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Endocarditis (infectious)


The endocarditis – an inflammation of the soyedinitelnotkanny (internal) cover of heart covering it cavities and valves is more often than infectious character. It is shown by high temperature of a body, weakness, a fever, short wind, cough, thorax pain, a thickening of nail phalanxes as "drum sticks". Quite often leads to defeat of valves of heart (more often aortal or mitralny), to development of heart diseases and heart failure. A recurrence is possible, the lethality at endocarditises reaches 30%.

Endocarditis (infectious)

The endocarditis – an inflammation of the soyedinitelnotkanny (internal) cover of heart covering it cavities and valves is more often than infectious character. It is shown by high temperature of a body, weakness, a fever, short wind, cough, thorax pain, a thickening of nail phalanxes as "drum sticks". Quite often leads to defeat of valves of heart (more often aortal or mitralny), to development of heart diseases and heart failure. A recurrence is possible, the lethality at endocarditises reaches 30%.

The infectious endocarditis arises in the presence of the following conditions: tranzitorny bacteremia, damage of an endokard and endoteliya of vessels, changes of a hemostasis and haemo dynamics, immunity violation. Bacteremia can develop at the available centers of a chronic infection or carrying out invasive medical manipulations.

The leading role in development of a subsharp infectious endocarditis belongs to the green streptococcus, in sharp cases (for example, after open heart operations) – to golden staphylococcus, more rare to an enterokokk, a pneumococcus, colibacillus. In recent years the structure of infectious causative agents of an endocarditis changed: the number of primary endocarditises of a sharp current having the staphylococcal nature increased. At bacteremia golden staphylococcus the infectious endocarditis develops almost in 100% of cases.

The endocarditises caused by gramotritsatelny and anaerobic microorganisms and a fungal infection have a heavy current and badly give in to antibacterial therapy. Fungal endocarditises arise more often at long-term treatment by antibiotics in the postoperative period, at long standing venous catheters.

Adhesion (sticking) of microorganisms to an endokard is promoted by certain general and local factors. The general factors the expressed immunity violations which are observed at patients at immunnosupressivny treatment at alcoholics are among, addicts, people of advanced age. The congenital and acquired anatomic damages of valves of heart, intracardial haemo dynamic violations arising at heart diseases belong to local.

The majority of subsharp infectious endocarditises develops at congenital heart diseases or at rheumatic damages of heart valves. The haemo dynamic violations caused by heart diseases promote a microtrauma of valves (mainly mitralny and aortal), to change of an endokard. On valves of heart the characteristic ulcer and warty changes having a cauliflower appearance develop (polipozny imposings of trombotichesky masses on a surface of ulcers). Microbic colonies promote bystry destruction of valves, there can be their sklerozirovaniye, deformation and a gap. The damaged valve cannot normally function - heart failure which very quickly progresses develops. The endoteliya of small vessels of skin and mucous, leading to development of vaskulit is noted immune defeat (trombovaskulit, a hemorrhagic kapillyarotoksikoz). Violation of permeability of walls of blood vessels and emergence of small hemorrhages is characteristic. Damages of larger arteries are quite often noted: coronary and kidney. Often the infection develops on the fitted a prosthesis valve, in this case the streptococcus happens the activator most often.

Development of an infectious endocarditis is promoted by the factors weakening immunological reactivity of an organism. Incidence of an infectious endocarditis constantly grows around the world. The people having atherosclerotic, traumatic and rheumatic injuries of heart valves treat risk group. Patients with defect of an interventricular partition, a koarktatsiy aorta have high risk of a disease of an infectious endocarditis. Now the number of patients with artificial limbs of valves (mechanical or biological), artificial drivers of a rhythm increased (electropacemakers). The quantity of cases of an infectious endocarditis increases because of application of long and frequent intravenous injections. Addicts have often infectious endocarditis.

Classification of infectious endocarditises

By origin distinguish primary and secondary infectious endocarditis. Primary usually arises at septic conditions of various etiology against the background of not changed heart valves. Secondary - develops against the background of already available pathology of vessels or valves at congenital defects, a disease of rheumatism, syphilis, after operation on prosthetics of valves or a komissurotomiya.

