抗中性粒细胞胞质抗体阳性的感染性心内膜炎18例临床分析

Clinical analysis of 18 cases of infectious endocarditis with positive anti-neutrophil cytoplasmic anti-bodies

目的通过分析ANCA阳性的感染性心内膜炎(IE)的临床特点, 旨在提高临床诊疗水平。方法收集2016年6月至2021年7月在郑州大学第一附属医院住院确诊为IE且同时伴有血清学ANCA阳性的18例患者的临床资料, 回顾性分析其一般情况、临床表现、实验室检查、影像学检查、治疗及转归。采用SPSS 20.0软件进行统计分析。计数资料以例数和百分比(%)表示, 计量资料以±s表示。结果 18例患者中, 男性12例, 女性6例, 平均发病年龄(50±16)岁。除2例为髓过氧化物酶(MPO)-ANCA阳性外, 余均为蛋白酶3(PR3)-ANCA阳性。主要临床表现有发热(88.9%, 16/18)、贫血(72.2%, 13/18)、脾大(44.4%, 8/18)、心脏杂音(33.3%, 6/18)、关节痛(22.2%, 4/18)、肝损伤(22.2%, 4/18)、栓塞事件(16.7%, 3/18)、Osler结节(11.1%, 2/18)和肾功能不全(11.1%, 2/18)。83.3%(15/18)的患者ESR、CRP和降钙素原(PCT)明显升高。血培养阳性率50.0%(9/18), 链球菌(77.8%, 7/9)为最常见的致病菌。所有患者超声心动图均提示有赘生物, 最常累及二尖瓣(66.7%, 12/18)和主动脉瓣(33.3%, 6/18)。2例患者被误诊为ANCA相关血管炎(AAV), 另1例最终确诊为以IE为首发表现的AAV患者。经积极手术和抗生素治疗后, 除1例死于多脏器功能衰竭外均达到临床治愈。结论 ANCA阳性的IE患者可出现类似于AAV的临床表现, 应高度警惕此类疾病, 避免误诊误治。

Objective To study the clinical features of infective endocarditis(IE)with positive anti-neutrophil cytoplasmic antibodies(ANCA)in order to improve the level of diagnosis and treatment.Methods Eighteen IE cases with positive ANCA admitted to the First Affiliated Hospital of Zhengzhou University from June 2016 to July 2021 were collected.The demographic information,clinical symptom,laboratory tests,imaging examinations,treatment and clinical outcomes were analyzed retrospectively.Statistical program for social sciences(SPSS)20.0 statistical software was used for analysis.Enumeration data were expressed as the number of cases and percentage(%),and measurement data were expressed as Mean±SD.Results Twelve cases were male and 6 cases were female,with an average age of(50±16)years.Sixteen patients had positive PR3-ANCA,in which 2 cases had positive myeloperoxidase(MPO)-ANCA.The major clinical manifestations included fever(88.9%,16/18),anemia(72.2%,13/18),splenomegaly(44.4%,8/18),cardiac murmur(33.3%,6/18),arthralgia(22.2%,4/18),liver damage(22.2%,4/18),thromboembolic events(16.7%,3/18),Osler's node(11.1%,2/18)and renal dysfunction(11.1%,2/18).Higher C-reactive protein(CRP),erythrocyte sedimentation(ESR)and procalcitionin(PCT)were detected in 83.3%(15/18)patients.The positive rate of blood culture was 50.0%(9/18)and streptococcus was the most common pathogen(77.8%,7/9).Echocardiograms of all patients showed abnormal vegetation,most commonly involving the mitral valve(66.7%,12/18)and aortic valve(33.3%,6/18).Two patients were misdiagnosed as ANCA associated vasculitis(AAV),but the other one was diagnosed as AAV with IE as the first manifestation.Except for one case who died of multiple organ failure,all cases reached clinical recovery after surgery and antibiotic therapy.Conclusion IE patients with positive ANCA may present with the clinical manifestations similar to AAV.We should highly alert to avoid misdiagnosis and treatment.