Infective endocarditis laboratory diagnosis. Endocarditis: symptoms and treatment

Today, carditis is increasingly coming to the fore among diseases of the cardiovascular system - the main cause of death in the adult population.

They are especially dangerous for the development of life-threatening complications for the patient, so their diagnosis and treatment are one of the main areas of fundamental medical science in the field of cardiology.

One of these types of heart problems is endocarditis - what kind of disease is it? Pathology is an infectious and inflammatory disease of the heart of an acute or chronic nature, in which the main target of pathogenic microorganisms is the inner lining (endocardium) of the atria and ventricles, as well as the valvular apparatus.

Statistics

The disease is common in all countries of the world and in various climatic zones. The incidence ranges from 3.1 to 11.6 per 100,000 inhabitants. Men suffer from endocarditis 2-3 times more often than women.

AT recent times in developed countries, there is a clear "aging" of this pathology. If earlier average age patients with endocarditis was 35 years old, now it is 50. There is also a higher risk of developing the disease in early childhood, especially in the presence birth defects hearts.

Mortality in this disease varies from 15 to 45%.

Kinds

The division into varieties of the disease is made on the basis of the causes that caused it. Conditionally divided into two large groups: aseptic and bacterial inflammation.

The first group includes rheumatic, Liebman-Sachs and Leffler. The second is diagnosed much more often, it includes a bacterial or septic and infectious process.

Etiology: causes and risk factors

Among the predisposing factors for the development of endocarditis can be noted:

• hidden foci of dormant infection different localization: tonsillitis, carious teeth;
• congenital and acquired heart defects, hereditary anomalies of its development;
• primary and secondary immunodeficiency;
• stress, sluggish chronic diseases causing weakening defensive forces organism;
• addiction;
• elderly age.

An increase in the number of episodes of the inflammatory process of the inner lining of the heart in older people is associated with a history of diseases predisposing to endocardial damage: calcification, involutive processes in the immune system, deterioration of blood rheology, an increase in the frequency of operations and medical and diagnostic procedures.

Learn more about this disease from the video:

Classification

By the nature of the flow

Here are distinguished:

• primary: occurs on healthy heart valves;
• secondary: develops on pathologically altered structures of the heart and blood vessels with rheumatism, congenital and acquired defects, syphilis, after surgery for valve replacement, etc.

According to the clinical course, there are:

• spicy: lasts up to 2 months. The reason is staphylococcal origin, trauma and medical and diagnostic manipulations in the area of ​​the cardiovascular system.

  With this form of inflammation, infectious-toxic manifestations rapidly increase, as well as valve vegetation and thrombus formation, purulent metastases to various organs are not uncommon;

• subacute: lasts more than 2 months. Develops with inadequate therapy of acute endocarditis;
• chronic relapsing A: more than 6 months. It is formed with deep damage to the myocardium or dysfunction of the valvular apparatus. It is more common in newborns and infants with hereditary heart defects, drug addicts and those who have undergone surgical interventions.

Check out ECG signs left atrial hypertrophy - detailed information awaits you.

stages

There are three stages of the pathogenesis of endocarditis: infectious-toxic, immuno-inflammatory and dystrophic.

By localization

According to the location of endocarditis:

• left-sided inflammation of the native (natural) valve;
• left-sided prosthetic valve endocarditis, which is divided into early (less than a year after installation) and late (more than a year has passed since the operation);
• right-sided endocarditis;
• associated with devices such as a pacemaker.

In addition, valvular, parietal and chordal pathology is distinguished.

With the development of the disease on the valvular apparatus, only the leaflets (valvulitis) can be involved in the process, which is more common in the rheumatic process. Whereas it covers all departments of the valve: cusps, valve ring, chords and papillary muscles.

The main signs of right atrial hypertrophy are described in detail in. Find out all the details!

Treatment

conservative

Antibiotic therapy is prescribed in a hospital after accurate identification of the strain of the microorganism.Preference in the treatment of endocarditis is given to antibiotics a wide range actions. With a fungal infection for a long time, Amphotericin B and Flucytosine are prescribed.

To maintain the work of the heart muscle and eliminate symptoms in the form of shortness of breath, increased blood pressure and tachycardia, edema are used ACE inhibitors, beta-blockers, aldosterone receptor antagonists, diuretics, cardiotonics.

Hemolytics, which thin the blood, are also in demand, especially in postoperative period for the prevention of thrombosis. As detoxification measures and for immunomodulation, plasmapheresis, ultraviolet autologous blood and intravenous irradiation blood laser.

Surgical

Need for surgical treatment occurs with complications.Surgical intervention involves mechanical excision of the modified valve with implantation of an artificial valve in its place with additional sanitation of the inflammation focus with broad-spectrum antibiotics.

Pathological zones can also be treated with low-frequency ultrasound.

Special symptoms in children

In childhood, this pathology is very rare. Most often in children, it develops in acute and is characterized by the following symptoms:

• acute intoxication of the body, manifested by weakness, headache, joint pain;
• inflammatory process in the endocardium;
• thrombi appear on the affected endocardium, which contribute to the development of thromboembolism.

The course of pediatric endocarditis does not differ from the development process in adults, but the symptoms increase rapidly, in addition, the treatment of the pathology also does not have any special differences. The destructive process affects all internal organs, especially the urinary system. Any infectious disease is a risk factor that must be cured immediately.

The course of the disease in HIV-infected people

Non-bacterial thrombotic endocarditis most often develops in HIV-infected patients.(Marantic). It occurs in 3-5% of virus carriers and in almost all AIDS patients. Usually this form of pathology develops asymptomatically, rarely causes thromboembolism. For treatment, anticoagulants are used to prevent the formation of blood clots. Carry out therapy aimed at eliminating damage to the valve apparatus.

infective endocarditis (IE) bacterial endocarditis) is a severe inflammatory disease of the heart valves with a poor prognosis and the formation of persistent complications that affect ...

Some heart diseases are more likely to occur against the background of others pathological conditions. This category includes endocarditis, which in its development to a lesser or greater extent affects the heart valves. Since the valve apparatus plays important role in the circulatory system, if it is damaged, it is extremely important to undergo treatment in a timely manner.

Endocarditis (EC) is based on an inflammatory process that affects the inner lining of the heart. In some cases, the infection that caused inflammation focuses on the valves or moves to inner wall adjacent vessels.

Today, more than 120 pathogens are known that can cause one form or another of endocarditis.

The disease is quite difficult to diagnose, since there is no specific symptoms. Therefore, often final diagnosis established after 2-3 months from the onset of the first symptoms. Also, 85% of patients are admitted to hospital treatment with the wrong diagnosis.

Video Endocarditis. Why is it important to treat your teeth on time?

Classification

Exist various classifications endocarditis, some of which were developed 20 years ago or more. If we take into account the modern views of medicine on the development of EC, then it is worth taking into account the division according to International classification diseases of the 10th revision. Accordingly, it is distinguished:

• Acute and subacute infective endocarditis (code I33.0). In turn, it can be bacterial, infectious, slowly flowing, malignant, septic, ulcerative.
• Candida endocarditis (code I39.8*).
• Acute rheumatic endocarditis (code I01.1).

There is a conditional clinical-morphological and etiological classification, according to which they distinguish:

• Infectious acute endocarditis, which may be bacterial or septic.
• Subacute or protracted endocarditis, also known as chronic.
• Thromboendocarditis is not infectious origin.
• Rheumatic endocarditis.
• Loeffler's endocarditis, also known as fibroplastic with eosinophilia.

Causes

Endocarditis is largely associated with diverse infections that can occur acutely or chronically. Secondary endocarditis is also isolated, which is combined, as a rule, with diffuse diseases connective tissue. Today, the ICD-10 indicates following groups infections that most often lead to the development of endocarditis:

• candidal;
• gonococcal;
• meningococcal;
• tuberculosis;
• syphilis;
• typhoid fever;
• Libman-Sachs disease.

Many changes in the endocardium are associated with rheumatism and rheumatoid arthritis. These diseases often develop due to streptococcal infection, which spreads throughout the body and settles in various organs and tissues. Under favorable conditions, streptococci on the endocardium cause inflammation with all the ensuing consequences.

As etiological factor often speaks Staphylococcus aureus and enterococcus. They are mainly isolated in acute endocarditis. Among the pathogens that cause endocarditis, also include beta-hemolytic streptococcus, Escherichia and Pseudomonas aeruginosa.

The causative agents of the disease can become ordinary “inhabitants” of the skin, mucous membranes, gastrointestinal tract who, with weakened immunity or changing conditions internal environment begin to behave like a pathogenic microflora.

Development factors

One of the conditions for the development of endocarditis is bacteremia, determined for a long time. Its occurrence may be associated with chronic foci of infection such as periodontitis, tonsillitis, furunculosis. Manipulations with which pathogens were introduced into the body could also be carried out. This happens when surgical interventions ah, catheterization, bronchoscopy, intravenous injection medicines or drugs.

