Basic introduction of the department: Common disease sites in cardiology: Common causes of heart: pathogen invading blood flow, abnormal heart valve, inhibition of defense mechanism, clinical manifestations, examination, diagnosis and treatment. The factors causing endocardial infection are: 1. Pathogens invade the blood stream and cause bacteremia, septicemia or septicemia, and invade the endocardium. 2. Abnormal heart valve is beneficial to colonization and reproduction of pathogenic microorganisms. 3. The defense mechanism inhibits the use of cytotoxic drugs by tumor patients and immunosuppressants by organ transplant patients. Clinical experience is related to pathogenic microorganisms, including various bacteria and fungi. Traditionally, it is divided into acute and subacute, and its clinical course and pathological changes are different. Acute infective endocarditis is also called ulcerative endocarditis, because ulcers usually form in the tired endocardium. This kind of endocarditis has an acute onset and is mostly caused by pyogenic bacteria with strong toxicity, among which Staphylococcus aureus is the most common, followed by Streptococcus pyogenes. Usually, pathogenic bacteria first cause suppurative inflammation in a certain part of the body (such as suppurative osteomyelitis, carbuncle, puerperal fever, etc.). ), and when the body's resistance drops (such as tumor, heart surgery, immunosuppression, etc.). ), pathogenic bacteria invade the blood stream, causing sepsis and invading the endocardium. This type of endocarditis mainly occurs on the normal endocardium and mainly invades the single aortic valve or mitral valve. Subacute cases mainly occur in organic heart disease, the first is valvular disease, and the second is congenital vascular disease. Clinical manifestations 1. Classification and manifestations of diseases Infectious endocarditis is often divided into acute and subacute according to the course of disease, symptoms of systemic poisoning and other clinical manifestations, but there is considerable overlap between them. (1) Acute infective endocarditis mostly occurs in normal hearts. Pathogens are usually highly toxic bacteria, such as Staphylococcus aureus or fungi. The onset is often sudden, accompanied by high fever and chills, and the symptoms of systemic toxemia are obvious. It is often a part of serious systemic infection, the course of which is sudden and dangerous, and it is easy to cover up the clinical symptoms of acute infective endocarditis. (2) Most subacute infective endocarditis has a slow onset, with general malaise, fatigue, low fever, weight loss and other nonspecific symptoms. A few patients began to have complications, such as embolism, unexplained stroke, worsening valve disease, refractory heart failure, glomerulonephritis and postoperative heart valve murmur. (3) History Some patients had a history of dental caries, tonsillitis, intravenous intubation, interventional therapy or intracardiac surgery before onset. 2. Common symptom characteristics (1) Fever is the most common symptom of endocarditis. Almost all patients have had different degrees of fever, with irregular heat pattern and long course of fever, and some patients have no fever. In addition, patients also have fatigue, night sweats, loss of appetite, weight loss, joint pain, pale skin and other manifestations, and the disease progresses slowly. (2) 80% ~ 85% patients with cardiac signs can hear heart murmurs, which can be caused by valve damage caused by basic heart disease and/or endocarditis. The original heart murmur can be changed by the vegetation of the heart valve, which appears rough and loud, like seagulls singing or music. Music-like murmurs can appear in people without heart murmurs. About half of the children have congestive heart failure due to heart valve disease and toxic myocarditis, and have dull heart sounds and galloping rhythms. (3) Embolization symptoms have different clinical manifestations due to different embolic sites, which usually occur in the later stage of the disease, but about 1/3 patients are the first symptoms. Small scattered petechiae can be seen in skin embolism, and there may be raised purplish red nodules on the flexion surface of fingers and toes, which are slightly tender and are osler nodules; Visceral embolism can cause splenomegaly, abdominal pain, hematuria and bloody stool, and sometimes splenomegaly is very obvious; Pulmonary embolism may include chest pain, cough, hemoptysis and lung rales; Cerebral artery embolism includes headache, vomiting, hemiplegia, aphasia, convulsion and even coma. Patients with long course of disease can see clubbed fingers and toes, but there is no cyanosis. At the same time, there are not many typical patients with the above three symptoms, especially infants under 2 years old often have systemic infection symptoms, and only a few children have embolic symptoms and/or heart murmurs. Examination 1. Blood routine examination Blood routine examination is progressive anemia, mostly positive cellular anemia, white blood cell count and neutropenia. The erythrocyte sedimentation rate increased rapidly and C-reactive protein was positive. When immune complex-mediated glomerulonephritis, severe heart failure or hypoxia lead to an increase in red blood cell count, serum globulin tends to increase, and even the ratio of albumin to globulin is reversed. Immunoglobulin increased, γ-globulin increased, circulating immune complex increased and rheumatoid factor was positive. 2. Positive blood culture is an important basis for the diagnosis of infective endocarditis. Anyone with fever of unknown cause, body temperature lasting more than 65438 0 weeks, and primary heart disease should actively carry out multiple blood cultures to improve the positive rate. If the blood culture is positive, a drug sensitivity test should be done. 3. Urine test often has hematuria, and there is mild proteinuria under the microscope. Gross hematuria suggests renal infarction. Erythrocyte cast and massive proteinuria suggest diffuse glomerulonephritis. 4. Electrocardiogram Due to the simultaneous existence of multiple myocardial lesions, fatal ventricular arrhythmia may occur. Atrial fibrillation indicates atrioventricular valve regurgitation. Complete atrioventricular block, right bundle branch block and left anterior or left posterior branch block have all been reported, suggesting that myocardial purulent lesions or inflammatory reactions are aggravated. 5. Echocardiography can detect vegetation with a diameter of more than 2mm, so it is very helpful for the diagnosis of infective endocarditis. In addition, during the treatment, echocardiography can dynamically observe the size, shape, activity and valve function of vegetation, and understand the degree of valve damage, which is of reference value for deciding whether to do valve replacement surgery. Examination can also find the original heart disease. 6.CT examination For those who suspect intracranial lesions, CT should be done in time to understand the scope of the lesions. Make a diagnosis according to clinical manifestations and related examinations. Treatment 1. The application of antibiotics is the most important measure to treat endocarditis. Antibiotics should be selected according to the culture results of pathogenic bacteria or their sensitivity to antibiotics. The course of treatment should be long enough to be cured as far as possible, usually 4 ~ 6 weeks. For those who are highly suspected of this disease in clinic, but the blood culture is repeatedly negative, according to experience, high-dose penicillin and aminoglycosides can be selected for treatment for 2 weeks, and blood culture and serological examination should be done at the same time, except for infections caused by fungi, mycoplasma and rickettsia. If it is ineffective, switch to other fungicides, such as vancomycin and cephalosporin. When infective endocarditis recurs, it should be treated again and the course of treatment should be extended appropriately. 2. Surgical treatment should be considered in the following cases: (1) valve perforation, rupture, chordae tendineae rupture and refractory acute heart failure. (2) Infection after prosthetic valve replacement cannot be controlled by drug therapy. (3) Complicated with bacterial aneurysm rupture or limb arterial embolism. (4) When infective endocarditis is caused by congenital heart disease and cannot be controlled by systematic treatment, it should be operated as soon as possible under the control of intensive support therapy and antibiotics.