infective endocarditis by dr. asmatullah sapand
TRANSCRIPT
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اللِه� حمِن�بِــســـِم� یِم الّر� ح� الّر�
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اسالمي دافغانستان
دولت جمهوريوزارت روغـتـیا دعــامـې
تـخـصـصي والیـتي دخوستروغـتـون
داخـلـِه دعـمـوميدیـپـارتـمـنـت
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: موضوع دکـنـفـّرانـسINFECTIVE ENDOCARDITIS
: کوونکی وړاندې او ترتیبلومړي - د داخله دعمومي څـپـانـد، الله ډاکترعصمت
تریني کال
: استاد رهنماسعیدي - هاشم ډاکترمحمد متخصص
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INFECTIVE ENDOCARDITIS
تعّریف•طبقِهبندي •الملونِهاومساعدکوونکيفکتورونِه •پتوفیزیولوژي•ډولونِه•کلینیکينښې •البّراتواريموندنې •تشخیص•اختالطاط•درملنِه•وقایويتدابیّر •
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INFECTIVE ENDOCARDITIS (IE)
I-Endocarditisتعّریف: •لِه سطحې داخلي د دزړه
انتان فنګسي یا او باکتّریایي. دی عبارت څخِه
له lesionلومړنی • یېvegetation چې دی عبارت څخه
موجودیت valvularد تشوشاتوپه( جریان دیاغي دوینې -jetکې
effect. کیږي( رامنځته پواسطه
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بندي IEد طبقِه طبقِه ډولِه پنځِه پِه کې ټولِه پِه
: کیږي بندي
Duration Culture results Heart side Infection setting Valve type
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نظّره Durationد لِه
IE: دی ډولِه دوه پِه نظّره لِه ددوام
Sub-acute bacterial endocarditis.
Acute bacterial endocarditis.طبقِه نوموړي چې وړده دیادولو
کیږي کارول نِه ډیّره مهال اوس بنديبندي طبقِه الندې یې پّرځای او
استعمالیږي: Short incubation IE (less
than 6wks) Long incubation IE (more
than 6wk)
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د Acute IE:ځانګړنې •. کیدل اخته والونو نورمالو د دزړهویجاړوونکي • او پرمختلونکي ډول سریع په
ناروغي.•. موجودیت محراق اومیتاستازس اختالط د•. : ستافیلوکوک سبب عمدهدننه • اونیو شپږ د کې صورت په تداو نه ۍد
مړینه.
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Sub Acute:ځانګړنې IE د
•. کیدل اخته والونو شویو تخریب د اوله له•. ناروغي سیرلرونکي بطي او سست دیا • او دننه یوکال د کې صورت په تداو نه ۍد
. مړینه وروسته
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نظّره لِه نتایجو دکلچّرد
: دی ډولِه دوه پِه Culture negative IE (HACEK,
Coxiella burnetti, Brucella, Chlamydia and Aspergillus species)
Culture positive IE
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نظّره ددواړوخواؤلِه دزړه
: دی ډولِه دوه پِه مخدره لِه چې کسان هغِه
کارآخلي درملو اویانوروزرقيښ دزړه پکې زیاتّره
اختِه( tricuspid- valveخوا)کیږي.
زړه دچپ سوا څخِه دې IEلِه. دي ډیّرزیات وقوعات
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اړوند چارو IEدروغتیايي
ډول دې دروغتیايي IEپِه کېانتانمعموال�او ځایونو چارواړوند
روغتونونِه،) - پّروسیجّرونوکتیتّر، pacemakerدیاالیزس،
انتقالیږي( TPNاو تِه بدن الرې لِه. IEاوباآلخّره کوي رامنځتِه
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نظّره لِه دډول والونو د: دي ډولِه دوه پِه
Native valve IE: Prosthetic valve IE: - Early ( <60 days of valvular surgery ) - Intermediate ( 60 days – 1 year ) - Late ( > 1 year )
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او غټ اړوند مّرض دټکي مهِم
تبِه•مّرمّر•ستونزې • وظیفوي دوالونو زړه دکفایِه • عدم زړه دد ECHOپِه • Vegetationکې
موجودیتموجودیت • امبولي دسیستمیکنښې • سیستمیککلچّرونِه • مثبت وینې د
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Pathophysiology
•:Turbulent blood flow د وینې ددداخلي زړه د کبله له جریان یاغي
کې پایله په او تخریب سطحې. کیدل چسپناک
کې Bacteremiaد • شتون پهد ته ساحې شوي تخریب نوموړي
. - نښلیدل او رسیدل انتانانتان • د والونو په زړه د بااآلخره
هجوم.
