Young men repeatedly fever six months after a sudden brain haemorrhage, the culprit behind it is TA!

First, medical history profile male, 39 years old, Shandong, 2020-06-18 admitted to Zhongshan Hospital infection department main complaint: 1 year ago repeated fever for half a year, six months ago sudden cerebral hemorrhage current history: patients in June 2019 no obvious cause under the emergence of fever accompanied by fatigue, Tmax 39 degrees C, At the same time, the left ankle, left middle finger between the knuckles appear redness accompanied by pressure pain, no cough cough sputum, urinary pain, abdominal pain diarrhea and other discomfort, to the local hospital to check blood routine did not see abnormalities, CRP 33mg/L, oral cephalosporine a week after the temperature leveled, nearly a month later left ankle, knuckle redness and self-improvement.
2019-06-24 Because of blood urine, proteinuria in my hospital nephrology diagnosis of IgA kidney disease, has been given glucocorticoids, propylene globulin, cyclophosphamide treatment, from December 2019 long-term acetate pyrethroid oral;
no fever from the end of December 2019.
January 2020 sudden left limb activity adverse, the local hospital to check the head CT show cerebral hemorrhage, after hospital treatment left limb activity improved, gradually returned to normal.
For the clear cause of cerebral hemorrhage, 2020-03-10 to a Shanghai Hospital, skull MRI shows the right frontal leaf, sub-acute late hemorrhagic lesions, left top leaf strip flaky abnormal signal, two-sided hypothione, right cerebrocephaly dot abnormal signal, microbleeding may, cerebral bridge small ischemia.
June 2020 to a medical center in Shanghai, check the blood routine WBC 11.6 x 10 x 9/L, N90.9%, ESR 25mm/H, CRP 46mg/L, heart super: two-tip valve dislocation, valve thickening, two-tip valve bio-formation, two-tip valve medium-heavy esthydration, aortic valve light diacritic.
in order to eliminate valve lesions caused by rheumatic diseases, visit Renji Hospital to check ACL, ANA, ds-DNA, p/c-ANCA, RF are negative, no evidence of rheumatic diseases.
because of the heart super tip two-tip flap fat creatures, income to my section.
since the onset of the disease, the patient's stomach, spirit can, two will not be unique, weight no significant change.
history: IgA kidney disease has been found for nearly a year and is now 15mg qd oral acetic acid.
denies any history of high blood pressure, diabetes or coronary heart disease.
, hospitalization examination (2020-06-18) (physical examination) T 36.5 degrees C, P 88 times / minute, R 12 times / minute, BP 122 / 80 mmHg Shenqing, skin scleum no yellow dye, no rash, the body shallow surface lymph nodes did not and swell.
's double lungs are unheard of.
heart-tip area and 3/6 esoteric period murmur, heart rate 88bpm, Rhythm.
abdomen is soft, no pressure pain, anti-jump pain, liver and spleen did not reach.
both lower limbs are edema-free.
( Laboratory Examination) Blood Routine: WBC 7.96X10?9/L, N 88.9%, Hb 122g/L, PLT 141X10?9/L; Inflammatory markers: ESR 21mm/H, hs-CRP 44.8mg/L, PCT 0.13ng/mL; Liver and kidney function: ALT// AST 9/12U/L, LDH 424U/L, Creatinine 92?mol/L; Cell immunity: number of lymphocytes 655cells/uL, CD4 plus lymphocytes count 146cell s/uL, CD4/CD8 0.6; Heart Marker: cTNT 0.007ng/mL, NT-proBNP 176pg/mL; Autoantibodies: ANA particles 1:100, Remaining negative; thyroid function, hepatitis markers, immune fixed electrophoresis (-); urine routine: protein , cryptogenic , white blood enzyme (-), red blood cell count 35/uL, white blood cell count 4/uL, bacteria count 25/ uL; fecal routine and OB(-); T-spot antigen A/antigen B:0/0; G test (-), cryptococcal membrane antigen (-); virus: EBV-DNA (-), CMV-DNA (-).
06-18 ELECTRON: OK.
06-18 expert heart super: two-tip flap thickened hair brown drooping accompanied by moderate and severe throb, local see multiple rope-like echo attachment flutter (maximum length 22mm), consider the formation of fat organisms and valve leaf perforation.
