Amorim Ana, Santos Ana, Trevas Sara
Anesthesiology, Hospital Central do Funchal, Funchal, PRT.
Internal Medicine Department, Hospital São Francisco Xavier, Lisboa, PRT.
Cureus. 2022 Jul 30;14(7):e27489. doi: 10.7759/cureus.27489. eCollection 2022 Jul.
Infective endocarditis is a sudden illness that rapidly causes cardiac and extracardiac injury. Embolic material travels into the arterial circulation causing embolic events in 20-50% of patients. The brain is one of the most frequent sites of embolism that potentially interferes with treatment options. Neurologic complications are the presenting symptom in 20% of the cases being associated with poor prognosis (45% of deaths versus 24% in patients without these complications). This is the case of a 63-year-old male patient presenting with main clinic of stroke. Multifocal signs and past aortic valvuloplasty raised the suspicion of infective endocarditis and antimicrobial therapy was initiated despite an initial negative transthoracic echocardiography (TTE). Imaging study revealed vascular lesions in different arterial territories of the brain, some of them with hemorrhagic transformation and multiple splenic and renal areas of infarction. Hemodynamic instability and acute pulmonary edema developed just before surgery. Transoesophageal echocardiography (TEE) confirmed a typical image of vegetation, conditioning severe aortic regurgitation, and a perivalvar abscess with fistulization to the right ventricle. Both were surgically repaired. The immediate postoperative period was characterized by cardiogenic shock, but the patient evolved favorably being transferred to the hospital ward where he continued his motor recovery. Early surgery is a mainstay in the treatment of infective endocarditis, reducing the embolic risk. Once happened, neurologic embolization may worsen the prognosis and raise doubts about further deterioration or hemorrhagic conversion following cardiopulmonary bypass. Optimal time interval between ischemic stroke and surgery has not yet been determined but recent data favour early surgery that, when indicated, should not be delayed. Most of the embolic events occur before admission making presentation variable. Clinical suspicion is highly important to the prompt institution of antibiotic therapy and the avoidance of subsequent embolic events. TTE is a sensitive tool in the diagnosis of endocarditis, but a negative result does not exclude the diagnosis specially when endocarditis is clinicalliy expected. Imaging should be systematically performed in the course of the disease to detect new and relevant complications, always being aware of the higher sensitivity of TEE to detect intracardiac complications.
感染性心内膜炎是一种突发疾病，可迅速导致心脏和心外损伤。栓子物质进入动脉循环，在20%至50%的患者中引发栓塞事件。大脑是最常见的栓塞部位之一，这可能会影响治疗方案。神经系统并发症是20%病例的首发症状，与预后不良相关（45%的患者死亡，而无这些并发症的患者死亡率为24%）。本文报道一名63岁男性患者，以中风为主要临床表现。多灶性体征和既往主动脉瓣成形术引发了感染性心内膜炎的怀疑，尽管最初经胸超声心动图（TTE）结果为阴性，但仍开始了抗菌治疗。影像学检查显示大脑不同动脉区域有血管病变，其中一些有出血性转化，脾脏和肾脏有多个梗死区域。手术前出现血流动力学不稳定和急性肺水肿。经食管超声心动图（TEE）证实了典型的赘生物图像，导致严重主动脉瓣反流，以及一个向右心室瘘的瓣周脓肿。两者均通过手术修复。术后即刻出现心源性休克，但患者病情好转，被转入医院病房继续进行运动功能恢复。早期手术是治疗感染性心内膜炎的主要手段，可降低栓塞风险。一旦发生神经系统栓塞，可能会使预后恶化，并对体外循环后进一步恶化或出血性转化产生疑虑。缺血性中风与手术之间的最佳时间间隔尚未确定，但近期数据支持早期手术，如有指征，不应延迟。大多数栓塞事件发生在入院前，表现各异。临床怀疑对于及时开始抗生素治疗和避免随后的栓塞事件非常重要。TTE是诊断心内膜炎的敏感工具，但阴性结果不能排除诊断，特别是在临床怀疑有心内膜炎时。在疾病过程中应系统地进行影像学检查，以发现新的相关并发症，始终要意识到TEE对检测心内并发症具有更高的敏感性。