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Epidemiology
زیات • نسبت په ؤ ښځینه د کې ؤ نارینه په( کیږي (.2:1واقع
په • خو شي کیدای واقع کې عمر هر په.65y<مسنو) وي(- زیات کې اشخاصو
رامنځته ۳۰-۲۰په • مړینه کې واقعاتو سلنهکیږي.
اړوند 1/3• چارو دروغتیايي یې برخه. لري اړه انتاناتوپورې
د %50 په• valvularواقعاتوکې. وي نه موجوده تاریخچه تشوشاتوکومه
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فتورونِه خطّري
•. استعمال ناوړه درملو وریدي د•. بټریګانې قلبي او والونه مصنوعي• : لکه ناقصې کسبي زړه Calcificد
aortic stenosis اوMitral valve prolapse with regurgitation.
لکه • ناقصې والدي .VSDدزړه•. کاتیتر الوعایي داخل•Regurgitation lesion>Stenotic
lesions
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الملونِه IEد : اسباب عام
•S. Aureus(60-70)%•Streptococci•Enterococci
: اسباب معمول غیّر•Fungi•Pseudomonas•HACEK
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HACEK
•Haemophilis parainfluenzae
•Actinobacillus•Cardiobacterium•Eikenella•kingella
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موندنې کلینیکيA .اعّراض
:IEحاد •. لړزه او تبِه درجِه لوړهیا • SOBسالنډيدبندونواوعضالتودرد•درد • بطنيدرد • پلورایي دسینېدرد • دمال
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حاد :IEتحتتبِه • درجِه کمِهاشتهايي • بېبایلل • دوزنستړیا•دبندونواوعضالتودرد•درد • بطنياواستفّراق • دلبدي
ۍ ۲دیادولووړدهچېاعّراضدانتاندمداخلېنږدې ن و ا. کیږي رامنځتِه وروستِه
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IEد داعّراضواوعالیموډیّرعام
mnemonic: FROM JANE•F-Fever•R-Roth’s spots•O-Osler’s nodes•M-Murmur•J-Janeway lesions•A-Anemia•N-Nail hemorrhage•E-Emboli
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یا Historyتاریخچِهحکایِه الندې معموال� کې تاریخچِه پِه
: وي موجودهشتون • تبې روماتیزمل دجّراحي • دوالونو دزړهتبِه•سالنډي•دبندونودرد•پدیده • امبولیکټکان • اودزړه ګنګسیت ستړیا،
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: IE د نښې تبِه•دمّرمّرشتون•• : لکِه، عالیِم غیّروصفي
Petechia, splinter hemorrhages, clubbing,
splenomegally عصبي اوتغیّرات.
• : لِه دي عبارت عالیِم وصفي ډېّرOsler’s Nodes, janeway
lesions and Roth Spots.
•. عالیِم کیدو داختِه وال دیومشخص
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Petechia-:
جملې • عالیمولِه دغیّروصفي. ده څخِه
مخاطي • اطّرافواو پِه زیاتّره . کیږي ښکاره ګانوباندې غشاء
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Splinter Hemorrhage
•. ده عالمِه غیّروصفيرنګِه • سورنصواری نوموړي
الندې نوک د چې دي کّرښېفشار پِه او کیږي راښکاره
نِه منځِه لِه سّره واردولوځي.
