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16534706
Endothelium 心內膜之感染, 不只侷限在 Valve
Mitral valve is the most commonly affected site
Tricuspid valve endocarditis more common on IVDU
Acute endocarditis : 破壞心臟, 散佈全身
- Group A Beta Hemolytic Strept
- S.a
Subacute endocarditis : 破壞心臟少, 散佈全身少, 症狀較 indolent
- Viridans 草綠色, Bovis ( 一定要想到 : 大腸癌 & IE )
- CONs ( Coagulase-negative Staph )
- Enterococcus
- HACEK - Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella
- Fungus
Staphylococcus is the single most common cause,
followed by streptococci (including viridans group streptococci) and enterococci
Blood cultures are the best method for detection of endocarditis but are negative in about 5% of patients;
33% to 50% of culture-negative endocarditis is attributed to prior antibiotic administration
For culture-negative cases without prior antibiotic administration,
infection is most often due to fastidious organisms :
HACEK, also Bartonella and Coxiella burnetii
High Risk Predisposing factor :
爛 Valve :
- 之前得過 IE
- Rheumatic heart
- Structure anomaly ( Bicuspid aortic valve, degenerative cardiac lesions (calcific aortic stenosis), Congenital heart disease )
- Prosthetic valve
- Mitral valve disease ( Medium risk )
Mitral valve prolapse is a common predisposing lesion
爛人
- IVDU (Intravenous drug abuse)
- Venous catheter, intravascular device
- Dentist problem
- HD
- DM, immunocompromised, HIV
- Cardiac device ( Pacemaker, ICD )
- Poor dental hygiene
3 套 B/C 間隔 10 分鐘從不同位置抽
AHA 建議至少三套血液,
從不同的入針處抽血
第一套和最後一套要間隔一個小時以上
* Coxiella burnetii : Q fever
現屬於非立克次體
牛羊糞便塵埃空氣傳染
常見症狀 : Atypical pneumonia, Hepatitis, Flu like fever
很少數才 IE
爛人爛心臟
發燒
爛血管
* Septic emboli : Systemic !!
- Brain : Stroke
- Heart : MI
- Lung : pulmonary infarction, pneumonia, empyema, or pleural effusion; multifocal pneumonia
- Vessel : Mycotic aneurysm
- Abdomen : infarction (AKI), Embolic splenic infarction, Emboli to the mesenteric arteries
- Peripheral : Janeway lesion, acute limb ischemia
Embolization of vegetation fragments is common (20% to 50% of patients)
* Bleeding :
- ICH
Occurs in about 5% of patients with infectious endocarditis
- Ruptured mycotic aneurysms
- Septic erosion of the arterial wall
- Conjunctiva hemorrhage
- Retinal hemorrhage : Roth's spot ( with central pale )
爛免疫
Glomerulonephritis !! Patients with IE can develop several forms of renal diseases
bacterial infection-related immune complex-mediated glomerulonephritis
A variety of organisms may be involved in patients developing glomerulonephritis.
The most common are Staphylococcus aureus in acute infective endocarditis (IE),
Streptococcus viridans in subacute IE, and Staphylococcus epidermidis in shunt nephritis.
The histologic findings in the glomerulonephritis are similar to those inpoststreptococcal glomerulonephritis or membranoproliferative glomerulonephritis :
hypercellularity (due in part to the influx of circulating inflammatory cells)and immune deposits in the glomerular capillary wall.
Rheumatic Factor :
不只 Rhematic arthritis Leprosy, Infective endocarditis, Tuberculosis,Infectious mononucleosis, Influenza AHepatitis A or cytomegalovirus 都可以高 !!
Arthritis , Arthralgia
Arthralgia was the most common musculoskeletal symptoms in IE (present in 38% of the cases reviewed),
followed by frank arthritis (in 31%), low-back pain (in 23%), and diffuse myalgias (in 19%)
約有 50% 的患者有肌肉與骨骼症狀如關節痛、
關節炎、腰背痛、大小腿肌肉瀰漫性酸痛等
單個關節症狀與一側性肢體肌肉酸痛是亞急性感染性心內膜炎的典型症狀之一
常為早期發現亞急性感染性心內膜炎的重要線索。
可能就和 rheumatic heart 也會關節炎ㄧ樣吧 ..
ESR
口訣 (FROM JANE)
Fever, Roths spots, Osler's nodes, Murmur
Janeway lesions, Anemia, Nail hemorrhage, Emboli
Fever + Chillness, Malaise, Weight loss, anorexia, Anemia !
晚期可見 Clubbing fingers
HEENT : Conjunctival hemorrhage
Retinal hemorrhage : Roth's spot 牙齒衛生
Heart : Murmur, EKG : Conduction abnormality ( Af, AV block... ) CHF
Murmurs which are present in about 90% of patients with endocarditis is one of the most important physical exam maneuvers
Congestive heart failure occurs in up to 70% of patients
from distortion or perforation of valvular leaflets, rupture of the chordae tendineae or papillary muscles, or perforation of cardiac chambers.
Kidney : Glomerulonephritis, Hematuria
Extremities : Osler node, Janeway lesion Pale, Cold, pulseless ....
CNS : About 20-40% of patients develop neurologic symptoms,
including embolic cerebral ischemic events (often in multiple areas, a clinical clue), CNS abscess,
intracranial hemorrhage, mycotic (or infected) aneurysm, meningitis, or seizures.
Abd : Splenomegaly, Ischemic bowel
Janeway lesions and Osler’s nodes, the reality is that these peripheral manifestations of endocarditis occur in only about 10% of patients.
Cardiac CT 至少和 TEE有同樣的能力（甚至之上）
能夠提供我們心臟瓣膜周圍的解構造或者併發症的訊息
在2015年的ESC guideline已經將Cardiac CT視為診斷IE的Major Criteria
結合Cardiac CT與18FDG-PET或者leukocyte scintigraphy（SPECT）
這兩種結合檢查對於Modified Duke Criteria中的可能族群以及心臟置入物感染特別有幫忙
Treatment
有可能因為併發症 unstable
Patients with endocarditis may present with hemodynamic instability, respiratory compromise,
pulmonary edema, diminished pulmonary capacity, altered mental status, and acidosis.
Systemic clot lysis or anticoagulation for treatment of endocarditis-associated stroke is controversial (concern of worsening underlying event) and best managed together with a stroke expert.
Current guidelines for native valve endocarditis recommend withholding anticoagulation for at least 2 weeks after a CNS embolic event to reduce the risk of hemorrhagic transformation.
Patients with prosthetic valves being treated with anticoagulants may be maintained on established regimens
https://jerryljw.blogspot.com/2018/07/diagnosis-and-management-of-infective.html
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