Uncle Zhang is 77 years old this year, suffering from hypertension for more than 20 years, diabetes for more than 20 years, 8 days ago he was discharged from the hospital on the third day after surgery because of the varicose vein of the right side of the great saphenous vein * "right lower extremity large saphenous vein closure + high ligation + point decortication + sclerotic closure". However, just 2 days after being discharged from the hospital, he suddenly fainted and fell, visited the local hospital, and his body temperature was found to be increased; on the 6th day after the operation, he had cold intolerance and fever, accompanied by a seizure of severe swelling and pain in the right side of the head, and the effect was not good after symptomatic treatment, and he went to the doctor again. Admission on the 8th day after surgery.
Physical examinations at admission are as follows:
* T39.3, R19 times/min, blood pressure 155/73mmHg, pulse 110 beats/min;
* Superficial lymph nodes without swelling, with ecchymosis scattered on the inside of the right lower extremity;
* The scalp on the top of the right side of the head is slightly red and the tenderness is obvious; a small purple-black bubble on the left cheek;
* Clear breath sounds in both lungs, no dry and wet sounds;
* Cardiac auscultation without murmur;
* The abdomen is flat and soft, no tenderness, and the liver and spleen are not enlarged under the ribs;
The image above shows the change in body temperature during the first week of admission
After admission, the patient still has daily chills, chills, high fever, and diarrhea. On the third day after admission, he developed chest tightness and shortness of breath and could not lie flat. Therefore, I consulted the infectious disease department and the respiratory department.
Laboratory test results are as follows:
* Urine routine: glucose ++++, residual negative;
* Fecal routine: fungus 3+,
* Triple blood culture: negative;
* Fecal culture: negative;
Lung CT results:
Abdominal examination report:
Head MR shows
Heart ultrasound results
Patient medication:
Summarize the characteristics of the patient's medical history as follows:
Patients, elderly men, who have previous diabetes mellitus and have surgery for varicose veins one week before the onset of the disease;
With repeated severe headaches, cold intolerance and fever as the main manifestations;
Symptoms of heart failure such as chest tightness and shortness of breath gradually appear during the course of the disease;
Examination reveals ecchymosis of the lower extremities and no murmur on cardiac auscultation;
Progressive increase in indicators of blood inflammation;
Repeated blood cultures and urine cultures were negative;
Imaging examination for only bilateral pleural effusions and partial atelectasis of both inferior lungs;
So the question is, what is the diagnosis of the current patient? We analyze them one by one:
Right lower pneumonia? Pneumonia may seem to be established in patients with fever, consolidation of the right lower lung, but can persistent fever and dyspnea be explained by pneumonia? Obvious bacteremia manifestations such as chills and chills during the patient's course and orthopnea phenomena cannot explain the dyspnea caused by pneumonia!
Septic shock? Some people have asked whether a severe infection can cause sudden heart failure of septic shock can be explained by septic shock? However, septic shock usually has a decrease in blood pressure, but this patient did not see a significant decrease in blood pressure!
Infective endocarditis? Patients with a history of vascular surgery before the onset of the disease, cold and high fever in the short term, and heart failure in the short term, so infectious endocarditis will naturally surface.
What's next?
Treatment regimens were adjusted according to infective endocarditis, with linezolid and meropenem, but fever persisted, and daptomycin was originally recommended because daptomycin was more effective against hemologic gram-positive bacteria (mainly Staphylococcus aureus) infection. However, first, daptomycin is self-funded, and the second is because the patient also has lung inflammation, and the concentration of dato in the tissue is very low, in order to treat both bloodstream infection and lung tissue infection, vancomycin was selected, and the body temperature was normalized for several days.
However, after using vancomycin for 4 days, the patient had fever again, and originally wanted to observe it again, but the body temperature rose again after 2 days, so he had to communicate with the family and switch to daptomycin treatment. At the same time, Zhao Min, director of the Department of Ultrasound, was contacted to perform esophageal ultrasound to confirm the presence of neoplasms of the heart valve, and the results confirmed the presence of aortic valve vegetations.
Final diagnosis: infective endocarditis.
Under the treatment of daptomycin combined with piperacillin tazobactam, the patient's body temperature has returned to normal, the symptoms of chest tightness and urgency have disappeared, and the inflammatory indicators have also come down. Thinking that everything is finally going well, blowing the trumpet of victory.
Due to daptomycin's own expense, the patient's economic pressure is high, and he has repeatedly asked the doctor in charge to adjust the medication in a timely manner. Therefore, it was observed that the body temperature had dropped for many days, and daptomycin was changed to vancomycin. However, the wind and cloud mutation, just one day after the discontinuation of daptomycin and the use of vancomycin, the patient had fever again, and the blood PCT was elevated again, but the re-examination of lung CT could see that the lung lesions were significantly absorbed.
What to do? How do I take the medication? Why does the patient have fever again?
We considered that it may be that the lesion on the heart valve has not been completely cleared, and the bloodstream infection is still the main contradiction, so after communicating with the patient's family, it is changed back to daptomycin again. After the replacement of daptomycin, the patient's symptoms improved again, the body temperature dropped rapidly to normal, and the inflammatory indicators decreased accordingly.
In order to find out whether the patient had cleared the heart valve vegetations, we did the esophageal ultrasound again, and the results confirmed that the lesion was significantly absorbed. After more than a month of tortuous treatment, the patient was finally discharged from the hospital smoothly.
This case gave me some inspiration, including:
Vascular surgery should pay attention to the occurrence of bloodstream infections;
Unexplained fever complicated with heart failure should be vigilant against infective endocarditis;
Definitive endocarditis sometimes requires ultrasound of the esophagus.