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It is only for medical professionals to read for reference in children with long-term fever with underlying heart diseases.
Don't ignore this disease.
Recently, a 2-year-old boy with intermittent fever for 13 days was admitted to the ward.
Except for fever, the child has no positive respiratory signs such as cough and sputum, and oral antibiotics on his own are ineffective for 6 days.
Since the onset of the disease, the child’s mental state is fair, with poor diet, poor sleep, and normal bowel movements.
Follow-up medical history, the child’s birth weight was 3.
45 kg, and he went to Beijing Children’s Hospital after birth.
He was diagnosed with congenital heart disease: ventricular septal defect (perimembranous) (3.
8 mm), atrial septal defect or patent foramen ovale (6.
3 mm) .
Physical examination: heart rate 130 beats/min, heart rate uniform, L3~5 systolic tremor, 3~5 intercostal murmur on the left edge of the sternum, 4/6 grade systolic murmur, conducted to the armpit, no heart failure in the child Symptoms and signs, the rest of the children have no positive signs.
Auxiliary examination report: white blood cells increased, CRP increased significantly, procalcitonin increased, streptococcal infection, Epstein-Barr virus infection, negative blood culture.
Heart color Doppler ultrasound report: ventricular septal defect (perimembranous) 4×4mm, tricuspid regurgitation with moderate regurgitation; tricuspid septal valve mass echo shadow (vegetation?).
Chest X-ray: Congenital heart disease, left pleural hypertrophy.
The following questions need to be analyzed after this child is admitted to the hospital: First, the child has fever for 13 days and has a longer fever.
So, what is the cause of fever? Fever is generally divided into infectious fever and non-infectious fever.
The child had a fever for 13 days and oral antibiotics by himself for 6 days were ineffective.
Except for common upper respiratory tract infections and fever caused by some infectious diseases, long-term fever needs to consider deep bacterial infections, such as meningitis, pancreatitis, infections caused by deep fungi, etc.
, and malignant factors such as fever caused by leukemia. Obviously, the children's blood test results do not support these diagnoses.
Clinically, we need to pay special attention to children who have fever for a long time.
It is likely to be a clinically uncommon cause.
In addition to fever, the child in this case has the disease basis of congenital heart disease.
In addition, the heart color Doppler ultrasound suggests suspicious growths.
We consider that the child may be infective endocarditis (IE).
So, can the child be diagnosed with infective endocarditis? Let's first look at the diagnostic criteria for infective endocarditis-Duke's criteria.
The criteria for confirming IE are validated from a pathological point of view.
If blood culture or histological examination of neoplasms proves to be related to causing embolism or intracardiac abscess or pathological lesions, then it is confirmed that there is active IE.
Validation based on the above-defined clinical standards, if it contains 2 major standards, or 1 major standard plus 3 minor standards, or 5 minor standards, IE can also be diagnosed.
This child has no skin, mucous or conjunctival ecchymosis, no Osler nodules, no Janeway nodules, no skin microthrombosis such as linear hemorrhage under nails, and no immunological signs such as glomerulonephritis.
The characteristics of a typical IE.
However, this patient meets 1 major criterion and the first 3 minor criteria (re-examination of cardiac color Doppler ultrasound suggests that the vegetation is slightly smaller than before, and the blood pressure of the right lower extremity rises transiently during hospitalization, and there may be small thrombus), so it still supports infectiousness Diagnosis of endocarditis.
Clinical manifestations of infective endocarditis in children and adolescents: Symptoms are usually slow, often manifested as long-term low-grade fever and various physical symptoms, including fatigue, fatigue, joint pain, myalgia, weight loss, chills and sweating.
But it can also be fulminant, such as rapid changes in symptoms, high fever, and critical illness.
This situation requires urgent intervention.
4 basic phenomena: bacteremia (or sepsis), valvulitis, immune response, embolism.
Why are children with congenital heart prone to infective endocarditis? In the past 20 years, with the decline in the prevalence of rheumatic heart disease, congenital heart disease has become the main cause of IE in children> 2 years old in developed countries.
