右心感染性心内膜炎致脓毒性肺栓塞33例的临床特点与治疗

摘要

目的 分析右心感染性心内膜炎致脓毒性肺栓塞的特点,提高对该病的诊治水平.方法 回顾性分析2002年6月至2010年5月北京安贞医院住院治疗的33例右心感染性心内膜炎致脓毒性肺栓塞患者的临床表现、血培养、超声心动图、胸部影像和诊治经过.结果 33例患者平均年龄(27±21)岁,32例(97.0％)有基础心脏病,27例(81.8％)为先天性心脏病.主要临床表现为发热(94.0％)、咳嗽(60.6％)、胸痛(48.5％)、呼吸困难(42.4％)、咯血(9.1％).血培养阳性率为31.0％,其中45.5％病原菌为葡萄球菌属细菌.所有患者均进行超声心动图检查,均发现右心赘生物.所有患者均进行X线胸片检查,表现为片状阴影(100％)、结节影(18.2％)、空洞(3.0％)和胸腔积液(63.6％)征像.5例患者进行胸部CT检查,病变类型和分布与X线胸片相似,但检出的病灶数目与类型增多.所有患者均静脉使用抗生素治疗,78.8％接受心脏手术治疗,23例治愈,5例好转,2例病情控制,1例病情未控制者自动出院,2例死亡,平均住院天数(43.1±33.2)d.结论 脓毒性肺栓塞病情隐匿,缺乏特异性,存在肺外感染灶的患者出现发热、胸部影像学改变应警惕本病,早期诊断,及时给予抗生素治疗,积极控制肺外感染灶,多数患者预后良好.%Objective The clinical characteristics of septic pulmonary embolism (SPE) caused by right-sided infective endocarditis (RIE) were reviewed in order to improve the diagnosis and treatment of the disease. Methods The clinical manifestations, blood culture, echocardiography, chest radiographic findings and therapy of 33 patients were analyzed retrospectively. The patients were hospitalized in Beijing Anzhen Hospital from June 2002 to May 2010 with SPE caused by RIE. Results The mean age of the patients was 27. 2 ± 21.0 years old. Most patients had underlying heart diseases (97. 0% of patients), including congenital heart disease (81. 8%). The symptoms included fever (94. 0%), cough (60. 6%), chest pain (48. 5%), dyspnea (42. 4%), and hemoptysis (9. 1 %). About 31. 0% of the blood cultures were positive. About 45. 5% of the pathogens were staphylococcal species. Echocardiography revealed infectious vegetations of right heart in all cases. Chest X-ray examination showed patchy infiltrates (100%), nodules (18. 2%), cavitation (3. 0%), and pleural effusion (63. 6%). Chest CT scan for 5 patients revealed similar but more lesions compared to chest X-ray. All patients received parenteral antibiotics. Heart surgery was documented in 78. 8% of the cases. Twenty-three cases were cured, 5 improved, 2 controlled, 1 uncontrolled and discharged voluntarily, and 2 died. The mean hospital stay was 43. 1 ± 33. 2 days. Conclusions SPE is usually insidious at onset without specific manifestations. The diagnosis is usually suggested by the presence of extra-pulmonary infection, febrile illness,rnand chest radiographic changes. Early diagnosis, appropriate antibiotic treatment, and active control of extra-pulmonary infection usually predict good prognosis for majority of patients.