Case Discussion       A 35-years-old man developed intermittent spiking fever 2 weeks prior to hospital admission. He didn't receive dental extraction in the recent one year and denied to be deneral malaise, night sweat and anorexia. The patient was admitted to A-Hospital on 2000, 08, 26 and received several doses of cefazoline, (a cephalosporin), during the hospitolization period. During the period at that hospital, productive cough with whitish sputum and hemorrhagic maculas on palms were noted. Echocardiogram showed bicuspid aortic valve with severe aortic regurgitation. Blood cultures drawn at the time of the fever were subsequently positive for gram-positive cocci. He was transferred to B-Hospital ES on 2000, 8, 29. Initial electrocardiography at ES demonstrated complete AV block. Hemodynamics were stable at that time. For further management of his A-V block, he was admitted to CCU.        Physically, in general, he was in acute-ill looking with clear consciousness. Blood pressure was 114/36 mmHg. Pulse rate was regular and 82/min. Body temperature was 39.2℃. Respiratory rate was 24/min. Conjunctiva was mild pale. Sclera was not yellowish. Neck was supple without jugular engorgement, carotid bruit or lymphadenopathy. The chest wall was symmetric without deformity. The breath sound was bilateral basal crackle without wheezing. Irregular heart beat with grade III/VI to and fro murmur over right sternal border . No S3 or S4 gallop was noted. Abdominal examination revealed unpalpable liver and spleen. No tenderness or rebounding tenderness was noted. Lower legs were not pitting edematous. Peripheral pulse was symmetric. There were some, linear dark red streaks over his digits of upper extrimities. Several 1-4 mm, non-tender, hemorrhagic maculas on palms were also noted. Laboratory Findings: 1. CBC:   WBC (/ul)  Hb (g/dl)  MCV (u3)  Plt (k/ul)  PTT (sec)  8/29 14260 10.2 91 79.3 52.6/37.6 8/31 19150 11.9 81.1 137   9/2 15530 10.4 84.8 260   9/4 27540 9.6 84.0 278    2. BCS:   A/G (g/dl) Bil(T/D) (mg/dl) ALP (U/l) GOT/GPT (U/l) r-GT (U/l) LDH (U/l) BUN/Cr (mg/dl) TG/Chol (mg/dl) 8/30 2.4/3.3     55     23/0.8   9/1   1.9   138     17/0.9   9/4 2.9/4.1 1.8/1.2 693 565/557     24.4/1.3   3. Elctrolyte: (8/30) Na: 138 mM; K: 4.9 mM; Ca: 1.04 mM (9/01) Na: 134 mM; K: 5.5 mM; Ca: 2.03 mM; Mg: 0.9 mM; P: 4.3 mg/dl (9/04) Na: 124 mM; K: 5.4 mM; Ca: 2.17 mM; Mg: 0.86 mM; P: 5.4 mg/dl 4. Others: Pericardial effusion culture (8/30): No pathogens Valve tissue culture (8/30): Staphylococcus aureus (3+) sensitive to oxacillin Sputum culture (8/30): No pathogens Vancomycin (9/1): 16.07 mg/ml (peak 30-40) C-Reactive Protein (8/30): 15.7 mg/dl ECG (8/29): Ventricular rate 78 bpm Axis within normal limit Complete AV block Echocardiogram (8/29): 1. LVEF 0.64 by M-mode 2. Vegetations over aortic valve with abscess formation 3. Suspected left to right shunt (Ao to RV) 4. AR, severe 5. Mild TR 6. Mild MR Swan-Ganz catheterization & R't heart catheterization: Indication: suspected L’t to shunt (Ao to RV) Findings:     RA mean: 8     RV: 28/5     MPA: 30/13 mean 20     Venous sampling: IVC RA RV PA PAWP     O2 saturation : 77 73.9 70.1 74.2 70.2 Clinical Course & Treatment:       Due to severe toxic manifestation and progression of hemodynamic deterioration. The patient undertook emergent operation on August 30. The operation findings were Antibiotics in penicillin G 3MU iv q4h with gentamicin 80 mg iv q8h, then shift to vancomycin and prostaphyllia. Op Findings: 1. Aortic valve: Thickening change of valve leafleat cogenital, cogenital bicuspid morphology. 2. Subaortic cavitation with vegetation below NCC was noted, about 2xl cm in size. 3. Poor leafleat comptation with severe AR. 4. Aorto-mitral discontinuity. 5. Pericardial cavity, full of yellowish turbid 6. Flagile heart tissue. 7. Heart 病案解說： 本病人有兩個星期持續發燒，伴隨全身勞累，夜間盜汗及食慾不振等非特異性症狀。此種沒有其他感冒症狀(流鼻涕、咳嗽、喉嚨痛或有痰)的發燒，往往被病人自己或醫師認為是感冒，其實不是，這是在診療病人時要小心。