The process is more active if the valves were previously changed against the background of rheumatism or birth defects. The use of prosthetic valves also contributes to the development of endocarditis.

The pathological process is directly related to destructive and ulcerative inflammation of the endocardium, which is accompanied by the deposition of platelets along with fibrin, bacteria and tissue particles. As a result, in addition to EC, a disease of the type of thromboembolism may develop. Accession to the inflammatory process of autoimmune mechanisms associated with circulation immune complexes and the development of an appropriate reaction to them, leads to an aggravation of the course of endocarditis.

Views / photos

Infectious acute endocarditis

The pathological formation most often involves the membranes of the heart valves, on which ulcerations or ulcers occur along with polyps. A damaged valve cannot fully function, which is why its insufficiency is formed. Ulcerations most often appear on the mitral valve, less often on the aortic valve. Ulcers spread rapidly and after a while can reach the tendon chords along with the parietal endocardium.

Video Bacterial endocarditis

Affected valves become a site of accumulation of fibrin with platelets. Due to the layering of these blood components, the valves swell, fibrin penetrates them. As a result, the risk of detachment of the tendon chords or individual parts of the valve increases. Also, the vessels can become clogged with detached blood clots, which entails the development of a septic infarction. If the process “fades out”, then wrinkling and deformation of the valves occurs, which causes disturbances in hemodynamics, cardiac conduction, etc.

Subacute or chronic endocarditis

Also known as protracted endocarditis. May be developmentally related pneumococcal infection, but more often occurs against the background of infection with streptococcus, hemolytic or ordinary. The pathological process is mainly involved aortic valve, which was subject to sclerosis or other change.

The course of the disease is often associated with recurrence pathological process, which increases the risk of heart attacks of various organs, as well as focal inflammation in the kidneys. In addition, the spleen may increase, previously existing anemia may progress.

Non-infectious thromboendocarditis

Inflammation of the endocardium may be associated with non-infectious developmental factors. Distinguish various forms of this disease, but the most common include:

• degenerative warty;
• abacterial;
• minimum.

Non-infectious EC often develops against the background of internal intoxications, it is also often determined in debilitated patients and in senile insanity. With it, the valves located in the left ventricle are often involved in the pathological process. Signs of inflammation, as a rule, are absent, while platelets with fibroblasts, macrophages and monocytes can be determined in the lesions.

Rheumatic endocarditis

Its development is based on infection of a person with group A beta-hemolytic streptococcus. various structures body, including the valvular apparatus of the heart. The connective tissue in it undergoes an inflammatory process. Chords and the parietal endocardium may also be affected. As a result, depending on the place of development of rheumatic endocarditis, the following can be distinguished:

• EC valves;
• EC chord;
• parietal EC.

The disease is characterized by acute course, during which heart defects are often formed. Among other manifestations of rheumatism, EC occupies one of the main places.

The pathological process can proceed in different ways, but most often they are isolated the following forms rheumatic EC:

• Diffuse - valve leaflets swell somewhat, but do not change.
• Acute polyposis (warty) - the lesion affects the deeper layers of the endocardium, resulting in upper layer partially exfoliates and fibrin, platelets, etc. are deposited on it.
• Recurrent polyposis - in addition to the formation of “warts” on the valves, calcium salts are deposited on them, which leads to an even greater disruption of their function.
• Fibroplastic - has the most unfavorable course, since it leads to irreversible changes and severe consequences.

Endocarditis in children

At a younger age, infective endocarditis is most often determined, which can occur primarily and secondarily. The first leads to inflammation of the mitral and aortic valves, and the second leads to direct damage to the inner lining of the heart.

The disease manifests itself in the same way as in adults, only the course is more active, which often causes severe complications according to the type of insufficiency of the heart, liver, kidneys.

The disease must be treated promptly. It is even better when prophylaxis of endocarditis in children is carried out.

Diagnostics

Exist various ways definitions of endocarditis that allow identification of both the course of the disease and the perceived risks to the patient's health. Great importance It has correct compilation clinical picture, which in most cases is diverse. This, in turn, often complicates the diagnostic process. Also, as necessary, instrumental and laboratory research methods are used, especially in case of difficulty in making a diagnosis.

Clinic

After infection of the patient, the first symptoms of endocarditis may appear two weeks later. First of all, fever may occur, which is often accompanied by increased sweating and chills. Sometimes the temperature reaction changes: it gets higher, then it drops to normal.

An extended clinic may include the following symptoms:

• Intoxication of the body, which is mainly expressed by weakness, lack of appetite, pain in the head and joints.
• The skin changes, becomes pale or with a yellowish tint, small hemorrhages may appear on various parts body (torso, legs, arms, mucous membranes).
• Disorder of the central nervous system can be expressed in psychosis, cerebral thromboembolism, meningoencephalitis.
• Lymph nodes (especially cervical and axillary) increase.
• The feeling of discomfort is often determined in the chest, with a projection on the heart.
• When EC is complicated by heart failure, shortness of breath occurs, swelling and pain in the heart appear.

The long course of the disease contributes to a metabolic disorder in the body, which is why the symptom of “drum sticks” is determined. It is when distal phalanges fingers thicken. There may also be a symptom of watch glasses, when the fingernails are rounded.

The severity of the clinic largely depends on the activity of the response. immune system, as well as the severity of the pathological process. Also, each form of endocarditis has its own characteristics. For example, in bacterial EC, the clinic is often severe, abscesses appear in various organs, and the septic state is complemented by severe destruction of the valves. At the same time, signs of a pronounced infectious process are not characteristic of fibroplastic EC.

Instrumental examination methods

To begin with, an electrocardiogram is made, on which signs of an increase in the left or right ventricle can be seen. At long course process, conduction may be disturbed, due to which arrhythmias are formed.

Helps in making a diagnosis echocardiography and phonocardiography. With the help of echocardiography, calcification is determined, the functioning of the valvular apparatus is evaluated, and in the presence of a defect, its nature is determined. Also held differential diagnosis in order to exclude rheumatism, for which blood cultures are performed.

The inflammatory process in the body can be confirmed laboratory diagnostics when in general and biochemical analysis blood is determined by neutrophilia, elevated ESR, bacteremia, etc. If rheumatoid endocarditis is suspected, an analysis is made for rheumatoid factor, C-reactive protein, gamma globulins.

Blood cultures- an important step in determining the infection in the body, especially if there is a suspicion of infectious EC / When taking blood for analysis, certain rules must be followed. The analysis is repeated two or three times, if the results match, the answer is considered positive.

Treatment

Endocarditis therapy can be prescribed as effectively as possible if it has been used correct diagnosis and established a reliable form of the disease.

There are several treatment options for EC:

• The use of antibacterial drugs.
• Carrying out symptomatic treatment.
• Performing immunocorrection.
• Surgery.

Antibacterial treatment- is carried out in order to eliminate infection in the body. To do this, one antibiotic is administered intravenously, and with its low efficiency, a scheme is drawn up for the use of combinations of antibacterial drugs. They usually need to be taken for a long time, about 3-4 weeks.

Before prescribing an antibiotic, the sensitivity to it of the microflora isolated by blood culture of the patient is necessarily checked. Depending on the pathogen, the following antibacterial agents are used:

• Streptococcus viridans endocarditis is treated with benzylpenicillin.
• In the presence of enterococci, benzylpenylline is combined with gentamicin or amikacin.
• Staphylococcal endocarditis is treated with semisynthetic penicillins, which in severe cases are combined with aminoglycosides or cephalosporins.
• Fungal endocarditis responds poorly to therapy, which is usually based on amphotericin B.

After two weeks, the effectiveness of antibiotic therapy is evaluated and, if necessary, the drugs are replaced with others.

Symptomatic treatment consists in the implementation of detoxification, the use of cardiac glycosides, thrombolytic drugs. Sometimes corticosteroids are prescribed, mainly with a pronounced allergic reaction.

Immunocorrection consists in the use of antitoxic sera, which perform the tasks of passive immunization. A good neutralizing effect on bacterial toxins circulating in the blood is given by the introduction of human immunoglobulin or hyperimmune plasma.

Surgical therapy used as a last resort when it doesn't help conservative treatment. It is based on the removal of the affected parts of the valvular apparatus and the installation of artificial valves, which can be biological or mechanical.

Video Elena Malysheva. Treatment of infective endocarditis

Forecast

Previously, mortality from endocarditis was very high, but after the start of antibiotic use broad action managed to reduce the figure to 30%. Today, mostly patients continue to die not from the endocarditis itself, but from the complications that the disease led to (thromboembolism, heart failure, intoxication).

