophlebitis sepsis
o Thrombus in the IVC pulmonary embolism
References

Ovarian vein thrombosis.ppt

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Disorders of Heart & Blood Vessels

Infectious & Inflammatory Disorders of Heart & Blood Vessels

Rheumatic Fever & Rheumatic Carditis
* Rheumatic fever is a systemic inflammatory disease that occurs as a result of a group A streptococcal infection of the throat
* Rheumatic Carditis refers to the cardiac manisfestations of rheumatic fever

Rheumatic Carditis
* An autoimmune disorder because it occurs after the body is exposed to a bacterial toxin that is similar to antigens within the body’s own tissues.
* Antibodies mistakenly identify the normal cells in the heart and joints and attacks them
* Involves heart, joints and nervous system.
* Occurs more often in children 2 to 3 weeks after streptococcal infection. (strept throat)
* Carditis (inflam. of the layers of heart), polyarthritis, rash, subq nodules, and chorea (involuntary muscle twitching) are the classic symptoms
* Adults do not have same degree of symptoms as children
* Polyarthritis
* Strep Throat
* A mild fever, if untreated, continues for several weeks. Tachycardia and arrhythmias occur r/t the fever.
* A red, spotty rash appears on the trunk but disappears rapidly, leaving irregular circles on the skin
* Several joints (knees, ankles, hips and shoulders) become swollen, red, warm & painful---migrates from joint to joint
* Sometimes marble size nodules appear around the joints.
* Motor disturbances cause involuntary grimacing and an inability to use skeletal muscles in a coordinated manner.
* Heart murmur suggests valve damage, a paricardial friction rub is indictive of pericarditis

Treatment
* Iv penicillin is drug of choice
* Bed rest
* Asa to prevent blood clots
* Steroids—to suppress the inflammatory response
* Tx depends on extent of damage—if arrhythmias or heart failure require extensive Tx: If mild symptoms may not require Tx.
* May require surgery to fix valves

Nursing Care
* Focused cardiac assessments
* diversions for weeks of bed rest (reading, puzzles and minimal activity)
* Must take prophylactic antibiotics before any invasive procedure , including dental to prevent endocarditis
* Susceptible to endocarditis

Infective Endocarditis (Bacterial Endocarditis)
* Inflammation of the inner layer of heart
* Caused by bacteria and fungi--strept and staph most often as found normally on skin, mucous membranes of mouth, nose, throat and other cavities.
* Considered an autoimmune response—not an infection.
* Most pathogens find their way into the blood stream through a cut or break in the skin or mucous membrane.
* Prolonged IV, insertion of pacemaker, cardiac cath, tracheal intubation, cardiac surg, foley cath and IV drug use are portal of entry

Endocarditis
* Once heart is infected, micros congregate around heart valves, chordae tendineae and papillary muscles.
* Fibrin, platelets, and blood cells stick to injured cells forming vegetations. The micros bury themselves in the vegetative mass so difficult for antibiotics to destroy.
* Mitral valve most common location of vegetation & blood leaks between chambers
* Can cause heart failure.
* Vegetations can break off and form emboli (mobile masses of tissue that circulate in the blood stream)
* Emboli may occlude small blood vessels and interfere with an organ’s blood supply.

Assessment Findings
* May have insidious onset with slight fever, headache, malaise, and fatigue.
* As it gets worse, purplish, painful nodules may be on pads of finger and toes. Black longitudinal lines (splinter hemorrhages) seen in nails.
* Spleen may be enlarged and abd. palpation causes pain
* May have heart murmur
* Petechiae (tiny reddish hemorrhagic spots on the skin and mucous membranes) are a sign of embolization
* Pronounced weakness, anorexia and weight loss are common
* Emboli can cause stroke, renal failure, and pulmonary emboli

Medical Management
* High doses of IV antibiotics given 2 to 6 weeks or longer.
* Bed rest Initially. As he improves may have bathroom privileges
* May need valve replacement
* Will have to take periodic antibiotics for life as prone to recurrence
* Changes in weight, pulse rate and rhythm and appearance of new symptoms reported

Myocarditis
* An inflammation of the myocardium-- muscle layer surrounding the heart
* A viral, bacterial, fungal or parasitic infection causes.
* Myocardium can become inflamed from the toxins of microorganisms, chronic alcohol abuse, radiation therapy or autoimmune disorders
* Most cases in the US are caused by viral
* An inflammatory response causes the muscle tissue to swell and interferes with ability to stretch and recoil.
* Cardiac output is reduced and circulation is impaired. Myocardium becomes ischemic causing tachycardia and arrhythmias
* Hypertrophic cardiomyopathy (enlarged & thicker heart) is a complication of myocarditis.

