周京敏－感染性心内膜炎.ppt

感染性心内膜炎 Infective Endocarditis Definition and classification 心（血管）内膜（瓣膜）感染 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 Pathology vegetation 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 Clinical 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, Toth 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 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 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 Management 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 Prevention 预防性应用抗生素 Prognosis Mortality: AIE: 20-50% SIE: 20% 5-year survival: 90% Case discussion 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） WBC: 15,400 mm3 CRP : 12.1 mg/dL Blood cultures: negative Lumbosacral MRI: n