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Osler’s Nodes
•. ده عالمِه وصفي ډیّرهسوررنګِه • یوشمیّر نوموړي
چې دي نوډولونِه اودرناکِهدالسواودپښودګوتوپِه
. کیږي رامنځتِه نّرموبّرخوکېحاد • تحت .IEپِه دي معمول ډیّر کې
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Janeway Lesions
•. ده عالمِه وصفيدرده • اوبې دایوشمیّرسوررنګِه
دالسوپِه چې دي خالونِهراښکاره تلوکې ورغوواودپښوپِه
کیږي.منځِه • لِه واردولوسّره دفشارپِه
ځي.
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Roth’s Spots
یا • شبکیِه دستّرګوپِه داRetina یا تّرشحي یو کې
Exudative د چې دی آفتIE. تشکیلوي عالمِه وصفي
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موندنې البّراتواري.A: اومهمِهالبّراتواريمعاینِهدوینېکلچّر ۍلومړن•. لږتّرلږهددروکلچّرونوآخیستل .Venipunctureدرېبیالبیلېد • ساحې ۰.مليلیتّراودماشومانوڅخِهد ۲۰-۱۰دکلچّرلپارهلِهکاهالنوڅخِهد • ۵-
۵. مليلیتّروینېآخیستل نتیجِه :مثبتِه
•. پِهلږتّرلږهدوهجداکلچّرونوکېوصفيانتاناتڅّرګندیږي پِه • ډول دوامداره پِه بیا انتانات غیّروصفي
: ــــــــ ډول الندې پِه لکِه څّرګندیږي کلچّرونوکېساعتِهوروستِهآخیستل ۱۲دوهپّرلِهپسېمثبتکلچّرونِهچېیولِهبلِهلږتّرلږه •
شویوي.درېپّرلِهپسېمثبتکلچّرونِهپِهکومکېچېدلومړياوآخّرکلچّرتّرمنځلږتّرلږه •
یوساعتوقفِهموجودهوي
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B .ـــــــــــــــــــ: نورمعاینات
• CBC• ESR & CRP• Complements Levels
(C3,C4)• RF• Urinalysis• Baseline Chemistry
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C .اوګّرافیک تصویّريـــــــــ: معاینات
CXR: • Multiple focal infiltrates.• Calcification of Heart valves.ECG:• لّري ارزښت تشخیصیِه نادرا�• شواهد اریتمیاګانو او اسکیمیا د
موجودوي .ممکِنEchocardiography: <<< <<< <<< ــــــــــــــ>>> >>>
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:Echoد استطبابات Transthoracic Echo (TTE): - First line if IE suspected. - Native valves.Transesophageal Echo (TEE): - Prosthetic valves. - Intracardiac complications. - Inadequate TTE. - Fungal or S. aureus or bacteremia.
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:IEد تشخیص Pelletier and Petersdorf Criteria (1977) - Definite IE, Probable&Possible IE - Reasonably Specific but lacked sensitivityVon Reyn Criteria (1981) - Added ‘’rejected IE’’ to the category. - Added more clinical criteria. - Improved specificity and clinical utility.Duke Criteria (1994) - Included the role of echo. In Dx. - Added IVDA as a “predisposing heart-condition”.
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Duke CriteriaMajor DC:• Positive cultures• Positive echo• New valvular regurgitationMinor DC:• IV drug abuser• Heart diseases• Fever >38 C
• Minor echo finding (deformed valve but no vegetation). >>>>>>>>>> cont.…. >>>>>
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>>>Cont.….Minor DC:
• Vascular embolic events (janeway lesions, septic pulmonary infarcts, arterial emboli).
• Immunological events (Osler’s nodes, Roth’s spots and GN).
• Enlarged spleen.
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Modified Duke Criteria
Definite IE:• Microorganisms in a valvular
vegetation, embolized vegetation or intra cardiac abscess.
• Histologic evidence of vegetation or intra cardiac abscess.
Possible IE:• 2 major• 1 major and 3 minor.• 5 minor.………………………………… cont. …………
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………………………………… cont. …………
Rejected IE:
• Resolution of illness with four days or less of antibiotics.