On a clinical current allocate the following forms of an infectious endocarditis:

  • sharp - duration up to 2 months, develops as a complication of a sharp septic state, severe injuries or medical manipulations on vessels, heart cavities: nozokomialny (intrahospital) angiogenny (kateterny) sepsis. It is characterized by the high-pathogenic activator, the expressed septic symptoms.
  • subsharp – duration more than 2 months, develops at insufficient treatment of a sharp infectious endocarditis or main disease.
  • long.

At addicts clinical features of an infectious endocarditis are the young age, rapid progressing of right ventricular insufficiency and the general intoxication, infiltrative and destructive damage of lungs.

At elderly patients the infectious endocarditis is caused by chronic diseases of the digestive system, existence of the chronic infectious centers, damage of heart valves. Distinguish the active and inactive (healed) infectious endocarditis. On extent of defeat the endocarditis proceeds with limited defeat of shutters of heart valves or with the defeat which is going beyond the valve.

Allocate the following forms of a course of an infectious endocarditis:

  • infectious and toxic - is characteristic tranzitorny bacteremia, adhesion of the activator on changed , formation of microbic vegetations;
  • infectious and allergic or immune and inflammatory - clinical signs of damage of internals are characteristic: myocarditis, hepatitis, nephrite, splenomegaliya;
  • dystrophic – develops when progressing septic process and heart failure. Development of crushing and irreversible damages of internals, in particular - a toxic degeneration of a myocardium with numerous necroses is characteristic. Damage of a myocardium arises in 92% of cases of a long infectious endocarditis.

Symptoms of an infectious endocarditis

The course of an infectious endocarditis can depend on a limitation period of a disease, age of the patient, activator type, and also on earlier carried out antibacterial therapy. In cases of the high-pathogenic activator (golden staphylococcus, gramotritsatelny microflora) the sharp form of an infectious endocarditis and early development of polyorgan insufficiency in this connection the clinical picture is characterized by polymorphism is usually observed.

Clinical displays of an infectious endocarditis are generally caused by bacteremia and a toksinemiya. Patients have complaints to the general weakness, short wind, fatigue, lack of appetite, loss of body weight. A symptom, characteristic of an infectious endocarditis, is fever – rise in temperature from subfebrilny to gektichesky (exhausting), from oznoba and plentiful sweating (sometimes, pouring sweats). The anemia which is shown pallor of skin and the mucous membranes sometimes getting "earthy", – gray color develops. Small hemorrhages (petekhiya) on skin, a mucous membrane of an oral cavity, the sky, on a conjunctiva of eyes and folds a century, in the basis of a nail bed, in clavicles, arising because of fragility of blood vessels are observed. Defeat of capillaries is found at a soft injury of skin (a pinch symptom). Fingers get a form of drum sticks, and nails — hour glasses.

At most of patients with an infectious endocarditis damage of a cardiac muscle (myocarditis), functional noise, connected with anemia and damage of valves comes to light. At defeat of shutters of mitralny and aortal valves signs of their insufficiency develop. Stenocardia is sometimes observed, noise of friction of a pericardium is occasionally noted. The acquired defects of valves and damage of a myocardium lead to heart failure.

At a subsharp form of an infectious endocarditis there are embolisms of vessels of a brain, kidneys, the spleens the trombotichesky imposings which came off from shutters of heart valves which are followed by formation of heart attacks in the struck bodies. Are found gepato-and a splenomegaliya, from kidneys - development of a diffusion and ekstrakapillyarny glomerulonefrit, is more rare - focal nephrite, artralgiya and polyarthritis are possible.

Complications of an infectious endocarditis

Complications of an infectious endocarditis with a lethal outcome are septic shock, embolisms in a brain, heart, a respiratory distress syndrome, an acute heart failure, polyorgan insufficiency.

At an infectious endocarditis complications from internals are often observed: kidneys (the nephrotic syndrome, a heart attack, a renal failure, diffusion glomerulonefrit), heart (defects of valves of heart, myocarditis, perikardit), lungs (a heart attack, pneumonia, pulmonary hypertensia, abscess), a liver (abscess, hepatitis, cirrhosis); spleens (a heart attack, abscess, a splenomegaliya, a gap), nervous system (a stroke, a hemiplegia, an encephalomeningitis, meningitis, brain abscess), vessels (aneurisms, hemorrhagic vaskulit, thromboses, a thrombembolia, thrombophlebitis).