Practically complete cure possible in the case when the diagnosis was carried out at an early stage of EC development and after the correct identification of the pathogen, it was prescribed the right treatment. It is important to note that it will take a long time to return to working capacity.

In some cases, the disease begins to reappear within 4 weeks from the end of treatment, then they speak of a relapse of EC. If symptoms appear after 6 weeks we are talking about a new infection.

Prevention

It is imperative that all foci chronic infection according to the type of tonsillitis, periodontitis were promptly cured. Also, if intercurrent pathologies are detected in patients with heart defects, appropriate therapy should be carried out.

Prophylactic antibiotic therapy can be carried out with the following interventions:

• tooth extraction;
• catheterization;
• bronchoscopy;
• tonsillectomy;
• appendectomy.

To eliminate additional provoking factors in the form of influenza, hypothermia should be avoided.

Inflammation of the inner lining of the heart, which is characterized by damage to the valvular apparatus and the layer of cells lining the surface of adjacent vessels, is classified in medicine as endocarditis. Often doctors note that the pathological process in question is not independent disease but is a consequence of other diseases. Endocarditis can develop at any age, almost 128 different microorganisms are considered potential causative agents of this inflammatory process.

A complete classification of endocarditis involves the division of the disease into the following types:

• rheumatic;
• infectious acute;
• Loeffler's endocarditis (parietal fibroplastic eosinophilic);
• chronic or subacute;
• thromboendocarditis of non-infectious etiology.

Symptoms of endocarditis

The considered inflammatory process can manifest itself completely suddenly, or for a long time to proceed absolutely asymptomatically. In addition, endocarditis is characterized by a variety of manifestations, having an acute or protracted course - all these features make it difficult to diagnose.

Usually, clinical picture develops maximally within two weeks from the moment of infection. by the most important symptom endocarditis is a fever that is accompanied by intense chills, excessive sweating. It is noteworthy that it is the inflammatory process under consideration that is characterized by variable temperature response body - the patient may complain of subfebrile body temperature for several months, or jumps increase / decrease / normalization of this indicator.

If the clinical picture is detailed, complete, then the following symptoms will be inherent in endocarditis:

• changes skin- they become pale yellow, punctate hemorrhages appear on the mucous membranes and skin, there are spots on the palms, torso and feet;
• pathological lesions of the kidneys are noted - a kidney infarction or focal nephritis is diagnosed;
• severe intoxication - constant, weakness;
• pathological lesion mitral or aortic valve;
• changes in the terminal phalanges and nail plates;
• pathological lesions of the central nervous system- cerebral thromboembolism, psychosis, meningoencephalitis;
• large joints upper and/or lower extremities;
• progressive;
• significant .

Note:the clinical picture, the nature of the course of endocarditis and the prognosis of the disease depend on the state of the immune system of a particular patient and the severity of the process.

Diagnostic measures

Often, the doctor can make a diagnosis according to the patient's complaints - fever with chills. Of course, a specialist will definitely conduct full examination of the patient and when thromboembolic complications, myocardial murmurs and positive results of bacteriological examination are detected, they simply confirm the preliminary diagnosis.

Be sure to the patient with endocarditis (or only if suspected) is carried out - signs of left ventricular or right ventricular hypertrophy, conduction disturbance, ventricular or atrial extrasystole will be revealed. Much less often, when conducting an electrocardiogram, the doctor notes atrial fibrillation or flutter.

Note:It is the electrocardiogram that makes it possible to diagnose endocarditis at the most early stages progression, which guarantees successful treatment.

echocardiography recommended for those patients in whom doctors suspect the development of endocarditis of an infectious origin. This method of examination allows you to objectively assess the condition of the valvular apparatus and timely detect calcification or rupture of the valve leaflet. Often, echocardiography is used to clarify the nature of heart disease, as well as to determine the appropriateness of surgical intervention.

Sufficiently informative in the framework of the diagnosis of the inflammatory process under consideration are blood tests- general, biochemical and immunological. will show anemia and shift leukocyte formula left, hallmark endocarditis will serve as a significant increase in ESR. the patient's blood reveals the presence of C-reactive protein, a decrease in the level of albumin and an increase in the amount of fibrinogen. An immunological blood test helps to detect rheumatoid factor and elevated levels of compliment components.

As part of the diagnostic measures, blood cultures for sterility are necessarily carried out, and this is the most milestone Examination of a patient with suspected endocarditis of an infectious origin. When conducting such a study, it is very important to follow the technique of blood sampling, and to obtain a truly reliable result, experts recommend conducting such an analysis at least twice in a row.

Treatment of endocarditis

This process is often difficult, because it is sometimes not possible to quickly make a diagnosis, to identify the pathology in time. Therefore, in this article we will highlight only the main directions of therapy for endocarditis:

In the treatment, bactericidal drugs are used in high doses, they are administered by intravenous drip infusion. Often, doctors note the lack of effectiveness in the application of a particular medicinal product and in this case, they carry out a change in treatment tactics.

The choice of a specific antibacterial drug for the treatment of the inflammatory process in question is made strictly on an individual basis, and the causative agent of the disease is the main indicator in this choice. For example, gentamicin, benzylpenicillin or amikacin intramuscularly, semisynthetic penicillins in combination with cephalosporins or aminoglycosides can be used as part of therapy. high efficiency in the treatment of endocarditis, vancomycin and fluoroquinolones have.

Note:the main condition effective treatment considered inflammatory disease antibacterial drugs is the continuity and compliance with the prescribed duration of treatment.

Immunocorrection

Doctors use passive immunization to neutralize microbial toxins circulating in the bloodstream with ready-made antitoxic sera. Hyperimmune plasma in combination with human immunoglobulin is considered the most effective - they are administered intravenously every day for 5 days.

Surgery

If conservative treatment of the disease in question does not give positive results, then doctors will decide on the advisability of carrying out surgical intervention. Indications for such cardinal treatment serve development following complications endocarditis:

• arterial thromboembolism;
• progressive heart failure;
• myocardial abscess.

Endocarditis in childhood

In childhood, infective endocarditis is most often diagnosed. The symptoms of this pathological process will be as follows:

• acute toxicosis;
• inflammatory lesion of the endocardium;
• blockage of blood vessels by blood clots.

In children, the aortic and mitral valves are most often affected and this is observed in the primary inflammatory process. If the child progresses secondary bacterial endocarditis, then the inner lining of the heart is directly affected.

The symptoms and nature of the course of the inflammatory disease in question in children are identical to those observed in adults. The only thing that can be noted as a feature of pediatric endocarditis is a severe pathological lesion of many internal organs, which is accompanied by intense cardiac, hepatic or renal insufficiency.

Diagnostic measures for the detection of pediatric endocarditis are reduced to blood and urine tests, an electrocardiogram, and seeding of pathogens.

Treatment of the inflammatory disease in question diagnosed in the patient childhood, is reduced to the use of large doses of penicillins, possibly its combination with gentamicin. It is worth remembering that even for adult patients, the dosage and duration of treatment are determined on an individual basis, and it’s not even worth talking about children - only a specialist can give effective and safe prescriptions.

Endocarditis is a complex disease that requires long-term treatment and often aggravated various complications. Doctors insist that patients in clinics and outpatient departments of medical institutions regularly undergo examinations by a cardiologist - an experienced specialist, even based on the results of elementary examinations, will be able to suspect the patient of the disease in question. And such early diagnosis is the key to successful treatment.

Tsygankova Yana Alexandrovna, medical observer, therapist of the highest qualification category

Endocarditis: causes, symptoms, course, therapy of various types

Endocarditis - a disease that affects the inner lining of the heart, as well as the aortic and heart valves. This is a serious, life-threatening pathology, characterized by rapid development, the danger of embolism blood vessels, internal vital important organs and the development of immunopathological processes.

Endocarditis is divided into infectious (bacterial) and non-infectious. Although in the vast majority of cases endocarditis is infectious nature, there are pathologies that develop as a reaction to metabolic changes within the framework of the immunopathological process or with mechanical damage to the heart.

Non-infectious endocarditis includes:

• Atypical warty endocarditis with;
• Rheumatic endocarditis;
• Endocarditis in rheumatoid, reactive arthritis;
• Fibroplastic endocarditis of Leffer;
• Non-bacterial thrombotic endocarditis.

Almost always, the above diseases are an indicator that the risk of developing infective endocarditis (IE) in these cases is extremely high, namely, it poses the greatest danger to the patient's life.

Causes of infective endocarditis

The disease occurs infrequently, but recently there has been a steady trend towards an increase in the incidence of IE, which is associated with an increase in resistance (resistance) bacterial microflora to antibiotics as a result of mutations. Another reason for the increase in the incidence of septic endocarditis is the increase in the number of people taking intravenous drugs.

Most often, the causative agents of this disease are pathogenic gram-positive microorganisms: in most cases, these are staphylococcal, streptococcal, enterococcal infections. Much less often, its development is provoked by other microorganisms, among which there may be Gram-negative bacteria, rare atypical pathogens and fungal infections.

