周京敏感染性心内膜炎.ppt

感染性心内膜炎,InfectiveEndocarditis,Definitionandclassification,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：nativevalveendocarditis人工瓣膜感染：prostheticvalveendocarditis(PVE)右心瓣膜感染性心内膜炎rightheartvalveendocarditis:drugabuse,AIDS,catheterization,EtiologyandMechanism,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,Heartstructuralabnormality,Endocardialinjury,thrombosis,Adhesionofbacteria,Disturbanceofbloodflow,Mechanism,vegetation,Systematicembolism,abscess,Endocarditis,Kidney,Liver,Jointdiseases,Immunesystemactivation,Pathology,Thrombusandbacteria,ClinicalManefestation,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：MurmurappearanceorchangeHeartfailureArrhythmia:heartblock,severe,血管损害：SystematicembolismSkin:petechiaeSpleen,kidney,limbs,Brain,Messentricembolism免疫反应表现：OftenseeninSIENocharacteristicsOslernode,Toth,ClinicalManefestation,EmboliclesionsonthefeetofapatientwithStaphylococcusaureusendocarditis,SkinandNailLesionsinstaphylococcalendocarditis.Typicalsubungual(splinter)hemorrhageandnumerouspetechiaeontheskinoftheabdomen,Labfindings,Bloodculture:MostimportantdiagnosticmethodVeinbloodX3timesNegativedoesnotexcludethediagnosis,Gramstainedsmearfrombloodculturebottleshowingviridansstreptococcifromptwithnativevalveendocarditis,Echocardiography,TTE:TEE:moreusefulVegetationAVorMVinsufficiencyAbscese,AortarootabscessinTEEstudy,PerivalvarabscessofMVannulus,andperforation,Vegetation,Diagnosis,TheConceptionofIEFever1weekinptswithstructuralheartdiseasesorheartoperationTheappearanceorchangeofcardiacmurmurSystematicembolismwithnoobviouscauseHeartfailurewithnoobviouscause,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,2.手术治疗没有办法之办法应掌握好指证：seeP315该开不开也不对,Management,3.对症治疗内科医生具备的常规知识HeartfailureSystematicembolismArrhythmias:Arterialaneurysm:depends,Management,治愈标准症状改善体征：anemia,spleen,cardiacmurmurLab:anemia,Urineproteinbloodculture(-):1,2,6w,Management,Recurrence:samebacteriaRepeatantibiotics,Prevention预防性应用抗生素PrognosisMortality:AIE:20-50%SIE:20%5-yearsurvival:90%,A56-ymanSeverelumbarpain,a7-wfever(39C),anda10-kgweightlossHistory:HBPwithdilatedLV,reducedLVEF,andMR+pE:agrade3/6holo-SM,andevidenceofsciatica（坐骨神经痛）,Casediscussion,WBC:15,400mm3CRP:12.1mg/dLBloodcultures:negativeLumbosacralMRI:non-specificTreatedwithanalgesicmedicationandphysicaltherapy,12thDay:Lefthemiplegia,CTofthehead:,recentinfarctionintheterritoryoftherightmiddlecerebralartery.,Whatisthenextstep?,TEE,35*5mm:mobile,Vegetat