Subacute endocarditis infection

Etiopathologic etiology and pathogenesis of subacute endocarditis infections occur in patients with rheumatic heart valve disease, If mitral and aortic insufficiency, and certain congenital heart diseases, such as ventricular septal defect, patent ductus arteriosus with two leaves and other organic aortic heart valve. Individual also occurred in the original no heart, on the basis of the pathogen to more conditional pathogens, such as Streptococcus viridans, Staphylococcus white, alkaline products such as acidophilus and Enterococcus. A minority of fungal infection, with more candidiasis. Route : grass green streptococcus infections and oral surgery, Enterococcus often occurred in the urinary tract surgery after childbirth or abortion. Staphylococcus aureus and Gram negative bacteria, and fungal infection occurs in the heart after surgery. Pathogenesis of oral surgery, abortion, childbirth or urinary tract surgery, heart surgery or respiratory infections, bacteria may enter the blood, As the host defense mechanism that does not cause harm. But bacteria have been attached to the heart valve lesions or endocardium, then locally platelets, fibrin deposition, enveloping the bacteria, formed vegetation, phagocytic cells of bacteria to devour the role play, when vegetation broken, lost, many bacteria release into the blood, forming process repeated chronic bacteremia. Infective endocarditis have some good site and occur in the blood or partial impact Whirlpool's location, If mitral regurgitation atrial face, aortic insufficiency of the ventricular surface. ventricular septal defect in the right ventricle face patent ductus arteriosus pulmonary artery intimal noodles. Subacute endocarditis infection is chronic way, the vegetation difficult to wipe out bacteria, the long-term survival, Due to the low virulence, fewer migratory infection. Pathological changes in the basic pathology of the heart valve lesions or endocardial vegetations are formed by the fibrin vegetation, WBC and platelet aggregation, in which bacteria hidden, where there is a lack of capillaries and less phagocytic cell infiltration Drug thus difficult to achieve deep, and bacteria are difficult to swallow, such as bacteria to the long-standing causes. Vegetation which is attached to the valve inflammatory reaction and focal necrosis, its surrounding lymphocytes, macrophages and fibroblasts cell infiltration. Necrotic cells surrounding a new capillaries, connective tissue and granulation tissue, dissipated when the inflammation, fibrosis vegetation, surface of the endothelial cell coverage, cured cases, three months to be completely healed, not cure patients, healing and inflammatory reaction cross-exist. Large and fragile vegetation, shedding can be addressed to the organ and peripheral arterial thrombosis, such as kidney, brain, spleen and mesenteric and limbs. congenital heart disease and infectious endocarditis cases, more complicated pulmonary embolism, local growth of bacteria can have a valve or ulcer perforation, tendons and papillary muscle rupture and bacterial aneurysm. Antigen - antibody complex in renal vascular ball deposition, renal vascular ball nephritis, As the immune response caused a small artery intimal hyperplasia, obstruction of the small blood vessels around and in charge of the performance of the skin and mucous membranes of silt, occur in the fingers or toes and the end of palms, slightly faster than the surface, tenderness ,5-15mm size. said Albright (Osler) nodules of palm and toe the size of several millimeters purple spots Janeway called nodules. Clinical manifestations majority of cases slow onset, fever, weakness, fatigue, a few rapid onset, chills, fever or embolization, Some patients before the onset of oral surgery, respiratory infections, abortion or childbirth history. 1, systemic infection most commonly fever, and formation of unknown causes sustained fever for more than a week, irregular low heat, In more than 37.5 ° C between -39 ° C, but also to intermittent heat or flip-heat, accompanied by weakness, night sweat, anemia splenomegaly, Advanced can poke fingers. 2, heart inherent in the performance of the signs of a heart attack, due to the vegetation growth or lost, valve damage tendons, murmur changes, or the emergence of new noises. If no noise except when endocarditis can not exist, advanced heart failure can occur. When the infection spread to beam or atrioventricular septal may trigger atrioventricular block and bundle branch block, arrhythmia rare, Premature or have atrial fibrillation. 