Diagnosis of an infectious endocarditis

When collecting the anamnesis find out existence of chronic infections and the postponed medical interventions from the patient. The final diagnosis of an infectious endocarditis is confirmed by data of tool and laboratory researches. In clinical blood test also sharp increase in SOE comes to light big . Has important diagnostic value repeated blood for identification of the causative agent of an infection. Blood sampling is recommended to be made for bacteriological crops at fever height.

Data of biochemical blood test can vary over a wide range at this or that organ pathology. At an infectious endocarditis changes in a proteinaceous range of blood are noted: (accrue α-1 and α-2-globulina, later – γ-globulins)))))))))), in the immune status (the CEC, immunoglobulin M increases, the general hemolytic activity of a complement decreases, the level of antifabric antibodies increases).

Valuable tool research at an infectious endocarditis is EhoKG allowing to find vegetations (the size more than 5 mm) on heart valves that is a direct symptom of an infectious endocarditis. More exact diagnostics is carried out by means of heart MPT and MCKT.

Treatment of an infectious endocarditis

At an infectious endocarditis treatment is obligatory stationary, before improvement of the general condition of the patient the bed rest, a diet is appointed. The leading role in treatment of infectious endocarditises is assigned to medicamentous therapy, mainly, antibacterial which is begun right after a bakposev of blood. The choice of an antibiotic is defined by sensitivity to it of the activator, prescription of antibiotics of a broad spectrum of activity is more preferable.

In therapy of an infectious endocarditis the good effect is rendered by antibiotics of a penicillinic row in a combination with aminoglycosides. The fungal endocarditis therefore medicine In is appointed for a long time will difficult respond to treatment (several weeks or months). Also use other means with antimicrobic properties (, anti-staphylococcal globulin, etc.) and non-drug methods of treatment – a plasma exchange, autotransfusion by ultraviolet of the irradiated blood.

At associated diseases (myocarditis, polyarthritis, nephrite) non-hormonal resolvents are added to treatment: diclofenac, indometacin. In the absence of effect of drug treatment surgical intervention is shown. Prosthetics of valves of heart with excision of the damaged sites is carried out (after subsiding of sharpness of process). Surgeries have to be carried out by the heart surgeon only according to indications and be followed by reception of antibiotics.

The forecast at an infectious endocarditis

Infectious endocarditis — one of the most serious cardiovascular illness. The forecast at an infectious endocarditis depends on a set of factors: the available defeats of valves, timeliness and adequacy of therapy, etc. The sharp form of an infectious endocarditis without treatment comes to an end with death in 1 – 1,5 month, a subsharp form - in 4–6 months. At adequate antibacterial therapy the lethality makes 30%, at infection of the fitted a prosthesis valves — 50%. At elderly patients the infectious endocarditis proceeds more inertly, often at once is not diagnosed and has the worst forecast. At 10-15% of patients transition of a disease to a chronic form with an aggravation recurrence is noted.

Prevention of an infectious endocarditis

Behind persons with the increased risk of development of an infectious endocarditis necessary observation and control is established. It concerns, first of all, patients with the fitted a prosthesis heart valves, the congenital or acquired heart diseases, pathology of vessels, with an infectious endocarditis in the anamnesis, having the centers of a chronic infection (caries, chronic tonsillitis, chronic pyelonephritis).

Development of bacteremia can accompany various medical manipulations: surgeries, urological and gynecologic tool inspections, endoscopic procedures, removal of teeth, etc. With the preventive purpose at these interventions appoint an antibiotic treatment course. It is also necessary to avoid overcooling, viral and bacterial infections (flu, quinsy). Carrying out sanitation of the centers of a chronic infection at least 1 time in 3 - 6 months is necessary.

Endocarditis (infectious) - treatment should be carried out only under the supervision of a doctor. Self-treatment is unacceptable!!!

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