Three, clinical analysis patients 39-year-old male, chronic disease course, 1 year ago had repeated fever for half a year, six months ago cerebral hemorrhage 1 time, accompanied by IgA kidney disease, long-term use of glucocorticoids, after entering my department to check blood routine N, hs-CRP, ESR elevation, check the heart region smell and 3/6 stage diasporosis, heart super-two-tip valve biological formation and leaf valve perforation.
Synthesis of current data, diagnosis and differential diagnosis considerations are as follows: infectious endocarditis: the heart super-sees the second-tip valve and perforation, the heart-tip region smells and diastic period murmurs, combined with the history of fever, first consider infectious endocarditis (IE), such as blood culture or blood mNGS detection of meaningful pathogens, then the disease is more likely.
Patients of young men, no hypertension, diabetes, hyperlipidemia and other atherosclerosis, cerebrovascular disease high-risk factors, no clear evidence of cerebrovascular malformation, hemangioma, vasculitis, so six months ago cerebral hemorrhage should consider IE bacteria embolism spread to the intracranial, cerebral infarction after secondary cerebral hemorrhage may be large.
to assess what pathogens IE is causing, the choice of anti-infection drugs is important.
In this patient needs to consider common Quality-positive bacteria such as streptococcus, Staphylococcus, Enterococcus, common Gheran-negative bacteria such as HACEK bacteria (Haemophilus genus, Cococillus genus, Mycobacteria genus, Aiken genus and Kimberly), as well as other rare pathogens such as Liquel, Candida, Baltong, bructum, etc.
such as penicillin-sensitive streptococcus and staphylococcus, the treatment of the preferred penicillin combined amino glycosides, such as penicillin resistance, optional cephalosporine combined amino glycosides.
high resistance of enterococcoscillus to penicillin, vancomycin is generally recommended.
cephalosporine or quinolones are available for treatment with HACEK myoarthritis.
the patient's long course of disease, symptoms are not typical, it is longer to consider relatively low toxic pathogens such as HACEK bacteria.
Rheumatoid immune system diseases or other systemic diseases caused by non-infectious endoencephalitis: vasculitis, white plug disease, antiphospholipid antibody syndrome and other rheumatoid immune system diseases can affect the heart valve caused by non-infectious inflammation, its heart super performance is sometimes more difficult to identify with IE, need to further improve blood culture, according to the results of identification.
Thursday, further examination, diagnosis and treatment process and treatment response 06-18 on the day of admission to the hospital to retain blood culture and blood mNGS, and to the cephalosporine 2g q12h and moxisa star 0.4g qd anti-infection.
cardiac surgery consultation: IE diagnosis is clear, if there are symptoms of biodesk embolism or heart failure can not be controlled, may consider emergency surgery.
06-19 blood culture: Erlan positiveococcus positive, while 3 bottles of yang, yang time 18h.
06-19 line head MRI flat sweep: right temporal lobe hemorrhage (subacute late stage).
06-20 blood (06-18 sampling) mNGS results showed that 279 defective bacterial nucleic acid sequences were detected.
06-21 Blood Culture Results: Defective Bacterial Deficiency, Drug Sensitivity Report is shown in the drawings.
24-hour urine protein quantification: 0.86g/0.44g, 06-22 nephromology consultation, consider acetic acid panisson 15mg qd treatment has been half a year, acetate panisson reduction of 10mg qd oral.
06-24 Follow-up blood routine WBC 11.6X10?9/L, N 78.6%, inflammation index decreased from the previous: hs-CRP 15.4mg/L, ESR 8mm/H, PCT 0.02ng/mL.
06-24, 06-26 blood culture is negative.
06-28 Review heart super: two-tip valve thickening brown drooping companion medium-heavy throb, local see multiple rope-like echo attachment fluttering, considering the formation of fat organisms and valve leaf perforation, aortic sinus widening, aorta with slightly brown with slight to mild aortic valve erotitis, left room increase, very little heart envelope fluid.
06-28 cardiac surgery, 06-30 lines of two-tip valve mechanical valve replacement, valve culture (-), valve mNGS detected defects in the bacterial nucleic acid sequence 17652.
07-05, the hospital continued anti-infection treatment.
