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個案病史：
This 26-year-old woman was well before. She developed fever
and general malaise about one month ago. No cough, sore
throat, rhinorrhea, or other symptoms was noted. She visited
local hospital 3 days after the onset of above symptoms. Some
kind of viral infection was informed over there. She was put
on some oral medication. However, the symptoms persisted. In
addition, progressively exertional dyspnea developed gradually
two weeks after onset of fever. Right flak pain was also noted
later. She visited another local hospital one week before
presentation to our hospital. At that local hospital,
microscopic hematuria and mild pyuria were noted by urine
analysis. Urinary tract infection was told and she was put on
oral antibiotics. Unfortunately, the symptoms did not resolve.
Finally, she visited our hospital for further management.
Tracing back her history, no special underlying disease, no
special travel history was noted. She lived in the urban area
of Pan-Chiao City and worked in a electronic company as a
counter.
Physically, the body temperature was
38o C, the blood pressure
was 120/80 mmHg, the heart rate was 110 beats per minute
regularly, and the respiratory rate was 24 times per minute.
Icteric sclera and mild pale conjunctivae were noted. A grade
II/VI pan-systolic murmur over apical area was found. Mild
hepatomegaly and knocking tenderness over right flank were
also noted. Otherwise was un-remarkable. The hemogram revealed
WBC count 16300/μl, hemoglobin 9.2 g/dl, and platelet count
151K/μl. The total bilirubin and direct bilirubin level were
3.5 mg/dl and 0.6 mg/dl respectively. The urine analysis
revealed microscopic hematuria with borderline pyuria. After
collection of two sets of blood culture, she was put on first
generation cephalosporine. Both sets of blood culture yielded
Streptococcus oralis two days later, which was susceptible to
penicillin by drug susceptibility test. The transthoracic
echocardiography revealed a shaggy vegetation over anterior
leaflet of mitral valve. Under the impression of infective
endocarditis, the antibiotics were shift to high dose
penicillin (3,000,000 units every 4 hours) plus gentamicin (60
mg every 8 hours). The fever subsided completely 5 days later
and her general condition as well as other associated symptoms
and signs improved gradually. After completion of 4-week use
of antibiotics, she was discharged from our hospital.
解析：
感染性心內膜炎（infective endocarditis,
IE）一般好發在已有問題存在的瓣膜上（如風濕性心臟病、人工瓣膜等）、或宿主有一些特別的危險因子（如靜脈藥癮者）。但臨床上亦可見此症發生在健康的宿主身上。文獻上常提及IE和先前的牙科手術或治療有關，但臨床上常常無法追溯到這樣的相關性。IE本身除了發燒外，初期並無明顯的症狀，經常會被誤以為是一般的病毒感染。但此時若能好好的聽病人的心音，發現有心雜音的存在，進而考慮是否為IE的可能性，應該能使IE的診斷較為容易。
其它IE較常出現的症狀包含倦怠，體力退化，敗血性栓塞，Osler node，Janway lesion，split
hemorrhage，hemolysis等等。臨床上診斷IE的最主要兩個條件是持續性的菌血症及心臟超音波發現有典型的贅生物（shaggy
vegetation）。常見的致病菌為金黃色葡萄球菌及草綠色鏈球菌等；有靜脈藥物成癮者，尚須考慮綠膿桿菌為其致病菌。IE一般的治療是以內科療法、投予長時間高劑量的抗生素為主。在給藥期間，應特別注意因長時間高劑量抗生素所導致的drug
fever。某些情況下，IE治療須考慮外科療法：持續性的菌血症，rupture of chordae
tendineae，perforation of valve，annular abscess，repeatedly
systemic
emboliaztion，無法控制的心臟衰竭等。
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Case Discussion
繼續教育考題