The defeat of the heart membrane in IE occurs with bacteremia. Synonymous with the concept of "infective endocarditis" are such definitions as septic or bacterial endocarditis. Bacteremia (the presence of bacteria in the blood) can develop under favorable conditions even after the most harmless procedures.

procedures with high risk development of bacteremia are:

1. Dental operations with damage to the mucous membranes of the oral cavity and gums;
2. Performing bronchoscopy using rigid instruments;
3. Cystoscopy, manipulations and surgical interventions on the organs of the urinary system, if there is an infectious component;
4. Conducted biopsy of the urinary tract or prostate gland;
5. Operation on the prostate gland;
6. Adenoidectomy, tonsillectomy (removal of tonsils and adenoids);
7. Operations performed on the biliary tract;
8. Previously performed lithotripsy (destruction of stones in the kidneys, urinary, gallbladder);
9. Gynecological operations.

Cardiologists identify risk groups that have prerequisites for inflammation of the endocardium, which require antimicrobial therapy to prevent endocarditis.

The high risk group includes:

• Patients who have previously had bacterial endocarditis;
• Operated for prosthetics heart valve if mechanical or biological materials were used;
• Having congenital and acquired complex with disorders related to the aorta, cardiac ventricles - the so-called "blue" defects;

The following categories of patients are at moderate risk:

• Patients with;
• With hypertrophic;
• Having all other heart defects (congenital and acquired), not falling into the first risk group, without cyanosis.

Patients with the following diagnoses are less at risk of developing this disease:

• and vessels;
• Defect of the interatrial and interventricular septum, including operated, up to six months after surgery;
• Implanted pacemakers and defibrillators;
• no valve damage.

Video: Endocarditis. Why is it important to treat your teeth on time?

How does IE develop?

The period from the penetration of the infection to the development of the IE clinic varies from several days to several months. It depends on the virulence of the pathogen, the state of the patient's immune system and the heart.

Inside the cavity of the heart, the pathogen settles on the valve leaflets and begins to grow, with the formation of colonies of microorganisms (vegetation). In addition to microorganisms, they contain erythrocytes, leukocytes, platelets, fibrin. As the infection progresses, the surface of the valves becomes deformed, forming a bumpy surface or ulcers with thrombotic overlay.

When the deformation reaches a significant size, heart valves lose their ability to close tightly, which leads to the development of hemodynamic disorders and the occurrence of acute heart failure. This condition develops rapidly and poses a danger to the life of the patient. Destroyed pieces of valves, fragments of colonies of microorganisms can come off from the destroyed valve. With the blood flow, they are carried along the small and big circle blood circulation, can cause ischemia of important organs and, which is accompanied by various neurological disorders, paresis and paralysis and other serious complications.

Classification of endocarditis

When making a diagnosis, the doctor must formulate a refined diagnosis that characterizes the main features inherent in this type of disease, which allows a more accurate and detailed idea of ​​the course of the disease.

1. According to the activity of the pathological process, active, cured, recurrent endocarditis is distinguished;
2. According to the probability and certainty of the diagnosis (probable or definite);
3. Type infectious agent(defined or not established);
4. By the nature of the affected valve, if prosthetics take place.

Several types of flow and severity of the inflammatory process are also distinguished, taking into account the initial characteristics of damaged valves.

• Spicy septic endocarditis can develop within a matter of hours or days, it is characterized by severe hectic fever, the rapid development of complications in the cardiovascular system. Acute IE is distinguished by a pronounced ability to penetrate into the surrounding tissues, which is due to the type of pathogen with high level virulence;
• Subacute infective endocarditis develops more slowly, from the penetration of the pathogen into the heart cavity to clinical manifestations lasts from several weeks to several months. Its course is more favorable, since its pathogen is less aggressive and capable of penetrating the surrounding tissues.

In addition, the disease is classified into the following types:

1. Primary IE - initially intact endocardium is affected;
2. Secondary IE - can develop against the background of existing heart disease.
3. The so-called "prosthetic" IE - develops when infected artificial valve hearts.

IE in children, symptoms

In young children, from the neonatal period to 2 years of age, possible development of congenital IE. As the cause of this disease are infectious diseases of the mother or intrauterine infection of the fetus. The development of acquired endocarditis in children is possible, as a complication meningococcal infection, salmonellosis, brucellosis, scarlet fever, HIV. More often in children, the aortic valve is affected, inflammation leads to destructive changes, perforation, leaf rupture. The course of this disease is difficult for children to endure, the risk of complications and death is high.

Signs and methods of diagnosing IE

Septic endocarditis begins acutely. Suddenly, the body temperature rises to 39-40 C, severe chills, muscle and joint pain. Mucous membranes and skin turn pale, appear on it small rashes (hemorrhagic rash), there are nodular rashes on the soles of the feet and palms of a crimson hue (Osper's nodules), disappearing a few days after the onset of the disease. If an infection joins, then the rashes suppurate, and later they scar. To nail phalanges the fingers of the upper and lower extremities thicken, they take characteristic appearance, known as " Drumsticks", and nails -" watch glasses. There may be hemorrhages under the nails in the form of reddish-brown stripes.

When listening to heart tones, extraneous noises are clearly defined, having different tones and loudness, depending on the degree of damage to the valves, heart failure is often diagnosed at the same time.

If the right parts of the heart are affected and developed pulmonary infarction may develop pleurisy, hemoptysis and pulmonary edema. Almost always, patients have kidney damage in the form of nephritis, there is a risk of developing renal failure. No less often develops damage to the spleen, liver with the development of hepatitis, abscess or liver infarction. In some cases, eye damage occurs that can lead to blindness. Often there are manifestations of arthralgia, with the development of periostitis, hemorrhage and embolism of the vessels of the periosteum, patients complain of pain in the bones.

These are classic signs of endocarditis, but sometimes they are modified or partially absent. To clarify the diagnosis, it is necessary to identify the presence of a pathogenic microorganism in the blood, for which laboratory methods explore arterial blood. Vegetations of microorganisms on the heart valve can be detected using. Often on initial stage endocarditis cannot be recognized because such or similar symptoms may accompany other acute infectious diseases.

figure: signs and complications of endocarditis

If IE is suspected, the doctor should evaluate all the signs of the disease together. If the first blood culture did not give positive result, it is carried out repeatedly, repeatedly. Also, if this disease is suspected, an echocardiogram should be prescribed, since this is the most informative method, allowing to detect and visualize the pathology of the heart valve and the growth of microorganisms. In the course of treatment with the help of echocardiography, the effectiveness of the therapy is monitored. In some cases, according to indications, a diagnostic biopsy of the endocardium is performed in order to confirm the diagnosis.

• Biochemical and general analysis blood confirm the ongoing inflammatory process in the body;
• Radiography chest determines changes in the lungs with;
• Ultrasound of the heart allows you to visually determine the presence of IE and describe it in detail.

Video: infective endocarditis on echocardiography

In the video: infective endocarditis of the tricuspid valve, vegetation. Echocardiography, apical access.

Treatment for infective and nonspecific endocarditis

After confirming the diagnosis of IE doctor prescribes massive antibiotic therapy The patient is given antibiotics large doses intravenously. After identifying the pathogen, it is necessary to choose the most effective drug that can suppress pathogenic microorganisms, for this, the endocarditis pathogen is cultured in a sterile environment in the laboratory and exposed to several drugs. Treatment for endocarditis is carried out for a long time, for 1.5-2 months until the infection is completely destroyed, which must be confirmed by repeated microbiological blood tests, monitoring the patient's condition, echocardiography, ultrasound and other diagnostic methods.

Fungal endocarditis is more difficult to treat. Most often, they are detected in weakened patients with depressed immunity, who previously received long-term ineffective antibacterial treatment; in patients with chronic systemic diseases: malignant tumors, HIV infection,. With severe heart failure, a decision can be made to perform a surgical intervention on the heart and excise microbial growths.

When appointed antibacterial treatment acute manifestations diseases may subside, however, if microorganisms are resistant to antibiotics, they are able to become covered with a protective film under which the infection persists. This period may continue long time, when suitable conditions arise, the film is destroyed, the microorganisms are activated again, which causes a relapse of the disease within 2-3 weeks after the end of treatment.

At the same time, symptomatic therapy is carried out to maintain the patient's cardiac activity, relieve the effects of intoxication, and prevent the formation of blood clots. All activities should be carried out with constant monitoring of blood composition in order to see the dynamics of the disease in time.

If valvular disease occurs during IE, life threatening heart failure, vascular embolism, the occurrence of foci of infection outside the valve ring, doctors may decide on the need for surgery during the active phase of the disease in order to save the patient's life. During surgery, surgeons correct the defect of the valves, sutured the torn leaflets. At total destruction valves can be held them.