3. Embolization phenomenon and disease loss (1) skin and mucosal lesions from the infected toxin role in the increase in capillary so brittle and cracked hemorrhage, or caused by micro-embolization. In the limbs to skin and eyes with alkaline membrane, and oral mucosa appeared beneath the bulk, in the fingers. tip-toe hold, there will be slightly higher than the surface of the purple or red Albright (Osler) nodules, can the hand or foot a small nodular bleeding (Janewey nodules), the tenderness. (2) cerebrovascular disease may have damaged the following performance : ① meningoencephalitis similar tuberculous meningitis, increased CSF pressure, protein and white blood cell count increased, chloride or sugar quantitative normal. ② brain hemorrhage sustained headache or meningeal irritation symptoms, is caused by bacteria aneurysm rupture caused. ③ cerebral embolism patients fever, sudden paralysis or blindness. ④ central retinal embolism can cause sudden blindness. (3) The most common renal embolization, or about 1 / 2 cases, the naked eye or microscopic hematuria. serious kidney dysfunction often due to bacterial infection, the antigen-antibody complex in renal vascular deposition of the ball, Renal vascular ball nephritis results. (4) Pulmonary embolism is common in congenital heart disease and infectious endocarditis cases, vegetation located in the right ventricle or pulmonary artery intimal surface, attacks, chest pain, dyspnea, hemoptysis, cyanosis or shock. If the infarct size, but also no obvious symptoms. There is also a coronary embolism, acute infarct performance, the PSE has left upper abdominal pain or pain left quarter of the ribs. have a fever and local friction sound. Mesenteric artery embolization, the performance of the acute abdomen, such as bloody. Limbs arterial embolization can be physically embolization pale chills, arterial pulse weakened or disappeared, limb ischemia pain. Laboratory and other checks a blood culture positive diagnosis can be established, and to provide a basis for the choice of antibiotics. To provide training, the positive rate, should pay attention to the following points : ① use of antibiotics, continuous culture 4 -6 meeting. ② blood volume per 10 ml, for aerobic and anaerobic training. ③ training will take a longer time, not less than three weeks. ④ culture positive for the drug susceptibility testing should be. 2, as a blood for anemia, normal leukocyte count or higher. 3, ESR increase 4, urine routine of proteinuria and hematuria, about 1 / 3 of patients with advanced renal insufficiency. 5, echocardiography or cardiac valvular heart endometrial wall vegetation, and the inherent heart abnormalities. Diagnosis and differential diagnosis of early diagnosis depends mainly on raising of the disease vigilance, Where an organic heart disease patients with fever of unknown origin sustained over a week, the need to consider the possibility of this disease. And immediately sent for blood culture and sensitivity test. Positive blood culture can diagnose this disease and pathogens. If the number of negative blood cultures, the need to rheumatic fever or recurrence of left atrial myxoma, non-bacterial endocarditis differential. Only heart murmur, fever, blood culture-negative, it can take a long time and fever diseases such as tuberculosis, brucellosis tumor, lymphoma, liver abscesses. If there is bleeding or embolism phenomena in the diagnosis of the disease is helpful, but the majority have entered the late phase of the disease. Prognosis of the disease prognosis and treatment sooner or later, antibiotics to control pathogens, Heart valve damage and the extent of the resistance in patients. After the artificial valve infections, particularly gram-negative bacteria and fungal infection had the worst outcome. Repeatedly relapsed poor prognosis. A treatment, the application of choice of antibiotics antibiotics according to culture bacteria or the antibiotic sensitivity. Because bacteria are more fibrin, platelet covered by the bacteria in the deep vegetation. antibiotics only through the plasma penetrate vegetation. Application of the principle of antibiotics : ① use fungicides, such as penicillin, streptomycin, cefazolin, vancomycin, and so on. ② larger dose. By in vitro bactericidal concentration of 4-8 times the administration. If the price for the determination of bactericidal drop to two patients with blood product dilution to cultivate bacteria, such as a : 8 or higher price drops sterile growth, and said antibiotics effective dose is enough. ③ enough to treatment. Normally take 4 -6 weeks, the sensitivity to antibiotics of bacteria or worse complications of a stubborn cases may be extended to eight weeks. ④ early treatment. Continuous blood culture 4 -6 times after treatment began testing, based on clinical characteristics and possible routes of infection. Pathogens can choose two different antibacterial spectrum antibiotics combined. Second, drug choice (1) pathogens is not clear who beta-lactam ring antibiotics (penicillin, cephalosporins) and