Case summary:
The patient, female, 34 years old, from Shunde, Guangdong, was admitted to hospital on April 10 due to palpitations and shortness of breath for 5 years, fever and fatigue for 2 weeks, and edema of both lower extremities for 3 days.
The patient started 5 years ago. He felt guilty and short of breath when he was tired or caught a cold. After examination, he found that the mitral stenosis of the rheumatic heart disease was closed and the symptoms were improved. After the treatment, the symptoms were improved after 2 weeks. Fever, body temperature up to 39 ° C, with sore throat, less cough, no sputum, fatigue, antibiotics (unknown name) and antipyretics in the clinic, fever has returned to normal, after the drug is again high fever, and then the drug is still not hot Retreat, and heart palpitations, increased shortness of breath, can not supine at night, nearly 3 days of lower extremity edema and emergency admission. Since the onset of the disease, poor appetite, weight loss, no abdominal pain, frequent urination, urgency, dysuria.
When I was young, I had joint redness, swelling, heat, pain, no history of hepatitis, nephritis, tuberculosis, hypertension, diabetes, no history of trauma, surgery and drug allergy.
Physical examination: T 38.7 °C, P105 beats/min, R 30 beats/min, BP 14/10 kPa. Normal development, normal nutrition, clear mind, semi-sitting position, the skin and mucous membranes are pale, no cyanosis, no bruises, ecchymoses, superficial lymph nodes are not touched, bilateral pupils are 3mm, and other large circles, light reflection Exist, pharyngeal congestion (++), centering the tongue, jugular vein engorgement, central trachea, thyroid is not large, neck soft. Thoracic symmetry, no deformity, both lungs can smell a little wet rales, the heart expands downwards, the first heart sounds hyperthyroidism, the second heart sounds enhance, the apex can smell the open sound and the 3o/6o systolic hair murmur , conduction to the left underarm, 3o/6o late rumbling murmur. Abdominal soft, no tenderness, no mass, 3cm under the liver ribs, quality, liver neck sign (+), spleen not touched, ascites sign (-). Double lower extremity edema (+), joints without deformity, redness, swelling, heat, normal limb muscle tension, bilateral knee reflexes, did not lead to pathological nerve reflex.
Laboratory inspection:
Hemoglobin 90g / L, red blood cells 3.10X 1012 / L, white blood cells 12.9 × 109 / L. Classification: Neutral 0.82, lymphatic 0.18, platelet 208×109/L.
Urine routine: protein (+), urine sugar (-), urine ketone body (-), red blood cells (+).
Biochemistry: blood sodium 140mmol / L, blood potassium 4.5mmol / L, blood glucose 5.3mmol / L, blood urea nitrogen 8.6mmol / L, creatinine 117μmol / L, carbon dioxide binding capacity 23mmol / L.
Liver function is normal.
Electrocardiogram: rapid atrial fibrillation, left ventricular hypertrophy and strain.
ESR: 65mm / h, anti-"O" 102kU / L, anti-DNase - B 80U / L.
Blood culture: The results were not returned.
Echocardiography: rheumatic heart disease, mitral stenosis and insufficiency
Discuss
Intern A: The characteristics of this case: 1 middle-aged female: 2 with chronic valvular disease; 3 fever for 2 weeks; 4 palpitations, increased air impotence and lower extremity edema; 5 jugular vein engorgement, hepatomegaly, hepatic neck sign (+ 6; increased white blood cell count, increased neutrophil ratio, mild anemia; 7 urine protein (+), red blood cells (+); 8 increased erythrocyte sedimentation rate; 9 electrocardiogram: rapid atrial fibrillation, left ventricular hypertrophy and strain; 10 ultrasound Heartbeat shows rheumatic heart disease, mitral stenosis and insufficiency.
Intern B: According to the clinical characteristics of the patient, there is fever, the total number of white blood cells in the blood routine increases, the proportion of neutrophils increases, and the erythrocyte sedimentation rate increases, which may be an infectious disease.
Teacher: I also think that there is the possibility of an infectious disease, but what is the estimated infection? The patient is suffering from cold, and has less cough. There is a little wet rales in the lower lungs. At the same time, lung infection is a common complication of rheumatic heart disease. Is this case caused by pulmonary infection?
Intern C: I think the main lesion in this case is not a lung infection, because the cough is not obvious, there is no phlegm, and antibiotics are still effective. More likely should be considered infective endocarditis, because the patient has the basis of chronic valvular disease, repeated fever in the past 2 weeks, accompanied by anemia, protein and red blood cells in the urine, increased heart failure, general Antibiotic treatment is not effective, so the diagnosis of this case should be appropriate to put infective endocarditis in the first place.
Teacher: I also agree with C's opinion that the diagnosis of this patient should be considered as infective endocarditis first. Although the positive evidence is lacking, such as the blood culture results are not returned, no neoplasms are found in the echocardiogram. However, we should know that typical cases are rare now. Even if the blood culture results are negative, infective endocarditis cannot be ruled out. As for the neoplasmic problems of heart valves, the positive detection rate is only 40%-50%. .
Intern D: May I ask the teacher, why is the culture of infective endocarditis blood negative? Can you see no neoplasms by echocardiography?