Signs & Symptoms of Myocarditis
* General chest discomfort relieved by sitting up,
* low grade fever, tachycardia, arrhythmias
* dyspnea, malaise, fatigue and anorexia
* pale or cyanotic skin, neck vein distention
* ascites and peripheral edema (right failure
* crackles (left failure), S3 gallop rhythm or pericardial friction rub

Medical Management
* Antibiotics if bacterial
* bedrest
* Na restricted diet
* cardiotonic drugs (digitalis related drugs)
* May need heart transplant

Nursing Management
* Monitor cardiopulmonary status
* daily weights, recording I & O
* assess lung sounds and monitor for edema
* Maintain bed rest to reduce cardiac workload and promote healing

Cardiomyopathy
* Cardiomyopathy is a chronic condition characterized by structural changes in the heart muscles.
* Various types and treatments
* Inflammation of the pericardium, (sac like structure that surrounds and supports the heart)-- can occur as a primary condition (one that develops independently of any other condition) or as a secondary condition (one that develops because of another condition).

Pericarditis
* Can occur with or without effusion ( the accumulation of fluid within two layers of tissue)
* Usually occurs secondary to endocarditis, chest trauma, MI,or cardiac surgery
* TB, malignant tumors, uremia and connective tissue disorders also cause

Pericarditis
* Intracellular fluid leaks into interstitial spaces. Fig 29-5 pg 446
* The exudate or effusion can be serous, resembling clear serum; fibrinous, like thick, congealed liquid; or purulent or sanguinous containing blood.
* Causes acute compression of heart or cardiac tamponade.
* The fluid takes up space the heart needs to expand or fill. This causes pulsus paradoxus or a drop in systolic BP on inspiration
* As cardiac tamponade progresses, stroke volume is diminished, reducing cardiac output and resulting in death if uncorrected.
* Pericardiocenteses, needle aspiration of fluid may be done and small cath. left in place so fluid will continue draining

Signs & Symptoms of Pericarditis
* fever and malaise, dyspnea or chest feels heavy
* Precordial pain--pain in anterior chest overlying the heart (classic symptom)
* Pain can be mistaken for esophagitis, indigestion, pleurisy or MI
* Moving and deep breathing worsen the pain
* Sitting upright and leaning forward relieve pain
* Pain in MI remains unchanged regardless of position, movement or breathing
* A pericardial friction rub, a scratchy, high pitched sound, helps diagnose. Heart sounds muffled by fluid. Resp are rapid and labored, severe hypotension & weak pulse

Medical Management

* Rest
* Analgesics
* Antipyretics
* Nonsteroidal anti-inflammatory drugs
* Sometimes corticosteroids

Nursing Assessment
* Assess for pericardial friction rub by asking him to briefly hold breath while auscultating heart sounds. A pericardial friction rub will not disappear when breath is held.
* Assess for cardiac tamponade and cardiac output. Assess for dyspnea, muffled heart sounds, Syncope, cough due to compression, pain and anxiety of trachea & bronchi, neck vein distention

Nursing Care
* Assess lung sounds q 8 hrs.
* Assess peripherial pulses, level of consciousness and anxiety level
* Assess for signs of cardiac tamponade--tachycardia, pulsus paradoxus (drop in systolic with inspiration), restlessness and distended neck veins.
* Give O2 and have emergency pericardiocentesis tray available

Pericardiocentesis
* Consent form signed, baseline vitals, measure amt. of fluid and describe before sending to lab. Site covered with sterile dsg and reinforced PRN. Assess for bleeding or leakage of fluid. Significant changes in breathing, heart rate or rhythm and BP reported stat. Should see improved vitals, increased Ua output

Client & Family Teaching

Thrombophlebitis
* Inflammation of a vein accompanied by clot formation
* Venous stasis(slowed circulation), altered blood coagulation and trauma to the vein predispose thrombophlebitis
* Venous stasis is most common cause
* Inactivity, reduced cardiac output, compression of veins in pelvis or legs and injury contribute to clot formation
* Some drugs and chemicals given IV irritate vein
* Oral contraceptives increase risk, especially if smokers
* Platelets clump together forming a clot when vein is irritated or injured
* Symptoms include pain, heat, redness and swelling
* Positive Homan’s sign (dorsiflexion)
* Capillary refill takes less than 2 seconds because of venous congestion
* may have fever, malaise, fatigue and anorexia
* Complains of discomfort in affected extremity
* Will have an elevated platelet count

Medical Management

* Complete rest of affected extremity essential to prevent the thrombus from becoming an embolus. Nurse should instruct him to maintain complete bedrest and do not massage area. warm compresses may be ordered
* Heparin and Coumadin ordered. Must watch for hematuria and other signs of bleeding
Nursing
Teaching
Thromboangitis Obliterans (Buerger’s Disease)
Buerger’s Disease
Assessment Findings
Buerger-Allen Exercises
Medical Managment
Tobacco in any form is restricted.
Analgesics to ease pain
Exercises
Nursing Management
Pt & Family Teaching