Photo: prosthetics mitral valve

In the treatment of non-infectious endocarditis, great attention should be paid to the treatment of the underlying disease.. To eliminate vegetations, anticoagulant drugs are prescribed that contribute to their disappearance.

What is the prognosis for endocarditis?

Until recently, until antibiotic and chemotherapy therapy was introduced into practice, the prognosis for this disease was extremely unfavorable, there was a high mortality rate among patients, and cases of recovery were isolated. Currently, the prognosis depends on many related factors.

With a favorable combination of circumstances, from 55 to 85% of all patients are cured with this diagnosis. To a greater extent, the course of the disease and the prognosis depend on the aggressiveness and pathogenicity of the infectious agent and the susceptibility to infection of the patient himself.

Regardless of the severity past illness, endocarditis in most cases affects the entire later life a person, since in the future there will always be a risk of developing heart valve disease and related complications. These include the development of myocarditis - inflammation of the middle layer of the heart muscle, which carries even more severe consequences because it can lead to the development of cardiomyopathy, rapid development heart failure and arrhythmias. This condition may require additional symptomatic therapy. Great danger is kidney failure and resulting intoxication of the body.

Disease prevention

In order to minimize the risk of developing this formidable disease, you should follow simple rules and monitor your health:

1. It is necessary to sanitize the foci of infections in the body in a timely manner, treat caries, diseases of the nasopharynx. It is necessary to be attentive even to the most common chronic diseases - tonsillitis, sinusitis, rhinitis; acute and chronic kidney diseases require special attention and attention.
2. After surgical interventions in persons at risk, it is necessary to carry out antibiotic therapy for preventive purposes. Operations include all dental procedures, including manipulations on the gums with a violation of the oral mucosa.
3. Should be avoided stressful situations, excessive physical and psychological stress, acute viral infections;
4. After infective endocarditis, patients should be on a permanent dispensary record with a cardiologist, take courses in a timely manner rehabilitation therapy in sanatoriums;
5. It is necessary to purposefully strengthen your immunity, for this you need to fully eat, lead a healthy lifestyle and regularly take multivitamins;
6. Timely immunization against mumps, measles, rubella viruses is of great benefit in preventing the development of complications;

Patients with infective endocarditis should carefully monitor their health throughout their lives, then they will be able to conduct a full-fledged, active image life without fear of recurrence of the disease.

Video: lecture on infective endocarditis

At myocarditis various etiologies in the intramural, subendocardial or subepicardial layers of the ventricular wall, parenchymal focal or diffuse inflammation develops with a predominant lesion of any area of ​​the heart. Uneven damage to the myocardium leads to a change in the transmembrane resting and action potential during repolarization (S - T - T).

Inflammatory process may damage the wiring system. As a result, on the ECG with myocarditis, especially often with rheumatic disease, atrioventricular, sinoatrial, intraatrial and intraventricular blockades occur. With rheumatic heart disease in the early days acute period in most cases, a slowdown in atrioventricular conduction develops (Zuckermann R. 1962).

Other types violations conduction in myocarditis are observed less frequently, but still quite often. Often, conduction disturbances persist with myocardial cardiosclerosis. Taran Z. M. and Szilagyi N. (1958) note an increase in the duration of the Q interval - T in 90% of cases of rheumatic heart disease.

At myocarditis. especially with the idiopathic type of Abramov-Fiedler, various arrhythmias often develop. First of all, these are rhythm disturbances, which are based on the re-entry mechanism: extrasystole, paroxysmal tachycardia, atrial fibrillation. This direction is probably due to the blockade process, which plays a significant role in the mechanism of the occurrence of a circular wave. However, other rhythm disturbances are also observed: ectopic rhythms, rhythm migration, atrioventricular dissociations.

Rare on ECG changes in the QRS complex are determined, indicating macrofocal necrotic (sclerotic) changes. Basically, their cause is not myocarditis, but comorbidities or complications (eg, coronary insufficiency, coronaritis, coronary artery embolism in endocarditis).

Often on ECG signs of overload (hypertrophy) of the heart departments are determined. Sometimes there is a decrease in the amplitude of the ECG teeth. ECG changes are especially pronounced in idiopathic and infectious-allergic myocarditis, in which rhythm disturbances often alternate and pathological symptoms gradually increase.

Patient Z. 23 years old. Clinical diagnosis: rheumatism, acute rheumatic heart disease. Rheumatic heart disease: mitral valve insufficiency. On the ECG: sinus rhythm, 67-75 per 1 min. Interval P - Q = 0.23 - 0.24 sec. P = 0.13 sec. QRS = 0.07 sec. Q - T \u003d 0.36 sec. (norm 0.35 - 0.33 sec.). RI>SI. AQRS = +84°. The PI,II,III,aVF wave is bifurcated. PV1-V2 two-phase (+ -) with an increased negative phase. QRSV1 complex type rSr'. QRSV2 complex type rS. Complex QRSI, V5, V6 type RS.

QRS III complex qR type. The QRS transition zone is slightly shifted to the left. The RS segment — TI, aVL, V3-V6 is slightly shifted down from the isoelectric line. The TV2-V5 wave is negative "coronary". TV1,V6 negative shallow. TI,aVL biphasic (- +), low.

Deceleration of atrioventricular conduction. intra-atrial blockade and changes in the RS-T segment and T-wave ("coronary" negative) are associated with rheumatic heart disease. There are signs of either right ventricular hypertrophy or incomplete right ventricular block right branch bundle of His: shift of the transition zone to the left, rSr'V1 and RSI, V6 at RV4

Signs of severe left atrial hypertrophy and intra-atrial blockade, possibly due to two reasons: moderate mitral valve insufficiency and dilatation of the left atrium, which developed as a result of myocarditis.

Conclusion. Slowdown A - V conduction (incomplete A - V blockade of the first degree). Intra-atrial blockade. Changes in the myocardium of the anterior septal region and the anterolateral wall of the left ventricle associated with current myocarditis. The vertical position of the electrical axis of the heart, the rotation of the heart clockwise, the shift of the transitional zone to the left and the incomplete blockade of the right branch of the bundle of His, probably characterizing the hypertrophy of the right ventricle. Hypertrophy of the left atrium.

Endocarditis

Endocarditis is an inflammatory infection that affects the inner lining of the heart, the endocardium.

Endocarditis usually occurs when an infection enters the body - bacteria or fungi. This infection can get to the inner lining of the heart most often from other foci of infection in the body. With endocarditis, the infection can also affect the heart valves and the inner lining of nearby vessels. The same infection can cause simultaneous kidney, liver and spleen disease. Left untreated, endocarditis can damage the heart valves and lead to a defect (called acquired heart disease). These heart defects can have life-threatening consequences. Treatment for endocarditis includes antibiotics and, in severe cases, surgery.

Symptoms of endocarditis

Endocarditis can develop both slowly and rather quickly, depending on the cause and the presence of concomitant diseases in the patient.

Symptoms of endocarditis include:

• Fever
• Chills
• The appearance of new or changes in previous heart murmurs
• Fatigue
• Joint and muscle pain
• night sweats
• Dyspnea
• Paleness of the skin
• Persistent cough
• Swelling in the legs, in the abdomen
• Unexplained weight loss
• Hematuria (blood in the urine)
• Pain in the spleen
• Osler's nodules are red, painful nodules under the skin on the fingers
• Petechiae - reddish or purple dotted spots that are hemorrhages in the skin and mucous membranes

When to see a doctor

If you have the symptoms described above that can occur with endocarditis, especially if you are at high risk of this disease, for example, if you suffer from heart disease, or have had endocarditis in the past, you should consult a doctor.

Causes of endocarditis

Endocarditis occurs when microbes enter the bloodstream and then attack the heart valves. Most often, the organisms that cause endocarditis may be bacteria, but may also be fungi or others.

Sometimes bacteria that normally live in the mouth, throat, or other areas of the body can cause endocarditis. In other cases, bacteria that cause endocarditis can enter the bloodstream in the following ways:

• Normal daily activity. This may include brushing your teeth or chewing food, especially if your teeth are affected by caries.
• Infections or other diseases. Bacteria can enter the bloodstream from other infected areas, such as skin lesions. Another possibility for bacteria to enter the bloodstream is gum disease, sexually transmitted diseases, and intestinal pathology.
• catheters and needles. Bacteria can also enter the bloodstream through a catheter, a thin plastic tube through which drugs are injected into the bloodstream. Bacteria that can cause endocarditis can also enter the bloodstream through needles during a tattoo or piercing procedure.
• Some dental procedures.

Usually, the immune system successfully fights microorganisms that enter the bloodstream. And even if the bacteria enter the heart, they may not cause anything.