病人在甲院住院時，已出現有micro emboli的現象在手掌，當時的心臟超音波只看到二瓣性的主動脈及厲害的主動脈閉鎖不全。(但依八月二十九日在乙醫院急診處的心臟超音波所見，八月二十六日應該已有主動瓣的vegetation)。 病人到乙醫院的一系列心電圖顯示心跳增快但心房-心室傳導障礙卻持續進行且越來越厲害，甚至已至complete A-V block，此和主動脈瓣和二尖瓣相對構造及介在他們中間的傳導系統功能受到阻礙有關。 從病史，病人外觀(acute ill looking )，理學檢查及乙院胸前心臟超音波及所見，主動脈的急性感染性心內膜炎合併厲害的主動脈瓣閉鎖不全，主動脈瓣環(aortic ring abscess formation)並影響A-V conduction及有周邊的emboli甚為明顯。而其血液培養及手術切下的主動脈瓣組織培養為革蘭氏陽性球菌staphylococces，為毒性相當強，組織破壞力很厲害的細菌，因此，病程發展很快。 正常的瓣膜得到感染性心內膜炎最常見的細菌是streptococcus viridans，其毒性不高病程亦較緩和，對抗生素治療之藥物抵抗性亦較少，因此預後較佳，需要外科開刀治療之機會亦少。本病人先天上為二瓣性的主動脈瓣，先天已有缺陷之瓣膜比較容易感染心內膜炎。急性心內膜須進行緊急開刀的情況有主動脈瓣環有abscess formation，瓣膜受損嚴重導致閉鎖不全嚴重，傳導障礙，有週邊栓塞(embolization)等現象﹐綜觀本病人﹐幾乎每一條都存在，因此，緊急開刀雖然具高mortality risk，仍然不得不進行。黴菌性心內膜炎或置換性瓣膜心內膜炎對內科治療的反應差，儘早開刀亦為一般之處置方針。 繼續教育考題 1. (D) 建議術前給予抗生素預防心內膜炎。這些病人不包括: A 風溼性心臟病 B 二尖瓣脫垂症(mitral valve prolapse)併瓣膜增厚或逆流 C 曾接受人工心瓣膜置換的病人 D 接受冠狀動脈繞道手術(CABG)者 2. (B) 建議術前給予抗生素預防心內膜炎。這些術式不包括: A 拔牙 B 經食道心臟超音波 C 膀胱鏡(cystoscopy) D 扁桃腺切除術(tonsillectomy) 3. (D) 主動脈閉鎖不全之嚴重度下列那一標準較可靠： A 發燒之體溫越高越厲害 B 有無週邊栓塞 C 雜音的音量大小與位置 D 舒張期血壓越小者越厲害 4. (A) 沒有瓣膜崎型的瓣膜，最容易發生心內膜炎的細菌是： A Streptococcus veridans B Fungus C Staphylococcus D Klebsiella pneumonia 5. (A) 下列有關於心內膜炎病原菌與致病途徑的組合,何者為錯? A Mouth (Streptococcus viridans) B Wounds/skin (Staphylococcus) C Bladder catheters (Coxiella, Chlamydia) D Gastrointestinal pathology (Streptococcus bovis) 6. (D) 下列有關於心內膜炎病原菌與致死風險性的組合,何者為錯? A Streptococcus viridans--low risk B Other streptococci, enterococci--intermediate risk C Other bacteria, staphylococci, fungi-- high risk D All are correct 7. (B) 下列有關於左側心內膜炎引起主動脈環膿瘍(ring abscess)後的併發症,何者為錯? A Ventricular septal defect B Pulmonary septic emboli C Complete heart block D Pericarditis 8. (B) 根據Durack 在1994年發表的心內膜炎診斷準則,下列何者不是major criteria? A positive cultures on 2 occasions before treatment B fever, a vascular phenomenon, and immunologic reaction C periannular abscess or evidence of dehiscence of a portion of a valve D phenomenaechocardiographic demonstration of an oscillating mass on a valve . 9. (B) 抗生素治療心內膜炎的原則應包括:(以下何者為非) A Use a bacteriocidal drug, not a bacteriostatic drug. B Blood cultures may be not repeated after initiation of antibiotic therapy. C Repeat blood cultures until the blood is sterile. D In addition to administering antibiotic therapy, it is important to call the surgeon early. 10. (D) 外科治療心內膜炎的原則應包括:(以下何者為非) A The surgeon should be involved early in the treatment of patients with active infective endocarditis. B Adequate debridement of the infective material is essential C Repair is possible only with vegetations on the tricuspid valve or mitral valve; it is usually impossible with infection involving the aortic valve. D Early surgical therapy for active infective endocarditis decreased the mortality by about 10%.

答案解說 答案解說: 1. 建議術前給予抗生素預防心內膜炎。這些病人不包括:  D. 接受冠狀動脈繞道手術(CABG)者, 其危險性和一般常人無顯著差 別，故不須在術前給予抗生素預防心內膜炎 2. 建議術前給予抗生素預防心內膜炎。這些術式不包括: B. 經食道心臟超音波造成菌血症的機率不高（小於10％）。 即使出現菌血症，這些細菌也不容易引起心內膜炎。所以術前不需抗生素預防. 3.主動脈閉鎖不全之嚴重度下列那一標準較可靠： D. 舒張期血壓越小者越厲害代表脈搏壓越大,主動脈閉鎖不全越嚴重 4.沒有瓣膜崎型的瓣膜，最容易發生心內膜炎的細菌是： A.   Streptococcus viridans 5.下列有關於心內膜炎病原菌與致病途徑的組合,何者為錯? A. Coxiella and Chlamydia cause infective endocarditis via inhalation . 6.下列有關於心內膜炎病原菌與致死風險性的組合,何者為錯? D. All are correct. The table below shows the risks associated with various pathogens. Pathogen Risk group Mortality Streptococcus viridans Low 5~10% Other streptococci, enterococci Intermediate 20~30% Other bacteria, staphylococci, fungi High >50% 7.下列有關於左側心內膜炎引起主動脈環膿瘍(ring abscess)後的併發症,何者為錯? B. Pulmonary septic emboli is usually the killer with right-sided infective endocarditis. 8.根據Durack 在1994年發表的心內膜炎診斷準則,下列何者不是major criteria? B. Fever, a vascular phenomenon, and immunologic phenomenon are minor criteria. 9.抗生素治療心內膜炎的原則應包括:(以下何者為非) B. Blood cultures should be repeated 48-72 hours after initiation of antibiotic therapy. 10.外科治療心內膜炎的原則應包括:(以下何者為非) D.   Early surgical therapy for active infective endocarditis decreased the mortality by about 50%. Top of Page