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。
|