右心感染性心内膜炎致脓毒性肺栓塞临床特点分析

Septic Pulmonary Embolism Caused by Right-sided Infective Endocarditis:Report of 16 Cases

目的探讨右心感染性心内膜炎致脓毒性肺栓塞(SPE)患者临床特点,加强对SPE认识,提高SPE诊治水平,改善预后。方法回顾性分析北京世纪坛医院和北京协和医院1990年1月至2016年12月收治确诊的16例右心感染性心内膜炎致SPE患者临床资料、实验室检查、治疗和预后。结果 16例患者男女比例10:6,发病中位年龄35,6岁,临床表现发热(100%)、咳嗽(75%)、呼吸困难(50%)、胸膜性胸痛(68.8%)和咯血(81.3%);16例患者均符合右心感染性心内膜炎诊断标准及明确诊断SPE,4例患者未发现易感因素,12例患者发现SPE易感因素/存在基础疾病和可能来源,包括静脉吸毒1例、感染3例(足趾部1例、起搏器2例)、存在基础疾病2例(白塞病1例、再生障碍性贫血1例)、先天性心脏病5例、同时存在基础疾病(再生障碍性贫血)及易感因素(中心静脉置管—PICC管)1例;可能病原菌葡萄球菌属4例、链球菌属3例、杆菌属3例、真菌2例、分枝杆菌属1例、未能明确病原菌1例及混合感染2例;胸片及胸部CT表现通常非特异,CT检查更有助于诊断,必要时应积极行肺动脉CT血管造影(CTPA,首先推荐)或V/Q显像明确;治疗方法除抗微生物治疗外,还包括拔除中心静脉置管、拔除/更换起搏器及心脏外科手术,结果3例死亡,13例治愈。结论 SPE是一种少见但严重的疾病,常表现非特异性临床和影像学征象,对于感染性心内膜炎患者,出现呼吸系统症状及胸部影像学异常时需高度警惕SPE。早期诊断及积极干预可改善预后。

Objective To study the clinical features of septic pulmonary embolism caused by right-sided infective endocarditis,to futher understand septic pulmonary embolism, improve the treatment level of septic pulmonary embolism and prognosis. Methods 16 cases of septic pulmonary embolism caused by right-sided infective endocarditis hospitalized in Beijing Shijitan Hospital and Peking Union Medical College Hospital between 1990 and 2016 were analyzed retrospectively,including the clinical characteristics,laboratory results,treatment and prognosis.Results The study included 10 males and 6 females with a median age of 35.6 years.Presenting clinical symptoms included fever（100%）,cough（75%）,dyspnea（50%）, pleuritic chest pain（68.8%）,and hemoptysis（81.3%）. All 16 patients met the diagnostic criteria for right-sided infective endocarditis and for SPE, among which 4 patients were not found the predisposing factors,while the other 12 patients were found the factors/underlying diseases and possible sources of susceptibility to SPE, including intravenous drug abuse（1 patient）,toe infection（1 patient）,pacemaker infection（2 patients）, congenital heart disease（5 patients）,underlying diseases（2 patients）1 patients of Behcet＇s disease, 1 patents of aplastic anemia）,and at the same time, 1 patients had both underlying diseases（aplastic anemia）and predisposing factors（PICC）.Possible pathogens were staphylococcus（4 patients）,Streptococcus（3 patient）,bacillus（3 patient）,fungus（2 patients）,mycobacteria（1 patient）,unidentified（1 patient）and mixed infections（2 patients）.Chest radiographic presentations and chest CT manifestations were usually non-specific,CT examination was more helpful to diagnosis, when necessary, CTPA（first recommended） or V/Q imaging should be actively performed.Besides antimicrobial therapy, the treatment included removal of the central venous catheter, removal and replacement of the pacemaker and cardiac surgery. In addition to 3 deaths,13 cases were cured. Conclusions We conclude that SPE is a rare but serious disease,it presents with variable and often nonspecific clinical and radiographic features.For patients with infective endocarditis, SPE diagnosis should be highly vigilant when respiratory symptoms and chest imaging abnormalities occur.Early diagnosis and active intervention can improve the prognosis of the patients.