In most cases, endocarditis affects people who have already had heart defects - an ideal environment for bacteria. In such patients, the inner lining of the heart, the endocardium, is damaged and allows bacteria to settle on it and multiply.

Risk factors

In a patient with a healthy heart, the risk of developing endocarditis is minimal. Even the most common heart disease does not increase the risk of endocarditis.

The risk of developing endocarditis is highest in the following cases:

• Artificial heart valves. Germs tend to settle on artificial heart valves than on normal ones. The risk of infection is highest in the first year of valve transplantation.
• Congenital heart defects. The risk of endocarditis in patients with congenital heart disease is higher.
• Previous endocarditis. With endocarditis, damage to the heart tissue, especially the valves, remains, and this, in turn, increases the risk of developing endocarditis in the future.
• Damage to the heart valves. Some diseases, such as rheumatic fever or other infectious diseases, can affect one or more of the valves in the heart, making them more likely to be affected by endocarditis.
• The use of intravenous drugs. Drug addicts mostly use non-sterile syringes and needles, or their sterilization leaves much to be desired. This greatly increases the risk of microbes entering the bloodstream that can cause endocarditis.

If you have a heart disease or other heart disease, talk to your doctor about the risk of endocarditis. Even if you have undergone heart surgery and you are no longer concerned about the existing heart disease, the risk of endocarditis still remains.

Complications of endocarditis

Endocarditis can lead to some complications, including:

• Stroke or damage to internal organs. With endocarditis on the inner shell of the heart - the endocardium - there are so-called. vegetation - growths of the affected endocardial tissue with bacteria and cell fragments. These vegetations can break away from the place of their formation and be carried away by the blood flow to the brain, causing a stroke, or to internal organs, such as the kidneys, lungs, intestines, or limbs.
• Infectious foci in other parts of the body. Endocarditis can cause foci of infection in other tissues and organs, causing the formation of a collection of pus there - an abscess. Such abscesses can occur in the lungs, kidneys, liver, spleen. An abscess can also occur in the wall of the heart itself, causing an irregular heartbeat. In severe cases of an abscess, surgery may be required.
• Heart failure. In the absence of adequate treatment of endocarditis, damage to the heart valves can occur, with a heart defect (if it was not there before) or a new defect is added to the existing one. As a result of heart disease, there is a violation of the normal functioning of the heart, its overload, and heart failure develops - a weakening of the heart muscle, when the heart is no longer able to adequately pump blood. In the absence of proper treatment, the outcome can be fatal.

Diagnosis of endocarditis

The doctor may suspect the presence of endocarditis based on the history and physical findings, such as fever, heart murmurs, etc., namely the appearance of new murmurs or a change in previous ones.

Infection in the initial stages can mimic other diseases. Therefore, different diagnostic methods are used to diagnose endocarditis:

Blood tests.

The most important research method in the diagnosis of endocarditis, which allows you to detect the presence of bacteria in the blood. A blood culture is usually performed to reveal a bacterial culture. In addition, a blood test reveals other signs of endocarditis - anemia, leukocytosis, etc.

Echocardiography.

Echocardiography is an ultrasound method for examining the heart. It is absolutely safe and inexpensive, and at the same time gives a lot of necessary information to the doctor. In the diagnosis of endocarditis, such a method of echocardiography as transesophageal echocardiography is currently used - that is, transesophageal. It is somewhat reminiscent of gastroscopy, which is used for diseases of the stomach, but at the same time, the patient “swallows” not just a probe, but a probe with an ultrasonic sensor. This method, unlike the traditional one, allows you to bring the sensor directly to the heart, and only a thin wall of the esophagus will separate them. This allows the doctor to get a clearer picture.

Electrocardiogram (ECG).

Chest X-ray.

A chest x-ray can show heart enlargement, which can be seen with endocarditis, as well as lung involvement (such as an abscess).

Computed tomography (CT) or magnetic resonance imaging (MRI).

These methods allow you to get a layer-by-layer section of a particular part of the body. They allow you to identify various lesions of organs and tissues, for example, abscesses that can occur with endocarditis.

Treatment of endocarditis

Usually, treatment of endocarditis begins with the use of antibiotics. In the case when there is already irreversible damage to the heart valves with the development of a defect, surgical intervention is required.

Antibiotics

Antibiotics are drugs that kill germs. They can act on different types of microbes that cause endocarditis, including fungi. In endocarditis, antibiotics are usually administered only intravenously. Usually, before prescribing an antibiotic, a culture test is performed to determine the best antibiotic for a given microbe. I would like to note that today medicine has quite powerful antibiotics in its arsenal.

Usually, the course of antibiotic therapy for endocarditis is from 4 to 6 weeks or more, for the complete destruction of microbes. If the fever and the most severe symptoms of endocarditis have passed, then the patient can be discharged, and receive a further course of antibiotics at home with regular monitoring of the condition by a doctor.

Tell your doctor about any symptoms that may indicate a worsening condition:

• Fever
• Chills
• Headache
• Joint pain
• Dyspnea

Diarrhea, skin rash, itching, or joint pain may indicate a reaction to an antibiotic, which is also a reason to call a doctor.

If you experience shortness of breath or swelling of the legs, which may indicate the occurrence of heart failure, you should also consult your doctor.

Surgery

In the case when endocarditis is marked by damage to the heart valves, even after the complete destruction of the infection with antibiotic therapy, it is impossible to restore the previous state of the affected heart valves by conservative methods. Requires surgical intervention. Sometimes surgery is required to treat a persistent infection in a patient's body or to replace diseased heart valves. In addition, surgery may be required in the treatment of fungal endocarditis.

Depending on your condition, your doctor may recommend either repairing the affected heart valve or replacing it with an artificial one.

The date of the: from 01/01/2015 to 12/31/2015

Electrocardiography (ECG) is an informative, accessible and non-invasive method of graphical representation of the electrical activity of the heart, which is traditionally used to diagnose coronary insufficiency, rhythm and conduction disorders, and some other conditions. In some cases, ECG can serve as an additional criterion for assessing the severity and prognosis of infectious diseases as a marker of involvement in the pathological process of the cardiovascular system (CVS). ECG changes in infectious diseases are usually minor and nonspecific, but in some cases they indicate with high certainty the development of serious complications, such as myocardial abscesses in infective endocarditis.

The causes that cause CCC damage and, accordingly, ECG changes can be attributed to one of three categories: 1) direct (due to the damaging effect of an infectious agent or its toxins) or indirect (due to immunopathological processes) action of the pathogen; 2) metabolic disorders, electrolyte balance or autonomic nervous system function, due to the characteristics of the infectious process; 3) adverse drug events (AAEs) of antimicrobial drugs.

Viral infections

HIV infection. CCC involvement is observed predominantly in the late stages of HIV infection. The most significant risk factor for the development of cardiac complications is a decrease in the number of CD4+ T-lymphocytes below 100 cells/l. The most common ECG changes in HIV-infected people are sinus tachycardia, decreased voltage of the QRS complex, nonspecific changes in the ST segment and T wave, and prolongation of the QT interval. The cause of these changes may be mitral valve prolapse, myocarditis with a decrease in the systolic function of the left ventricle, dilatation of the heart cavities, including its right sections, up to the clinical picture characteristic of dilated cardiomyopathy. Pericardial effusion may also occur, and much less commonly, infective endocarditis.

Prolongation of the QT interval, even asymptomatic, in the absence of ventricular arrhythmias, is associated with an increased risk of death, and the frequency of this syndrome increases as the immune status worsens.

Rhythm disturbances in HIV-infected people, both in children and adults, are relatively rare and are characterized by a benign clinical course. The most typical rhythm/conduction disorders are sinus tachycardia, first-degree atrioventricular (AV) block, supraventricular extrasystoles that almost never progress to supraventricular or ventricular tachycardia, and high-grade AV block.

Quite often, ECG signs of right ventricular hypertrophy are detected, reflecting pulmonary hypertension, often developing with HIV infection.

Rubella. An acute viral disease predominantly of childhood, the prevalence of which has a steady downward trend due to mass vaccination. The disease proceeds with fever, lymphadenopathy and maculopapular rash with a clear staging of rashes face-torso. Myocardial damage is extremely rare, but the appearance of ECG changes indicates a more severe course of rubella. Most often, changes in the ST segment and the T wave are detected on the ECG. Deviation of the electrical axis to the left reflects transient or permanent damage to the left leg of the His bundle and is often accompanied by hemodynamic disturbances.

