感染性心内膜炎诊断标准的评价——附病理证实216例分析

Evaluation of diagnostic criteria for infective endocarditis:an anal ysis of 216 pathologically proven patients

目的 为提高诊断的敏感性 ,中华医学会儿科学分会心血管学组和中华儿科杂志编委会提出感染性心内膜炎 (infectiveendocarditis ,IE)诊断标准 (简称试行标准 )。本研究评估Duke标准与试行标准对IE的诊断价值。方法 从 15所医院收集经尸检或手术证实 (有血培养及超声心动图检查资料 )的IE 193例 (A组 ) ,≤ 17岁 12 7例 ,平均年龄 8 5岁 ,≥ 18岁 66例 ,平均年龄 3 5 9岁 ,及临床诊断IE而手术未发现IE征象的 2 3例患儿 (B组 ) (除 2例成人 ,平均年龄 4 7岁 )的病历资料。以Duke标准及试行标准对 2 16例进行诊断评估 ,并比较二种诊断标准对IE诊断的敏感性及特异性。结果 ( 1)A组病例中 ,连续 2次血培养阳性并为相同病原菌的有 50例 ( 2 5 9% ) ,1次血培养阳性有 3 6例 ( 18 7% ) ;超声心动图发现心内膜受累征象 165例 ( 85 5% ) ,160例 ( 82 9% )为赘生物 ,其中 10 0例的赘生物呈摆动团块 ( 62 5% )。B组病例中 ,连续 2次血培养阳性并为相同病原菌的有 3例( 13 0 % ) ,1次血培养阳性 2例 ( 8 7% ) ,超声心动图检查仅 1例 ( 4 3 % )伴有三尖瓣赘生物。 ( 2 )A组病例中按Duke标准 94例 ( 4 8 7% )被确诊为IE。按试行标准 ,156/ 193例 ( 80 8% )被确诊为IE ,其中62例 ( 3 2 % )符合心内膜受累超声心?

Objective Eighteen to twenty-four percent of patients with infective endocarditis (IE) proved pathologically were clinically possible IE by the Duke criteria In order to improve the sensitivity, the new criteria (trial) for the diagnosis of IE was proposed by Pediatric Cardiology Association of China and Editorial Committee of Chinese Journal of Pediatrics The aim of this study was to evaluate and compare the value of the new criteria (trial) for the diagnosis of IE with the Duke criteria Methods Group A consisted of 193 patients proved with IE at autopsy or surgery, where the cases had the results of blood culture and echocardiography data, and Group B had 23 patients with clinical diagnosis of IE in whom evidence of IE was not found at surgery All the above cases were collected from 15 hospitals They were analyzed and classified by the new criteria and at the same time by the Duke criteria The sensitivity and specificity of both criteria for the diagnosis of IE were compared Results (1) In Group A, same microorganisms were detected twice in blood culture in 50 patients (25 9%), while 36 patients (18 7%) had only one positive blood culture Endocardial involvement was found by echocardiography in 165 cases (85 5%), including vegetation in 160 (82 9%), perforation of aortic valve in 4 (2 1%), and partial dehiscence of ventricular septal defect (VSD) patch in one (0 5%) Vegetation appeared oscillating masses in 100 cases (62 5%) One hundred and eighty (93 3%) patients had predisposing heart conditions, and 151 (72 8%) with congenital heart diseases Fever was revealed in 178 cases (92 2%) Vegetation or perforation of aortic valve was detected in all patients without fever Heart failure was complicated in 91 patients, 7 of whom had no fever Vascular phenomena including petechiae and major arterial emboli occurred in 21 and 28 cases, respecti-vely Among immunologic phenemena, glomerulonephritis occurred in 9, elevated rheumatoid factor in 17/25 and elevated CRP in 51/71 In Group B, the same microorganism was detected in blood culture twice in only 3 patients and 2 patients had one positive blood culture Vegetation in tricuspid valve was found by echocardiography in one patient (2) Ninety-four cases (48 7%) of Group A were clinically confirmed IE by the Duke criteria The diagnosis was made on the basis of two major criteria in 42, one major and 3 minor criteria in 52 14 of 99 as possible IE were excluded by the modified Duke criteria On the other hand, a definite diagnosis of IE was made in 156 patients (80 8%) by the new criteria Of them, 94 met with definite criteria of the Duke criteria, 62 (32%) met with echocardiographic evidence of endocardial involvement (major criteria) and two minor criteria No patient of Group B was clinically definite with the Duke criteria, but one patient was clinically definite with the new criteria (trial) (3) The sensitivity and specificity for the diagnosis of IE were 80 8% and 95 7%, respectively, with the new criteria (trial), 48 7% and 100%, respectively, with the Duke criteria Conclusion With the addition of echocardiographic evidence of endocardial involvement (major criteria) and 2 minor criteria as definite diagnostic criteria, the sensitivity of the new criteria (trial) is superior to that of the Duke criteria, but there is no significant difference in specificity for the diagnosis of IE between the two criteria