Etiopathogenesis
Septic endocarditis - inflammation of the inner layer of the lining of the heart with sepsis. A characteristic sign of pathological anatomy in such a case is ulceration of the valves of the organ. The diagnosis is further complicated by the fact that it develops mainly in unhealthy people with a reduced immune response of the body. Often, septic endocarditis affects patients with rheumatic diseases, who in turn have defective heart valve structures. Patients with congenital defects of this organ are also at risk of encountering pathology.
Patients of advanced age are also susceptible to septic endocarditis. As a rule, they already have dilatation of the left chambers of the heart, in which the mitral and aortic valves are affected.
But inflammation of the right myocardium is typical for injection drug users and patients with intravascular catheters.
The picture of septic endocarditis depends on the agent by which it is caused. Fungus and gram-negative microflora become the cause of the disease very rarely, and if there are exceptions, then only in drug addicts and people who have undergone heart valve replacement. In addition to the above reasons, the disease is caused by ordinary or green streptococcus, less often white, Staphylococcus aureus, enterococcus.
The disease is difficult to recognize. Often, the final diagnosis is made with an obvious picture of pathology, when symptoms of heart failure appear.
Classification according to the course of the disease:
- Sharp - lasts more than a half moon;
- subacute septic endocarditis - up to three months;
- chronic, which can last for years.
According to the clinical and morphological form, the disease is divided into primary (the outdated name is Chernogubov's disease) and secondary. The first type occurs in about thirty percent of the total number of patients with unchanged valves. The second is diagnosed in the vast majority of patients with rheumatic heart disease. Occasionally, the secondary variant is diagnosed in people with congenital malformation, as well as atherosclerotic, syphilitic lesions.
Clinical manifestations
The clinical and anatomical picture of septic endocarditis depends on many factors: stage, prevalence of damage to certain organs, differentiation by infectious agents. The disease is usually preceded by tooth extraction, tonsillectomy, surgery or research on the urethra, abortion. The disease develops imperceptibly, usually within two weeks from the moment of injury, but is rapidly gaining momentum.
The main clinical manifestations:
fast fatiguability;
- fever;
- losing weight;
- prostration;
- hematuria;
- night sweats;
- arthralgia.
Other manifestations of the disease are also possible. Embolism causes paralysis, chest pain due to myocarditis or pulmonary infarction. Vascular disorders provoke pain in the limbs, abdominal region, hematuria.
Severe disorders are also manifested in the brain in the form of ischemia, abscesses, toxic encephalopathies, subarachnoid hemorrhages as a result of rupture of a mycotic aneurysm, meningitis.
Delivers problems to the patient and remitting fever with chills. The pulse is often high, it accelerates even more with the development of heart failure.
The appearance of the patient will also tell a lot. The patient can be observed pallor and mucocutaneous manifestations. As a rule, these are small ruby petechiae like hemorrhages that do not brighten when pressed. The main localization of the rash is the oral cavity, conjunctiva, upper chest. On the mucous membranes, they are distinguished by pallor in the middle of the formation. Subungual linear hemorrhages also attract attention. It is important to differentiate them from traumatic injuries.
Arterial embolism causes gangrene of the arms or legs. The fingers of the upper extremities may change according to the type of "drumsticks", nodules appear on the surface of the palms. Sometimes patients have mild jaundice.
It is very important to listen to the heart if septic endocarditis is suspected.
Signs noted on auscultation:
- deafness of blows;
- arrhythmia;
- cardiopalmus;
- gallop rhythm.
Symptoms of malformation:
- weakening (disappearance) of the second tone over the aorta;
- systolic murmur at the top;
- diastolic over the aorta and Botkin's point;
- Flint noise.
With infective endocarditis, splenomegaly is common. With a necrotic lesion of the spleen, a typical rubbing noise occurs. The liver remains of normal size until the development of heart failure.
Modern diagnostic methods
The world clinical practice has generalized and derived the criteria that are used for the diagnosis of septic endocarditis. They are divided into large and small. The large ones include blood tests, during which a culture of microbes responsible for infecting the body is sown.