* Avoid caffeine, tobacco products, & OTC drugs that cause vasoconstriction, such as nasal decongestants.
* Inspect fingernails, toenails, and skin on arms and legs daily
* Wear properly fitting shoes and stockings or socks
* avoid prolonged exposure to cold
* When cold weather teach to wear thick socks or insulated boots and gloves

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Lemierre’s Disease

Lemierre’s Disease
Presentation by:by Brandy Harkins

Patient Presentation
* 20 year old female
* Diagnosed with infectious mononucleosis 2 days prior to admission
* No remarkable previous medical history
* Blood pressure – 101/72
* Pulse – 167 beats/min
* Respiratory rate – 52/min
* Shortness of breath and chest pain with shallow breathing
* Sore throat
* Headache
* Fever
* Decreased appetite
* Abdominal pain (no nausea, vomiting, diarrhea or constipation)
* Pale
* Initial diagnosis was pneumonia

Laboratory Findings
* Blood culture positive at 24hrs (Fusobacterium necrophorum)
* Monospot negative
* EBV-VCA IgG positive
* Increased fibrinogen, PT & PTT
* Increased bilirubin
* Liver enzymes – AST 74 (19-45), ALT 44 (8-37)
* WBC’s – 15.3 (4.0-10.9)
* Plts – 106 (150-400)

Fusobacterium necrophorum
* Normal flora in oral cavity, female genital tract, and gastrointestinal tract
* Pleomorphic gram negative bacillus (GNB)
* Non-motile
* Non-spore forming
* Strict anaerobe

Disease Association
* Can cause parotitis, otitis media, sinusitis, odontogenic infection, mastoiditis and Lemierre’s syndrome (necrobacillosis)
* Produces lipopolysaccharide endotoxin, hemagglutinin, leukocidin, and hemolysin
* Invasion usually from intra-oral disease (bacterial tonsillitis, EBV, dental disease)

Questions to Consider
* What organism is usually responsible for Lemierre’s sydrome?
* Why has Lemierre’s become the “forgotten disease?”
* What are the symptoms of the syndrome?
* What age group is most commonly affected?
* What are the stages commonly seen with Lemierre’s and at which stage does the red flag appear?

Lemierre’s Syndrome
* Thrombophlebitis of the internal jugular vein (IJV) due to anaerobic infection (usually F. necrophorum)
* Virulent toxin production with platelet aggregation IJV thrombosis
* Causes severe disease as primary pathogen in healthy individuals
* Generally affects young adults 16-29 y/o
* 1 in 1,000,000 infected per year
* Common in the early 20th century, but disappeared with antibiotics
* Used to have 100% mortality rate…today’s rate is 6-20%

Disease Presentation
* Sore throat
* Tender/swollen lymph nodes
* Prolonged fever
* May experience abdominal pain, nausea or vomitting
* Bacteremia
* Increased WBC’s or left shift
* Hyperbilirubinemia and slight increase in liver enzymes

Classical Characterization
* Primary infection in oropharynx
* Septicemia documented by at least one positive blood culture bottle
* Evidence of internal jugular vein thrombosis
* At least one metastatic focus (usually pulmonary)

Stages
* Patient generally exhibits three stages
1. Pharyngitis – sore throat (< 1 week)
2. Local invasion of lateral pharyngeal space and IJV septic thrombophlebitis swollen/tender neck = red flag
3. Metastatic complications – fever, pulmonary infiltrates or possible joint involvement

Treatment
* Fatal if untreated
* 1-2 weeks IV antibiotics and 2-4 weeks oral antibiotics
* Aggressive approach when patient has pharyngitis and tender/swollen neck
o Get blood culture
o Look for evidence of IJV thrombophlebitis with CT, MRI, ultrasound
o Use antibiotics affective against anaerobes (clindamycin, metronidazole, etc.)
* Anticoagulant therapy controversial
* May require surgery to remove the IJV because of continuing sepsis, localized collection of pus, or embolism

So why’s it so hard to diagnose?
* Rarely seen in the antibiotic-era…most physicians have never seen it
* Can present with pneumonia-like or meningitis-like clinical picture
* Many sore throats have a viral etiology and are not treated with antiobiotics, therefore a patient can be misdiagnosed and untreated for long periods of time before clinicians suspect Lemierre’s
* More severe with longer duration of symptoms than viral sore throat!

Summary
* Lemierre’s syndrome is usually caused by Fusobacterium necrophorum
* Affects healthy young adults
* Patient presents with fever, sore throat, swollen/tender neck (red flag)
* 3 stages – pharyngitis, IJV thrombosis, and metastatic complications
* Disease severity is often underestimated and left untreated or is treated as a case of pneumonia or meningitis


References
Credits:This case study was created by Brandy Harkins, MT(ASCP) while she was a Medical Technology student in the 2004 Medical Technology Class at William Beaumont Hospital, Royal Oak, MI.

Lemierre’s Disease.ppt

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