感染性心内膜炎 infective endocarditis. definition and classification...

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

Vegetation

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.