Temperature changes and drug use five, the final diagnosis and diagnosis basis of the final diagnosis: infectious endocarditis (defective lack of bacteria) cerebral hemorrhage (the biological shedding caused brain infarction followed by blood may be issued) IgA kidney disease diagnosis basis: the patient 39-year-old male, repeated fever for six months, followed by sudden cerebral hemorrhage, hospital heart hyperspiration two-tip flap thickening hair drooping accompanied by heavy erfuscation, local see multiple ropes Sample echo attachment flutter, considering the formation of fat organisms and valve leaf perforation, blood culture and blood mNGS detected defects of lack of bacteria, by cephalosporine, Moxisa star anti-infection after the temperature drop, blood culture turn yin, transferred to cardiac surgery line two-tip valve replacement, valve mNGS detected a large number of defects of the lack of bacterial nucleic acid sequence, infectious endoencephalitis (defective lysium bacteria) diagnosis is clear.
patient's external head MRI right frontal leaf, substrate section bleeding, residual micro-bleeding, considering the cause of bacterial embolism shedding.
6, experience and experience of deficiency bacteria used to be called nutritional variant streptococcus, is now classified as a nutrient-defective genus, is a Glo-positive bacteria, usually planted in the human mouth and respiratory tract, in the host immunity decline can cause disease, serious cases of systemic infection, the most common is infectious endoencephalitis (IE).
Some international studies show that IE caused by defective lack of bacterial bacteria accounted for about 5% of all IE cases, characterized by severe damage to valve structure, more likely to cause organ embolism, heart failure and other complications, treatment failure rate and infection recurrence rate is higher, the overall prognosis is poor.
there are few studies on defective lack of bacterial IE in China.
patient in this case concurrent cerebral hemorrhage, with two tip valve leaf perforation, consistent with the defective lack of bacterial IE characteristics.
treatment, the defective bacterial IE anti-infective drug preferred cephalosporine, the alternative is loxyfluorostar, the guidelines recommend postoperative anti-infection treatment course of 6 weeks.
Part of the IE disease hidden, such as this case of patients, mainly manifested as repeated low fever, although the valve structure has been damaged, but the patient has no chest tightness, end sitting breathing, less urine and other heart failure symptoms, admission to check the heart marker is only NT-proBNP mildly elevated, if not heart super-check, it is difficult to find infection lesions.
also reflects the important role of heart super in fever to be diagnosed and treated.
Patients have IgA kidney disease, long-term oral hormones, cover up fever symptoms, IE symptoms are more atypical, coupled with clinicians on IE vigilance is not high, not timely diagnosis and treatment, resulting in disease exacerbation, cerebral hemorrhage, valve perforation, after 1 year to be diagnosed. one of the serious complications of
IE is organ embolism, infection of the blood line spread to the skin, brain, spleen, kidneys, small intestine, bone and other organs throughout the body, which is another important manifestation of IE in addition to fever, for patients who have had embolism events, especially to take into account the diagnosis of IE.
studies have shown that bacterial embolisms can occur in 50% of IE patients, more than half of them before IE is clearly diagnosed.
IE, the diameter of the fat organism is greater than 10mm, the lesions and the two-tip valve are the high-risk factors for embolism.
patient in this case occurred in the two-tip valve, the maximum diameter of the fat biomass 22mm, with embolism high-risk factors.
15%-36% of IE will have a brain infarction (including secondary cerebral hemorrhage after a cerebral infarction), more than half of which also occurs before IE is diagnosed, and some patients develop brain abscesses.
studies have shown that the rate of IE and clots decreased significantly after effective anti-infection.
For young men such as patients in this case, the cause of sudden cerebral hemorrhage is unknown, in addition to considering atherosclerosis, vascular malformation, hemangioma rupture, vasculitis and other common causes, but also need to consider IE concurrent intracranial bacterial embolism, secondary cerebral hemorrhage this differential diagnosis, tracking the original stove, clear diagnosis.
addition, the patient's initial complaint of the left ankle, left middle finger between the knuckles appear redness accompanied by pressure pain, may also be caused by bacterial embolism.
Cai Sishi Jin Wenxuan Ma Yuyan Source: SIFIC Infection Officer Micro!-- Content Show Ends -- !-- Determine whether the login ends.