Teacher: It is reasonable to say that since infective endocarditis must have bacteremia, blood culture should be positive. In fact, there are many cases of confirmed endocarditis, blood culture is negative, may be The timing of blood draw is not good, the number of blood draws is insufficient, the amount of blood drawn is insufficient, or antibiotics have been used. In order to improve the positive rate of blood culture, it is best to draw blood in the fever period of chills, and continuously draw blood for 3-5 times within 24-28 hours, each time taking 10 ml of blood. If antibiotics have been used, special medium should be used. Problems that are difficult to detect with sputum may be related to the fact that the sputum is too small or the cut surface used does not show the sputum.
Intern E: Teacher, like this case, do you have to wait for the blood culture results to be treated? How to choose antibiotics?
Teacher: As mentioned above. This case has not been diagnosed before treatment, it is still necessary to do some differential diagnosis, to exclude rheumatic activity, lupus erythematosus, lymphoma and so on. In this case, since the diagnosis of infective endocarditis has been placed first, and the patient is still in a state of high fever and heart failure, then the blood culture results cannot be awaited. Generally, this case is after admission. Blood culture, pumping once a hour, starting treatment immediately after 3 consecutive strokes, at this time can only take no empirical medication, with 10 million units of green toxin and gentamicin intravenous infusion, after the drug sensitivity results come back Only use the corresponding drugs.
Now I want to ask you, what are the principles of antibiotic treatment for infective endocarditis?
Intern F: The principles of antibiotic treatment for infective endocarditis are: 1 early application; 2 with large doses; 3 courses for longer: 6-8 weeks; 4 with fungicides; 5 when pathogenic microorganisms are unknown, acute application For broad-spectrum antibiotics that are effective against Staphylococcus aureus, Streptococcus, and Gram-negative bacilli, subacute individuals use antibiotics against most Streptococcus including Enterococcus.
There is another problem. If it is highly suspected to be infective endocarditis, and blood culture is negative, the effect of medication is not good. How to replace antibiotics?
Teacher: If the effect is not good after applying antibiotics, you should change the drug in time. This is for sure. The key is the quality of the drug selection technique. One thing worth noting here is that when re-selecting the drug, don't always think of expensive antibiotics, and constantly upgrade. This often not only cures the disease, but also aggravates the patient. The burden, on the contrary, sometimes chooses some of the more common antibiotics that are usually used less, but it is very effective, which may be related to the current use of higher-level antibiotics to make bacteria resistant.
Intern C: Teacher, what if you don't use a lot of antibiotics?
Teacher: If the medical treatment is still not effective, the surgical valve replacement can be performed immediately. The indications are as follows: 1 severe valvular reflux caused by heart failure; 2 fungal endocarditis; 3 although treated with antibiotics Blood culture continued to be positive or repeated recurrence; 4 although repeated antibiotics were treated with recurrent aortic embolization with ultrasound to confirm the presence of neoplasms; 3 aortic valve involvement caused by atrioventricular block, myocardial or annulus abscess must be surgical drainage. Surgical closure of the arterial catheter or repair of ventricular septal defect is an important measure for the treatment of refractory endocarditis.
Intern H: May I ask the teacher how to identify fungal endocarditis and bacterial endocarditis?
Teacher: It is difficult to distinguish between fungal and bacterial endocarditis. Fungal endocarditis can have the following characteristics: 1 The disease occurs mostly in old and weak, long-term use of antibiotics, immunosuppressants or hormones. Patients, after valve repair or replacement (especially mechanical valves). Long-term insertion of intravenous catheter or catheter is not uncommon; 2 is diagnosed as infective endocarditis and antibiotic treatment does not improve or even worsen, multiple blood cultures are negative; 3 course can last from six months to one year, Often there are aorta, especially lower extremity arterial embolization; 4 fundus examination in addition to Roth point, white exudate, hemorrhage, uveitis or endophthalmitis is often characteristic of fungal endocarditis; 5 systemic fungal infection Evidence, etc.
Intern C: Teacher, how should I prevent infective endocarditis?
Teacher: In order to prevent the occurrence of infective endocarditis, there are risk factors (such as prosthetic valve replacement, history of infective endocarditis, body-pulmonary bypass, heart disease and congenital heart disease). Subject to surgery or instrumentation that may cause temporary bacteremia due to bleeding or significant trauma, such as oral, upper respiratory surgery or operation, urinary, reproductive and digestive surgery or operation, antibiotics should be used before surgery to prevent infection. Endocarditis.
The following points should be noted through the discussion of this example:
(1) At present, typical cases of infective endocarditis are rare. Therefore, for patients with predisposing factors, if there is unexplained fever for more than two weeks, it should be highly suspected to be infective endocardium. Due to inflammation, it is necessary to do multiple blood cultures in time and look for neoplasms, and try to increase their positive rate as much as possible.
(2) Before making a diagnosis of infective endocarditis, a differential diagnosis should be made, especially rheumatic activity and lupus erythematosus should be excluded.
(3) The treatment must follow the early use of antibiotics, the use of fungicides should be large, the treatment is long enough, intravenous medication, combined medication and other medication principles.
(4) For those with predisposing factors, preventive use of antibiotics before invasive examination or surgery to prevent the occurrence of infective endocarditis.
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