the amino-glycosides antibiotics (streptomycin, kanamycin, gentamicin) combined to kill most bacteria, it can be the first choice. first to penicillin G1000-2000 million units intravenous infusion, intramuscular injection of streptomycin daily 1.0g, effective, be six consecutive weeks. If this treatment fails, can be used benzophenone isoxazole penicillin, the daily 6-methoxy 12g or two benzene penicillin, Daily 6 - 12g, intravenous drip of vancomycin can be used daily 2 - 3g, 4-6 pm intravenous injection. or intravenous drip. Cephalosporins antibiotics wider scope and a pair of penicillin resistance will be allowed to use such antibiotics. First-generation cephalosporins against Gram-positive cocci, and the larger the second, three generations of cephalosporins Apart from the role of Gram-negative bacilli also a strong antibacterial effect. Central ethylene amines such as cephalosporins (cefazolin Ⅵ), to the new complex (cephalosporins it be), a daily 4 - 8g. 3 -4 hours intravenous injection, West Li-xin (cefuroxime), daily 1.5-4.5g, 3-4 pm meeting, intravenous injection. If positive blood culture can be adjusted according to susceptibility type and dosage of antibiotics. (2) of the pathogens Gram-positive cocci, the choice of drug treatment of the foregoing, In large doses of penicillin G attention to the need for ① probenecid could be used to slow down the penicillin excretion by the kidneys. Penicillin could raise four times the concentration of no significant renal dysfunction, could be probenecid each 0.5 g oral, 3 -4 times daily. ② penicillin G potassium salt per one million units of potassium ion 39.1 mg, high-dose application, the need to hyperkalemia. (3) Gram-negative bacillus infections, reference tables, or may choose cephalosporins. (4) fungal infection can be two amphotericin, for the first time, 10 mg intravenous fluids, after each additional 5 - 10 mg / d until 0.5-1mg/kg/d, with a total dose of 3.0 g, A total of six weeks. Garlic fluid, 5-fluorocytosine, close with itraconazole or ketoconazole there is a certain role, but the effects are not two amphotericin. Table 3 -6-1 Gram-negative bacilli of antibiotics in the treatment of endocarditis bacteria antibiotics (daily dose, 2 -3 pm intravenous) treatment (weeks) (1) E. coli ① Ampicillin + 6 ~ 8g kanamycin a ~ 1.5 ② 6 g ~ 8g Ampicillin + gentamicin 320,000 24 ~ u ~ 4 ~ 6 6 4 (2) Proteus Cefadorxil Penicillium 8g-6 ~ + kanamycin 1 ~ 4 ~ 6 1.5g (3) pneumoniae cefazolin Ⅰ 4 ~ 6g + gentamicin 24 u ~ 320,000 4 ~ 6 (4) of Pseudomonas aeruginosa ① carbentcillin 40g + 20 ~ 24 ~ gentamicin 320,000 u ② carbentcillin tobramycin 20 ~ 150 ~ 40g 250mg 4 ~ ~ 6 4 6 (5) producing alkaline strain adriamycin 1.5 ~ 2g + chloramphenicol 2g intramuscular six (6) anaerobic bacillus lincomycin-1.8-2.4g + chloramphenicol Erythromycin 2g + a ~ 1.5g chloramphenicol 2g 4 ~ ~ 6 6 4 (7) Salmonella chloramphenicol synergies methyl + 2g Amine * 2g oral ampicillin 6g + SD * 2g synergies oral 4 ~ ~ 6 4 6 * SD synergies between sulfamethoxazole oxazole 0.4 g + Trimethoprim 0.08g mixture general administration 3-5 days, if the temperature dropped, leukopenia, heart rate and the effective treatment of note, if the full dose of antibiotics in the treatment of inconclusive results, required to stop a few days observation, sending blood culture. There is vegetation antibiotics completely controlled the disease difficult, but not inhibit anticoagulant therapy vegetation formation, Efficacy and certainly difficult, and it has led to internal organs bleeding risk. 3, the standard cure and recurrence after treatment to restore normal body temperature, spleen reduced symptoms disappeared, in the course of antibiotics after the end of the first, second and sixth weeks respectively for blood culture, such as clinical recurrence was not observed negative blood culture, that can be cured. The disease recurrence rate of about 5 -10% more than at the end of 6 weeks after relapse, and recurrence over the following circumstances : ① long before treatment course, is not sensitive ② antibiotic dosage or inadequate treatment, ③ with serious lung, brain or heart damage endometriosis. This is when antibiotic treatment dose should be increased, treatment should be extended, the treatment of recurrent, Joint should take the medication doses and longer course of treatment. 4, surgical treatment following surgical treatment to be considered : ① valve perforation, the rupture, severed tendons, occurred refractory acute heart failure. ② valve replacement workers after infection, medical treatment beyond. ③ with bacterial aneurysm ruptured artery embolization or limbs. ④ congenital heart infection endocarditis, the treatment is still uncontrollable, Surgery should strengthen support and antibiotic therapy under control as soon as possible.