And as the survival period of patients with congenital heart disease has been significantly prolonged, related IE has also increased year by year.
There are structural abnormalities in the heart or large blood vessels, and the abnormal pressure gradient causes obvious blood turbulence (which can lead to endothelial damage and platelet thrombosis).
Aortic valve disease is the most common, and secondary orifice atrial septal defect rarely occurs.
The neoplasms of infective endocarditis often exist in the low-pressure cavity of the defect, the periphery of the defect, or the contralateral side of the defect (the contralateral endometrial injury caused by the high-speed jet).
For example, vegetations exist in the pulmonary artery during patent ductus arteriosus or systemic pulmonary bypass, and vegetations occur on the chordae of the mitral valve during mitral valve regurgitation.
The location of this child's heart vegetation is located on the tricuspid valve septum, and the location is relatively rare.
It should be considered that it may be related to the child's ventricular septal defect, left to right shunt, and tricuspid regurgitation with moderate reflux.
The most taboo disease in medicine is to avoid doctors.
After the child was diagnosed with congenital heart disease after birth, he did not reexamine the heart color Doppler ultrasound.
In fact, we recommend that children with congenital heart disease should have regular cardiac surgery follow-ups and timely surgical treatment.
Because children with congenital heart disease, once suffering from pneumonia, the heart cannot bear the load, and heart failure is very prone to occur.
Those with severe residual valve damage need to undergo valve repair or replacement.
In addition, children with congenital heart disease should also pay attention to oral hygiene to prevent gingivitis and dental caries; prevent infection; if oral surgery, tonsillectomy, cardiac catheterization and cardiac surgery are performed, it can be 1~ before surgery.
Antibiotic treatment was used for 2 hours and 48 hours after surgery.
References: [1] Chen Lin, Tax Xing, Wen Zheqi.
Interpretation of the 2015 AHA Children’s Infectious Endocarditis Management Science Statement[J].
Chinese Journal of Circulation,2016(s2).
[2]Wang Weiping.
Pediatrics.
8th edition [M].
People's Medical Publishing House, 2013.
Don't ignore this disease.
Recently, a 2-year-old boy with intermittent fever for 13 days was admitted to the ward.
Except for fever, the child has no positive respiratory signs such as cough and sputum, and oral antibiotics on his own are ineffective for 6 days.
Since the onset of the disease, the child’s mental state is fair, with poor diet, poor sleep, and normal bowel movements.
Follow-up medical history, the child’s birth weight was 3.
45 kg, and he went to Beijing Children’s Hospital after birth.
He was diagnosed with congenital heart disease: ventricular septal defect (perimembranous) (3.
8 mm), atrial septal defect or patent foramen ovale (6.
3 mm) .
Physical examination: heart rate 130 beats/min, heart rate uniform, L3~5 systolic tremor, 3~5 intercostal murmur on the left edge of the sternum, 4/6 grade systolic murmur, conducted to the armpit, no heart failure in the child Symptoms and signs, the rest of the children have no positive signs.
Auxiliary examination report: white blood cells increased, CRP increased significantly, procalcitonin increased, streptococcal infection, Epstein-Barr virus infection, negative blood culture.
Heart color Doppler ultrasound report: ventricular septal defect (perimembranous) 4×4mm, tricuspid regurgitation with moderate regurgitation; tricuspid septal valve mass echo shadow (vegetation?).
Chest X-ray: Congenital heart disease, left pleural hypertrophy.
The following questions need to be analyzed after this child is admitted to the hospital: First, the child has fever for 13 days and has a longer fever.
So, what is the cause of fever? Fever is generally divided into infectious fever and non-infectious fever.
The child had a fever for 13 days and oral antibiotics by himself for 6 days were ineffective.
Except for common upper respiratory tract infections and fever caused by some infectious diseases, long-term fever needs to consider deep bacterial infections, such as meningitis, pancreatitis, infections caused by deep fungi, etc.
, and malignant factors such as fever caused by leukemia. Obviously, the children's blood test results do not support these diagnoses.
