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<Brief
History>
This
38-year-old male was admitted to the hospital because of
hemoptysis and leg edema for more than one month.
The patient had
been a heroin addict and received abstinence program at a
psychiatry hospital. He denied use of morphine, heroin or
other illicit drugs over the past one year. Cough of
blood-tinged sputum and lower leg edema developed and
continued since one month ago. Sudden onset of shortness of
breath, cold sweating and left chest tightness prompted his
seeking medical help at the emergency department.
On physical
examination, he appeared acutely ill-looking in moderate
respiratory distress. His consciousness was clear. Body
temperature was 37.1°C, radial pulse was regular with rate of
109/minute, respiratory rate was 30/minute, and blood pressure
80/50 mmHg. A dragon tattoo was found at the trunk. Several
needle track were identified at both groins which were without
discharge. There was no splinter hemorrhage, Osler’s nodes or
Janeway lesions. Jugular venous pressure was raised. Clubbing
fingers and grade 2 leg pitting edema bilaterally were noted.
Chest auscultation revealed crackles bilaterally and decreased
breath sound at the left lung. No heart murmurs were audible.
The abdomen was distended and tympanic, without organomegaly
or tenderness.
<Lab
Data> Table 1
1.CBC/DC
|
WBC |
N/L |
RBC |
Hgb |
MCV |
PLT |
|
17.46k |
88/5 |
2.49 M |
6.4 g/dl |
78.9 fL |
37k |
2.SMAC
|
Na |
K |
Glu/ |
GOT |
GPT |
BUN |
|
130mEq/L |
3.9mEq/L |
125mg/dl |
56IU/L |
25IU/L |
50mg/dl |
|
Cr |
CK |
CK-MB |
|
|
|
|
2.0 mg/dl |
69IU/L |
0IU/L |
|
|
|
3.ABG
(room air)
|
PH |
PCO2 |
PO2 |
HCO3 |
|
7.53 |
28.4 mmHg |
54.9 mmHg |
23.6
mmol/L |
4.Serology
|
VDRL |
TPHA |
HBsAg |
Anti-HBs |
Anti-HCV |
Anti-HIV |
|
1X |
1: 320 |
negative |
positive |
positive |
negative |
<Coure and Treatment>
After admission, a chest
radiograph (fig
1) showed pleural effusion at the
left lung and a chest tube was inserted. Oxacilline and
ceftazidime were begun at high doses because bacterial
endocarditis was suspected. Cultures of the blood and sputum
specimens yielded methicillin-senistive Staphylococcus
aureus.
Transthoracic echocardiogram revealed a
vegetation of 1.4 x 0.5 cm in size at the septal leaflet of
the tricuspid valve with moderate tricuspid regurgitation.
Tachypnea, hypotension, and hypoxemia (Table 2) continued to
worsen despite antimicrobial therapy. Emergent surgical
intervention with tricuspid valve valvectomy was performed and
culture of the excised vegetation also revealed
methicillin-senistive S. aureus
. He was discharged in good
condition 6 weeks later.
Table 2 (ABG after admission)
|
|
Day 2 |
Day 3 |
Day 4 |
Day 5 |
|
PH |
7.573 |
7.547 |
7.45 |
7.58 |
|
PCO2 |
27.9 |
32.8 |
39.2 |
33.8 |
|
PO2 |
94.2 |
88.4 |
81.3 |
73.8 |
|
HCO3 |
25.7 |
28.4 |
26.8 |
27.3 |
|
Oxygen |
8L/min( mask) |
8L/min (mask) |
12l/min( large
volume) |
<案例分析>
此病例為一靜脈注射毒癮者合併金黃色葡萄球菌心內膜炎的典型例子。在國外以靜脈注射毒癮者為主的心內膜炎感染者，病原菌通常是來自皮膚的表層，金黃色葡萄球菌的感染比例佔了50％以上，其他如鏈球菌、腸球菌佔20％，革蘭氏陰性菌則以綠膿桿菌為主，黴菌感染也偶有所聞，主要是念珠菌。有時還合併多種病菌一起感染。金黃色葡萄球菌的心內膜炎病程通常是一急性發作表現，感染的瓣膜以三尖瓣居多（佔50％以上），敗血性肺栓塞常是三尖瓣心內膜炎的合併症而心雜音常常是聽不出來的。
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Case Discussion
繼續教育考題