感染性心内膜炎 infective endocarditis. definition and classification...
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感染性心内膜炎Infective Endocarditis
Definition and classification
心（血管）内膜（瓣膜）感染
急性 (AIE) ：毒力强，病程短，中毒症状明显
亚急性（ SIE, SBE) ：毒力低，病程长
自体瓣膜感染： native valve endocarditis
人工瓣膜感染： prosthetic valve endocarditis (PVE)
右心瓣膜感染性心内膜炎
right heart valve endocarditis: drug abuse, AIDS, catheterization
Etiology and Mechanism
• 草绿色链球菌， 50%
• 葡萄球菌，葛兰氏阴性杆菌• AIE ：
– 葡萄球菌，可发生于无器质性心脏病患者
• SIE ：– 链球菌， esp. 院外感染，几乎均有心脏病基础
• PVE ：– 表皮葡萄球菌，术后 1 年内
Endocarditis
Heart structural abnormality
Endocardial injury
thrombosis Adhesion of bacteria
Disturbance of blood flow
Mechanism
vegetation
Systematic embolism, abscess
Endocarditis
Kidney, Liver, Joint diseases
Immune system activation
Pathology
Thrombus and bacteria
Clinical Manefestation
全身表现：发热，高热，低热，无发热乏力，多汗，贫血，体重减轻，食欲不振
心脏：Murmur appearance or change
Heart failure
Arrhythmia: heart block, severe
血管损害： Systematic embolismSkin: petechiaeSpleen, kidney, limbs,Brain,Messentric embolism
免疫反应表现：Often seen in SIENo characteristics Osler node, Toth
Clinical Manefestation
Embolic lesions on the feet of a patient with Staphylococcus aureus endocarditis
• Skin and Nail Lesions in staphylococcal endocarditis.• Typical subungual ("splinter") hemorrhage and numerous
petechiae on the skin of the abdomen
Lab findings
• Blood culture:
– Most important diagnostic method
– Vein blood X 3 times
– Negative does not exclude the diagnosis
Gram stained smear from blood culture bottle showing viridans streptococci from pt with native valve endocarditis
Echocardiography
TTE:
TEE: more useful
• Vegetation
• AV or MV insufficiency
• Abscese
Aorta root abscess in TEE study
Perivalvar abscess of MV annulus, and perforation
Diagnosis
The Conception of IE
• Fever > 1 week in pts with structural heart diseases or heart operation
• The appearance or change of cardiac murmur
• Systematic embolism with no obvious cause
• Heart failure with no obvious cause
Management
1. Antibiotics:
• 原则： 早期、足量、联合、杀菌、 4-6周
• 根据药敏选择• 经验性：
院外：链球菌：青霉素 院内：葡萄球菌：头孢唑林 +丁卡
2. 手术治疗–没有办法之办法
–应掌握好指证： see P315
–该开不开也不对
Management
3. 对症治疗
• 内科医生具备的常规知识• Heart failure
• Systematic embolism
• Arrhythmias:
• Arterial aneurysm: depends
Management
治愈标准• 症状改善• 体征： anemia, spleen, cardiac murmur
• Lab: – anemia, – Urine protein– blood culture (-): 1,2,6 w
Management
Recurrence: –same bacteria–Repeat antibiotics
• Prevention– 预防性应用抗生素
• Prognosis– Mortality:
• AIE: 20-50%• SIE: 20%
– 5-year survival: 90%
A 56-y man
• Severe lumbar pain, a 7-w fever (<39°C), and a 10-kg weight loss
• History: HBP with dilated LV, reduced LVEF, and MR + — + +
• pE: a grade 3/6 holo-SM, and evidence of sciatica （坐骨神经痛）
Case discussion
• WBC: 15,400 mm3
• CRP : 12.1 mg/dL
• Blood cultures: negative
• Lumbosacral MRI: non-specific
• Treated with analgesic medication and physical therapy
• 12th Day: Left hemiplegia
• CT of the head:
recent infarction in the territory of the right middle cerebral artery.
• What is the next step?
• TEE
35 * 5 mm: mobile Vegetation on the anterior MV
• The patient recovered and was discharged
two weeks later.
3rd month follow-up visit, only slight, left-
sided muscular weakness.