Spirochetoses

Lyme disease. Systemic tick-borne borreliosis (Lyme disease, chronic erythema migrans) is an infectious natural focal disease. It is characterized by transmissible transmission (causative agent - spirochete Borrelia burgdorferi, which is carried by the tick Ixodes scapularis), polymorphism of clinical manifestations (damage to the skin, nervous and cardiovascular systems, joints), and a tendency to a protracted recurrent course. There are early and late periods of the disease. In the early period, 2 stages are distinguished. At the 1st stage, developing after a few days - 1 month. after a tick bite, migratory annular erythema (erythema migrans) at the site of a tick bite is found as the most constant symptom, other symptoms of the acute period are variable and transient (Fig. 1). In about 20% of cases, the skin lesion is the only manifestation of stage 1 Lyme disease. Changes on the ECG in isolated erythema migrans are rare, mainly in the form of AV blockade of the 1st degree, an increase in the amplitude of the S wave.

In the 2nd stage of the disease, along with general symptoms (weakness, headache, fever with chills, lymphadenopathy), there are signs of damage to the nervous system (meningitis, encephalitis, neuritis of the cranial and peripheral nerves), 4-10% of patients develop cardiac disorders , most often in the form of myopericarditis with the development of left ventricular dysfunction, cardiomegaly. Rhythm disturbances occur in the form of sinus arrhythmia, bradycardia, ventricular extrasystoles. Changes in the terminal part of the ventricular complex may be recorded. The most common ECG symptom is a conduction disturbance of the type of AV block, up to a complete transverse block, which is a rare but typical manifestation of systemic tick-borne borreliosis. Recording transient blockade is rather difficult due to its transient nature, but ECG recording is desirable in all patients with erythema migrans annulare, since complete transverse blockade is usually preceded by less pronounced arrhythmias. Conduction disturbances usually resolve on their own in 2–3 weeks, but complete AV block requires the intervention of cardiologists and cardiac surgeons. The 3rd stage is formed in 10% of patients after 6 months - 2 years after the acute period. At this stage of the disease, the most studied are joint lesions (chronic Lyme arthritis), skin lesions (acrodermatitis atrophic), as well as chronic neurological syndromes, resembling the tertiary period of neurosyphilis in terms of development. The appearance of any new specific ECG manifestations at this stage is not typical.

On average, CVS damage in Lyme disease occurs in 8% of patients over the age of 18 years, the most typical ECG changes are conduction disturbances, which are characterized by a benign course and are prone to spontaneous resolution, the need to install an artificial pacemaker is extremely rare. The rapid reverse development of AV blockade is observed against the background of parenteral administration of ceftriaxone (Fig. 2) .

ECG registration is a valuable screening method for suspected Lyme borreliosis: according to one study, 3 out of 10 children with suspected borreliosis showed changes in the ECG.

Leptospirosis. An acute infectious disease caused by various serotypes of Leptospira. It is characterized by general intoxication, fever, damage to the kidneys, liver, nervous system and muscles. In severe forms, acute renal failure, jaundice and hemorrhagic syndrome are observed. Refers to zoonoses with natural foci. Human infection occurs through contaminated water bodies, less often through food products or through contact with infected animals (pigs, etc.).

With leptospirosis, AV blockade of the first degree is often found on the ECG, as well as ECG signs characteristic of acute pericarditis. The detection of ECG changes in leptospirosis with a high probability indicates the involvement of the cardiovascular system, most often in the form of myocarditis, and as a result, a worsening prognosis.

Endemic (tick-borne) relapsing fever (synonyms: tick-borne borreliosis, tick-borne spirochetosis, tick-borne relapsing fever) is an infectious disease that occurs in the form of febrile attacks alternating with periods of normal temperature (apyrexia is a fever-free period). In the USSR, by 1938, it was basically liquidated. The centers of an infection remain in a number of the countries of Asia, Africa and America. It is caused by borrelia B.hermsii and B.turicatae and is characterized by a high relapsing fever with a sudden onset. Febrile episodes last from 3 to 6 days and are accompanied by headache, arthralgia, myalgia, nausea and tension of the occipital muscles, neuritis of the cranial nerves. Myocarditis develops rarely, a typical ECG manifestation of myocarditis is a prolongation of the QT interval.

Trichinosis. It develops as a result of eating meat contaminated with Trichinella larvae larvae. Clinical manifestations include fever, myalgia, headache, skin rashes, nausea, vomiting, diarrhea, swelling of the legs, cough, subconjunctival and subungual hemorrhages. The frequency of detection of ECG changes, according to different authors, is different: for example, it was previously reported that ECG changes were detected in 21-75% of patients, according to later observations, this figure is 13%. Most often, transient non-specific disturbances in the processes of ventricular repolarization are recorded on the ECG in the form of changes in the ST segment and the T wave. Less often, ECG signs characteristic of pericarditis are detected.

Bacterial infections

Diphtheria. The causative agent is Corynebacterium diphtheriae, a gram-positive bacillus. Infection occurs by airborne droplets and by direct contact with the secret of the respiratory tract, infected objects and through third parties. The most significant risk factors for cardiovascular disease are older age, low socioeconomic status, and severe airway disease. In 2/3 of patients with diphtheria, signs of mild myocarditis are revealed, in 10-25% - cardiac dysfunction. Diphtheria is characterized by two types of ECG changes: asymptomatic disorders in the form of prolongation of the PQ interval and changes in the T wave, and deviations that have clinical manifestations of varying severity in the case of the development of high-grade AV blockades and intraventricular blockades. ECG changes in severe diphtheria last several days after the disappearance of clinical symptoms. ECG abnormalities (ST segment and T wave changes) have been observed in experimental animals after vaccination against diphtheria/tetanus/pertussis.

The defeat of the CCC is the leading cause of death in adult patients with diphtheria, accounting for approximately 1/3 of all causes of death in this infection. Diphtheria toxin causes severe acute myocarditis. 24-hour ECG monitoring upon admission of a patient to a hospital makes it possible to more reliably predict heart damage in diphtheria. The risk of CCC involvement is higher in patients with fever, toxic and membranous forms of the disease. A deterioration in the prognosis is evidenced by ventricular arrhythmias, an increase in the level of AST above 80 U / l, leukocytosis above 25.0 ∙ 109 / l and the spread of fibrinous films over more than 2 anatomical regions.

Tetanus is caused by the anaerobic gram-positive bacterium Clostridium tetani. There are 4 forms of tetanus: generalized, localized, neonatal and cephalgic. The involvement of the CCC is noted most often in the generalized form, the characteristic clinical manifestations of which are trismus, "sardonic smile" due to increased tone of the orbicular muscle of the mouth, and generalized convulsions. The ECG reveals sinus tachycardia, prolongation of the QT interval, nonspecific changes in the ST segment and T wave.

Whooping cough. Whooping cough is caused by Bordetella pertussis, a small, non-motile, non-spore-forming, aerobic Gram-negative coccobacillus. The disease is characterized by acute catarrh of the respiratory tract and bouts of spasmodic cough. The course of whooping cough can be complicated by the addition of secondary infections, damage to the central nervous and cardiovascular systems. The most typical ECG changes in the development of cardiac complications are sinoauricular and atrioventricular blockades. These changes develop due to the activation of the sodium channels of the cardiac conduction system by the guanine-nucleotide-binding protein of pertussis toxin.

streptococcal infections. CCC damage occurs both due to the development of inflammatory processes, for example, in acute rheumatic fever (ARF) caused by group A β-hemolytic streptococci, and due to the direct damaging effect of streptococcal toxins in other diseases of streptococcal etiology.

The most characteristic ECG changes in ARF are 1st degree AV block, which is one of the minor diagnostic criteria for the disease. Other conduction disorders, such as complete AV block and Mobitz type I AV block, are much less common in ARF. The most characteristic ECG changes in invasive streptococcal infections are changes in the ST segment - T wave. Other ECG abnormalities in ARF are less common: sinus tachycardia, P wave changes, T wave inversion, extrasystolic rhythm disturbances. The clinical manifestations of ARF include cardiomegaly, congestive heart failure, development of dysfunction of the mitral and/or aortic valves with a corresponding auscultatory picture.

Myocarditis caused by group B streptococci is accompanied by a decrease in ECG voltage in the leads from the limbs, and involvement of the pericardium with the development of myopericarditis is also possible.

The defeat of the pericardium in the form of acute purulent pericarditis with elevation (rise) of the ST segment on the ECG has been described in diseases caused by group G streptococci.

ECG changes in invasive streptococcal infections usually disappear with adequate antibiotic therapy.

Typhoid fever is an acute, cyclically occurring intestinal infection caused by salmonella typhoid fever, Salmonella typhi, with a fecal-oral transmission mechanism, characterized by fever, general intoxication with the development of typhoid status, roseous skin rashes, hepatosplenomegaly and damage to the lymphatic system of the small intestine. About 16 million cases of the disease are registered annually worldwide, of which about 600,000 are fatal.