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طــــــا IEد اخـتــــــالت
څلور کې ټولِه ډولِه پِه: ورکوي اختالطات
.1Embolic
.2Local spread of infection
.3Metastatic spread of infection
.4Formation of immune complexes- GN and Arthritis
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Embolic اختالطاتنږدې IEد 1. ناروغانوکې ۴۰پِه ٪
پیښیږي.الندې 2. پِه امبوالیزیشِن
: تړاؤلّري حاالتوپورې.Vegetation د• اندازه زړه • .Vegetationدچپعوامل، • .Strepاو S. Aureusفنګسي
Bovis.سّره. 3 پیل پِه بیوتیک دمؤثّروانتي
. کمیږي اندازه ډیّره پِه وقوع یېډول. 4 الندې پِه اختالطات نوموړي
دي:>>>>>>>>>>>
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.1Stroke
.2MIد د vegetationــ ټوټوپواسطِه د
coronary .شّراینوبندښت.3Ischemic limbs.4Hypoxia from Pulmonary
emboli..5Abdominal pain (splenic or
renal-infarction)
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انتان انتشار Localدکفایِه 1. عدم دزړه
) کبلِه ) لِه تخّریب دوالونودپّراخ ــ3 .Perivalvular abscess:
aortic valveپِه ــ ، IVDA اوS. Aureus پِه. دي ډیّرمعمول حاالتوکې
نږدې ممکِن سّرایت conductionــ تِه نسجوکړي
. Arrhythmiasاود وګّرځي سبباومړینې امبوالیزیشِن د کې حالت دې پِه ــ
لوړه وي.اندازه4 .Pericarditis5 .Fistulous intracardiac
connections
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نورو انتشار دانتانغړوتِه
.1Metastatic abscessانساج نّرم او دماغ توری، پښتورګي، ــ
2 .Meningitis/Encephalitis3 .Vertebral Osteomyelitis4 .Septic arthritis
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تداويډولِه دوه پِه کې ټولِه پِه تداوي
: نیسي صورت درملنِه طبي درملنِه جّراحي
ډولِه دوه پِه بیاهِم درملنِه طبي: نیسي صورت
یا درملنِه EmpiricalتجّربويRx.
. درملنِه سببي او تیوریک
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: درملنِه طبيد انتاناتو دالندې معموال� درملنِه طبي
: کیږي کارول خاطّر پِه درملنې
.1 Strep.viridans.2Strep.pneumonia, pyogens,
B,C,G,bovis.3Enterococci.4Staphylococci.5Hacek organisms
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.......: ادامِه درملنِه طبي: کیږي کارول درمل الندې معموال�
1. Penicillin G (for penicillin sensitive)
2. Ceftriaxone (Alternative for penicillin)
3. Vancomycin (for penicillin resistant)
4. Gentamicin (together with penicillin or - vancomycin)
5. Rifampicin6. Nafcillin or Cloxacillin
� IEد معموال دوام هفتې 6 – 4درملنېدی
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عواملو IEد دفنګسيدرمــلــنـــِه:
• Amphoterecin B 1mg/kg QID for 2 weeks, max upto 4 wks. Do not exceed 50mg/day.
• Flucytocine 150mg/kg oral for four days.
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درملنې دجّراحياستطبابات
دطبي ◄ چې کفایِه عدم هغِه دزړه. کړي - ورنِه ځواب سّره درملنې
تّر ◄ چې ورځووروستِه 10-7کلِه. موجودوي - انتانات الهِم
◄. اندوکاردایتس فنګسي.septal abscessد ◄ موجودیت ◄. انتانات متکّرراودوامداره ◄ پّرلپسې
امبوالیزیشِن.
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مخنیوی IEد څخِه
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پِه عملیې طبي هغِهچې کې -IEکومو
Prophylaxis نِه یا او شي بایدتّرسّره
ــــــــــ: شي
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پِه پتالوژ قلبي ۍهغِهچې کې -IEکومو
Prophylaxis � حتما باید: ــــــــــ شي تّرسّره
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Referencesآخیستنې
•CMDT 2015•Harrison’s principles of IM•Davidson 22nd edition•Wikipedia•Medscape•WebMD
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مــنــنــِه
Thank you
سوکالِه او آباد یو دافغانستان
هیلِه پِه