周京敏－感染性心内膜炎

null 感染性心内膜炎 感染性心内膜炎Infective EndocarditisDefinition and classificationDefinition 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, catheterizationEtiology and MechanismEtiology 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nullEndocarditisHeart structural abnormalityEndocardial injurythrombosisAdhesion of bacteriaDisturbance of blood flowMechanismPathologyPathologyvegetationSystematic embolism, abscessEndocarditisKidney, Liver, Joint diseasesImmune system activationThrombus and bacteriaClinical ManefestationClinical 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, severeClinical ManefestationClinical Manefestation血管损害：Systematic embolism Skin: petechiae Spleen, kidney, limbs, Brain, Messentric embolism 免疫反应表现： Often seen in SIE No characteristics Osler node, TothEmbolic lesions on the feet of a patient with Staphylococcus aureus endocarditis Embolic lesions on the feet of a patient with Staphylococcus aureus endocarditis nullSkin and Nail Lesions in staphylococcal endocarditis. Typical subungual ("splinter") hemorrhage and numerous petechiae on the skin of the abdomenLab findingsLab findingsBlood 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 Gram stained smear from blood culture bottle showing viridans streptococci from pt with native valve endocarditis EchocardiographyEchocardiographyTTE: TEE: more useful Vegetation AV or MV insufficiency Abscese Aorta root abscess in TEE studyAorta root abscess in TEE studyPerivalvar abscess of MV annulus, and perforationPerivalvar abscess of MV annulus, and perforationnullVegetationDiagnosisDiagnosisThe 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 causeManagementManagementAntibiotics: 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 ManagementManagement2. 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ManagementManagement3. 对症治疗 内科医生具备的常规知识 Heart failure Systematic embolism Arrhythmias: Arterial aneurysm: depends ManagementManagement治愈 症状改善 体征：anemia, spleen, cardiac murmur Lab: anemia, Urine protein blood culture (-): 1,2,6 wRecurrence: same bacteria Repeat antibiotics nullPrevention 预防性应用抗生素 Prognosis Mortality: AIE: 20-50% SIE: 20% 5-year survival: 90% Case discussionCase discussionA 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）nullWBC: 15,400 mm3 CRP : 12.1 mg/dL Blood cultures: negative Lumbosacral MRI: non-specific Treated with analgesic medication and physical therapy null12th Day: Left hemiplegia CT of the head:recent infarction in the territory of the right middle cerebral artery. What is the next step? TEE null35 * 5 mm: mobileVegetation on the anterior MVnullThe patient recovered and was discharged two weeks later. 3rd month follow-up visit, only slight, left-sided muscular weakness.