Big signs:
- two positive blood cultures taken at least twelve hours apart;
- three out of three positive crops;
- out of four blood cultures or more, the maximum is positive;
- proven endocardial damage;
- characteristic symptoms of acute septic endocarditis on ultrasound of the cardiovascular system.
Small signs:
- predisposition;
- fever;
- vascular changes;
- change in laboratory blood rates. The presence of anemia, a shift in the leukocyte formula, an increased erythrocyte sedimentation rate, the presence of C-reactive protein, a decrease in platelets, etc.
The final diagnosis is made in the presence of the so-called pathological criteria:
- the presence of a positive blood culture;
- the presence of an intravascular substrate;
- myocardial abscesses.
All of the above positions must be confirmed histologically or by adding criteria: two large, or one large, plus three small or five small.
The diagnosis of septic endocarditis is questioned, provided that there were not enough criteria for a certain infectious myocardial lesion, but it was not possible to refute it entirely.
The suspicion of pathology is removed if, when taking antibiotics for four days, the disappearance of symptoms is observed or signs of infection are absent in blood samples for the same duration of therapy.
Differential diagnosis
Young and middle-aged patients with suspicion of septendocarditis require careful differential diagnosis with rheumatic lesions accompanied by an increase in temperature. In older people, the diagnosis should be separated from cancer problems. In a pathomorphological study of patients with some types of cancer, thromboendocarditis may be detected, which did not manifest itself in any way during a person's life.
This disease is often mistaken for malaria. The diagnosis changes in favor of endocarditis if no plasmodia is found. Blood in the urine and back pain are encouraging to think about urolithiasis (Urolithiasis). However, groin pain is symptomatic for this disease.
An imperceptible debut (low-grade fever, loss of strength, pain in the joints and head) makes it possible to differentiate bacterial endocarditis from rheumatism, and in aortic insufficiency - from visceral syphilis. In all these cases, the tactics are decided by positive tests for microbial culture.
Patient treatment and observation
This disease is always treated in a hospital setting with adherence to medication and diet.The patient's physical activity is minimal.
For certain septic endocarditis, massive antibiotic treatment is used. The drug is chosen, taking into account the sensitivity of the alleged infectious agent to it. Usually, the appointment of a broad-spectrum drug from a number of penicillins, cephalosporins is indicated. They are often combined with aminoglycosides. Antimycotics and NSAIDs may be prescribed.
For endocarditis with an unexplained pathogen, combined antibiotics are used, for example, tetracycline, terramycin, erythromycin. It is preferable to change the drugs every two to four weeks due to the development of microorganism resistance to them.
The effectiveness of treatment can be assessed by the following criteria:
48–72 hours after the start of therapy, the state of health, appetite improves, chills disappear;
- at the end of the first week, the body temperature drops to normal values, the disappearance of petechiae, embolism, an increase in hemoglobin, a decrease in ESR, the sterility of crops is recorded;
- at the end of the third week - the transition to normal leukoformula, ESR, spleen state;
- at the end of treatment - the rate of ESR, proteinogram, hemoglobin. New vasculitis and thromboembolism do not occur.
Sometimes surgical intervention cannot be avoided. As a rule, this happens in cases where conservative therapy has not been successful.
In terms of further observation, the patient is shown prosthetics of the heart valve system. It is important to know that a relapse of an infectious disease is always possible.
Sanatorium treatment in an institution with a cardiological focus may be recommended. Dispensary observation of a patient who has had infective endocarditis is mandatory.
In terms of prognosis, it is worth noting that patients do not recover often without treatment. With early antibiotic therapy, about 70 percent of patients with infection of their own valvular structure and 50 percent of those with lesions of prosthetic structures overcome the disease.
Conclusions
Septic endocarditis is a complex disease that often leads to death, therefore the main position in its prevention is prevention. For all patients with heart defects and diseases that are dangerous in the spectrum of bacterial endocarditis, it is important to thoroughly sanitize the foci of infection by taking antibiotics.
You should also do with even minor surgical interventions such as tooth extraction.