Clinically, we need to pay special attention to children who have fever for a long time.
It is likely to be a clinically uncommon cause.
In addition to fever, the child in this case has the disease basis of congenital heart disease.
In addition, the heart color Doppler ultrasound suggests suspicious growths.
We consider that the child may be infective endocarditis (IE).
So, can the child be diagnosed with infective endocarditis? Let's first look at the diagnostic criteria for infective endocarditis-Duke's criteria.
The criteria for confirming IE are validated from a pathological point of view.
If blood culture or histological examination of neoplasms proves to be related to causing embolism or intracardiac abscess or pathological lesions, then it is confirmed that there is active IE.
Validation based on the above-defined clinical standards, if it contains 2 major standards, or 1 major standard plus 3 minor standards, or 5 minor standards, IE can also be diagnosed.
This child has no skin, mucous or conjunctival ecchymosis, no Osler nodules, no Janeway nodules, no skin microthrombosis such as linear hemorrhage under nails, and no immunological signs such as glomerulonephritis.
The characteristics of a typical IE.
However, this patient meets 1 major criterion and the first 3 minor criteria (re-examination of cardiac color Doppler ultrasound suggests that the vegetation is slightly smaller than before, and the blood pressure of the right lower extremity rises transiently during hospitalization, and there may be small thrombus), so it still supports infectiousness Diagnosis of endocarditis.
Clinical manifestations of infective endocarditis in children and adolescents: Symptoms are usually slow, often manifested as long-term low-grade fever and various physical symptoms, including fatigue, fatigue, joint pain, myalgia, weight loss, chills and sweating.
But it can also be fulminant, such as rapid changes in symptoms, high fever, and critical illness.
This situation requires urgent intervention.
4 basic phenomena: bacteremia (or sepsis), valvulitis, immune response, embolism.
Why are children with congenital heart prone to infective endocarditis? In the past 20 years, with the decline in the prevalence of rheumatic heart disease, congenital heart disease has become the main cause of IE in children> 2 years old in developed countries.
And as the survival period of patients with congenital heart disease has been significantly prolonged, related IE has also increased year by year.
There are structural abnormalities in the heart or large blood vessels, and the abnormal pressure gradient causes obvious blood turbulence (which can lead to endothelial damage and platelet thrombosis).
Aortic valve disease is the most common, and secondary orifice atrial septal defect rarely occurs.
The neoplasms of infective endocarditis often exist in the low-pressure cavity of the defect, the periphery of the defect, or the contralateral side of the defect (the contralateral endometrial injury caused by the high-speed jet).
For example, vegetations exist in the pulmonary artery during patent ductus arteriosus or systemic pulmonary bypass, and vegetations occur on the chordae of the mitral valve during mitral valve regurgitation.
The location of this child's heart vegetation is located on the tricuspid valve septum, and the location is relatively rare.
It should be considered that it may be related to the child's ventricular septal defect, left to right shunt, and tricuspid regurgitation with moderate reflux.
The most taboo disease in medicine is to avoid doctors.
After the child was diagnosed with congenital heart disease after birth, he did not reexamine the heart color Doppler ultrasound.
In fact, we recommend that children with congenital heart disease should have regular cardiac surgery follow-ups and timely surgical treatment.
Because children with congenital heart disease, once suffering from pneumonia, the heart cannot bear the load, and heart failure is very prone to occur.
Those with severe residual valve damage need to undergo valve repair or replacement.
In addition, children with congenital heart disease should also pay attention to oral hygiene to prevent gingivitis and dental caries; prevent infection; if oral surgery, tonsillectomy, cardiac catheterization and cardiac surgery are performed, it can be 1~ before surgery.
Antibiotic treatment was used for 2 hours and 48 hours after surgery.
References: [1] Chen Lin, Tax Xing, Wen Zheqi.
Interpretation of the 2015 AHA Children’s Infectious Endocarditis Management Science Statement[J].
Chinese Journal of Circulation,2016(s2).
[2]Wang Weiping.
Pediatrics.
8th edition [M].
People's Medical Publishing House, 2013.
