Endocarditis

Endocarditis - inflammation of the valvular or parietal endocardium with rheumatism, less often with infection, including septic and fungal infections, with collagenoses, intoxications (uremia).

Subacute (prolonged) septic andocarditis (infectious andocarditis) is a septic disease with localization of the main focus of infection on the heart valves, less often on the parietal endocardium.

Etiology. Streptococci or Staphylococcus are the most common pathogens of the disease, less often Gram-negative bacteria (intestinal, pseudomonas aeruginosa, Proteus, etc.), pneumococci, fungi, bacterial forms, etc.

Pathogenesis. The defeat of the heart valves (infection) is caused by changes in humoral and local (cellular) immunity with the distortion of immunological reactions and the damage of various organs and systems (vessels, myocardium, kidneys, liver, nervous system, spleen, etc.). Significantly more affected affected valves with acquired and congenital heart defects, valve prostheses.

Symptoms, course. Characterized by fever of the wrong type, often with chills and sweat, sometimes with pains in the joints, pallor of the skin and mucous membranes. Perhaps a long febrile course. At the primary cardiovascular system, developed on intact valves, functional noises can first be heard, later heart disease, more often aortic, is formed. With secondary endocarditis, the character and localization of existing noises change due to progressive deformation of the valves or formation of a new defect. When the myocardium is damaged, there are arrhythmias, conduction disorders, signs of heart failure. Almost constant vascular lesions in the form of vasculitis, thrombosis, aneurysms of arteries and hemorrhages, localized in the skin and various organs (hemorrhagic rashes, cerebral vasculitis, infarcts of the kidneys and spleen, mycotic arterial aneurysms, etc.). Often there are signs of diffuse glomerulonephritis, an increase in the liver, mild jaundice, and hyperplasia of the spleen. Complications: formation of heart disease, rupture of valves, progressive heart failure, impaired renal function (proteinuria, hematuria, azotemia). Other complications are possible.

Laboratory data: typical hypochromic anemia, moderate leukopenia, significantly increased in ESR, blood levels of alpha-2 and gamma globulins, C-reactive protein. In blood cultures carried out repeatedly before the application of antibiotics, many patients can detect the causative agent of endocarditis and determine its sensitivity to antibiotics. According to some data, a more productive sowing is not venous, but arterial blood (from the femoral artery). Diagnosis is assisted by the echocardiography, which allows to detect vegetation on the valves or their dysfunction.

Acute septic endocarditis is considered as a complication of general sepsis, in zthiology, pathogenesis and the clinic, this form of the disease is not significantly different from the subacute form, characterized only by a more acute course.

Treatment of septic endocarditis should be early and etiotropic taking into account bacteriological data. Apply bactericidal antibiotics, preferably in individualized doses, depending on the concentration of antibiotic in the blood and the sensitivity of the pathogen. In the case of an unknown pathogen, treatment starts with high doses of benzylpenicillin IM or I / O up to 18,000,000 - 20,000,000 units or more in combination with streptomycin to 1 g IM daily or aminoglycosides (gentamicin, tobramycin at a rate of 4 - b mglkg per day). In the absence of effect or after bacteriological clarification, semi-synthetic penicillins (oxacillin, methicillin or ampicillin im / 12 g / day), cephalosporins (kefzol up to 8-10 g IV, etc.) are prescribed. The duration of antibiotic therapy is determined by the patient's condition and should be Not less than 4 weeks; Premature discontinuation of therapy or an unreasonable decrease in the dose of antibiotics can contribute to the occurrence of relapses of the disease and the formation of a microbial pathogen refractory to antibiotics. With reduced immunoreactivity of the body, antibacterial agents are combined with passive immunotherapy (with staphylococcal endocarditis - with antistaphylococcal plasma or antistaphylococcal gamma globulin), using immunomodulators (thymalin, T-activin, etc.). In case of complications related to hypersensitivity (diffuse glomerulonephritis, vasculitis, myocarditis, etc.), a combination of antibacterial agents with short courses of corticosteroid medication at medium doses (prednisolone 15 mg / day) is justified. To prevent thrombosis, for example, in cardiac patients developing against the background of angiogenic sepsis (infection of the intravenous catheter), a controlled hypocoagulation is created with heparin of 20 000 - 25 000 units I / O IV or IV. For the inhibition of proteolytic enzymes apply contrikal (up to 40 000 - 60 000 U / in drip). With ineffective treatment of endocarditis, as well as in the presence of refractory heart failure, the indications for surgical removal of the affected valve and its subsequent prosthetics are expanded.

The prognosis is always serious, but with prolonged and persistent therapy, in a significant part of cases, recovery and recovery of work capacity occurs.

Prevention: timely sanation of chronic foci of infection in the oral cavity, tonsils, nasopharynx, paranasal sinuses, etc., active antibacterial therapy of acute streptococcal and staphylococcal diseases (angina, etc.). Tempering the body. Preventative rational antibacterial prophylaxis (short courses) in patients with heart defects in the occurrence of intercurrent diseases, during surgical interventions and invasive instrumental studies (catheterization of the heart, kidneys, etc.). Dispensary observation of persons who have experienced acute streptococcal, staphylococcal infections.