Complications in the form of intestinal obstruction, ulceration and perforation usually develop on the 4th week of the disease. Changes on the ECG are recorded both in the acute period of the disease, lasting up to 4 weeks, and during the convalescence period, the duration of which reaches 2 months. Damage to the CCC develops as a result of a direct effect on the myocardium due to Salmonella typhi invasion or under the action of toxins (endotoxin, enterotoxin, cytotoxin) produced by Salmonella. The level of cardiospecific enzymes increases only in the acute period. The severity of myocarditis in typhoid fever depends on the patient's previous health status, anemia, cardiovascular pathology and nutritional deficiency have the greatest negative impact.

Typical ECG changes in typhoid fever include ECG signs of myocarditis: prolongation of the PQ interval, prolongation of the QT interval, ST segment depression, and T wave inversion. with concomitant Wolf-Parkinson-White syndrome.

Although typhoid fever is characterized by relative bradycardia, that is, a heart rate that does not correspond to the height of the fever, sinus bradycardia as such is very rare in typhoid fever. There are only a few reports of sinus bradycardia due to sick sinus syndrome, which developed against the background of typhoid fever. Sinus bradycardia in typhoid fever is refractory to atropine, but in most cases disappears on its own when the patient recovers.

A brief description of ECG disorders in various infectious diseases is presented in Table. 1.

Infectious diseases of the heart

ECG changes in myocarditis may be a consequence of myocarditis itself, caused by one or another infectious agent, or be secondary, reflecting the effect of fever, hypokalemia, vitamin deficiency, or adverse drug events when taking drugs for the treatment of myocarditis, primarily antimicrobial agents.

Myocarditis can develop against the background of many infectious diseases, although its most common causative agents are viruses, especially enteroviruses (Coxsackie).

Pathogens that cause acute myocarditis:

1. Bacteria: Borrelia burgdorferi, Brucella spp. Campylobacter spp. Chlamydophila pneumoniae, Chlamydia psittaci, Clostridium perfringens, Corynebacterium diphtheriae, Coxiella burnetii, Ehrlichia spp. Legionella pneumophila, Listeria monocytogenes, Mycobacterium tuberculosis, Mycoplasma pneumoniae, Neisseria meningitidis, Rickettsia spp. Salmonella spp. Shigella spp. Staphylococcus aureus, Streptococcus pyogenes, Vibrio cholerae.

2. Fungi: Aspergillus spp. Blastomyces spp. Candida spp. Coccidioides immitis, Cryptococcus spp. Histoplasma capsulatum.

4. Viruses: Coxsackie A and B viruses, cytomegalovirus, echovirus, Epstein-Barr virus, hepatitis B and C virus, human immunodeficiency virus, paramyxovirus.

Since the pathological focus during a viral infection is localized in ischemic areas, such foci, as a rule, are located in the subendocardial layer of the myocardium. Manifestations of viral myocarditis depend on the virulence of the infectious agent and on the hormonal and immunological status of the macroorganism. Infection of the fetus with rubella virus, paramyxovirus, and coxsackievirus can cause congenital malformations. Myocarditis is accompanied by various changes on the ECG, most often - AV blocks of varying degrees, other conduction disorders, changes in the ST segment and T wave, sometimes simulating acute coronary syndrome, and ventricular arrhythmias (Fig. 3) .

Pericarditis- an inflammatory disease of the pericardium caused by many infectious agents, and in some cases, simultaneous damage to the pericardium and myocardium is possible.

Typical causative agents of acute pericarditis:

1. Bacteria: Haemophilus influenzae, Mycobacterium spp. Neisseria gonorrhoeae, Neisseria meningitidis, Salmonella spp. Staphylococcus aureus, Streptococcus pneumoniae.

2. Fungi: Aspergillus spp. Blastomyces spp. Candida spp. Coccidioides immitis, Cryptococcus neoformans, Histoplasma capsulatum.

3. Viruses: Coxsackie A and B viruses, echovirus, Epstein-Barr virus, HIV, influenza virus, paramyxovirus, parvovirus B19.

In the early stage of pericarditis, PQ segment depression is recorded on the ECG, followed by ST segment elevation, normalization of the ST segment, T-wave inversion, and normalization of the ECG (Fig. 4; Table 2). In pericarditis, the ECG may resemble the ECG in acute coronary syndrome. Differential diagnosis of ECG changes due to myopericarditis, acute coronary syndrome and premature ventricular repolarization syndrome is presented in Table. 3 . The evolution of ECG changes can last from several days to several weeks. With the formation of an effusion in the pericardium, a decrease in the voltage of the ECG teeth is noted (Fig. 5).

Endocarditis. With endocarditis, ECG changes often develop, the appearance of which indicates an invasive form of infection, a high risk of complications and a fatal outcome. Conduction disturbance indicates the spread of the infectious process to the perivalvular region. ECG changes are very often recorded in patients with artificial valves. Unfortunately, there has not been a single prospective study of ECG changes in infective endocarditis. Autopsy studies confirm that the most common ECG change is sinus tachycardia, which was recorded in 53% of patients with verified infective endocarditis. More rarely, other changes were detected on the ECG: a decrease in the voltage of the QRS complex (44%), AV blockade of varying degrees (9%), ST-segment elevation, atrial fibrillation, ventricular tachycardia and supraventricular tachycardia (Fig. 6).

In patients with infective endocarditis who, on the background of adequate antimicrobial therapy, have a fever for a long time and have chest pain and shortness of breath, the detection of AV blocks on the ECG indicates the development of a perivalvular abscess and requires surgical treatment (Fig. 7).

Mycoplasmosis. Mycoplasma pneumoniae causes diseases of the upper and lower respiratory tract in about 70% of those infected, in 20% they are asymptomatic. In closed communities (army, prisons) there are epidemiological outbreaks. Involvement of the CCC is rare and in the vast majority of cases - in individuals with clinically manifest forms of mycoplasmal infection. The most common ECG abnormalities are changes in the terminal part of the ventricular complex in the form of T wave inversion. Bradycardia, prolongation of the PQ interval and a narrow QRS complex can also be recorded. In the absence of symptoms of cardiovascular disease, ECG changes are rare and nonspecific. Prior cardiac pathology does not affect the risk of development and the severity of ECG disorders.

An increase in intracranial pressure of an infectious genesis due to meningitis (as, indeed, in non-infectious diseases, for example, with subarachnoid hemorrhage, brain tumors) can also cause ECG abnormalities. The mechanism of development of ECG changes in patients with increased intracranial pressure depends on the etiology of the disease and is realized through an increase in the tone of the sympathetic and parasympathetic nervous system during the acute period of subarachnoid hemorrhage; release of large amounts of norepinephrine and epinephrine from brain tumors; electrolyte disturbances in meningitis and arrhythmogenic effect in tumor lesions of the limbic structures of the brain. Hypokalemia, which develops with brain tumors, hemorrhages, and with an increase in the activity of the autonomic nervous system, also contributes to the development of ECG disorders. Characteristic changes on the ECG with an increase in intracranial pressure include a high P wave, a high U wave, an inverted U wave, ST segment and T wave changes, T wave serration, sinus tachycardia (Fig. 8).

Antimicrobials

Antimicrobials can block sodium channels, leading to prolongation of repolarization and prolongation of the QT interval. Fluoroquinolones have a similar proarrhythmic effect, prolonging the QT interval and increasing the risk of torsades de pointes (Fig. 9). The proarrhythmic effect of fluoroquinolones increases significantly in the presence of electrolyte disorders (hypomagnesemia, hypokalemia, hypocalcemia), alcoholism, and concomitant use of class I antiarrhythmic drugs, especially quinidine, and class III. The arrhythmogenic effect disappears after discontinuation of fluoroquinolones. Most often, prolongation of the QT interval occurs against the background of the use of sparfloxacin (14.5 cases per 1 million appointments), ciprofloxacin causes prolongation of the QT interval much less frequently (1 case per 1 million appointments). Azole antifungals also have the property of prolonging the QT interval. Especially often, the proarrhythmic effect of azoles is realized when co-administered with antihistamines (loratadine, terfenadine, ebastine). Antimicrobials of the macrolide class have the same effect. Among the macrolides, erythromycin has the most potent proarrhythmic effect, followed by clarithromycin, roxithromycin, and azithromycin. For example, clarithromycin causes QT interval prolongation in 3 cases per 1 million appointments.

Conclusion

The main provisions regarding the role of the ECG in infectious diseases are presented in Table. 4. ECG changes in various infectious diseases develop for various reasons: under the influence of the infectious process itself, as well as due to metabolic disorders or dysfunction of the autonomic nervous system caused by this process. In some cases, the detection of ECG changes facilitates the differential diagnosis of the underlying disease, for example, with Lyme borreliosis or ARF. However, much more often, the assessment of ECG changes, without carrying additional diagnostic value, provides important information for assessing the severity of an infectious disease, its prognosis, as well as the effectiveness and safety of treatment. Many antimicrobials have a proarrhythmic effect, and timely detection of ECG signs of a high risk of developing rhythm disturbances can significantly reduce the incidence of severe AAEs.