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组织和赘生物培养等。常用的实验室检测包括血培养、血清学检测、分子检测、骨髓培养[7]等方法。本患者有基础心脏病变(室间隔缺损和窦瘤破裂),术前血培养均为阴性,在术后赘生物培养明确病原菌后追问才得知其有牛羊接触史,没有考虑到布鲁氏菌感染。这说明个人史和既往史在明確罕见心内膜炎病原菌方面有一定帮助,应详细问诊;对于多次血培养阴性、不能明确病原菌的感染性心内膜炎,应考虑罕见病原菌如布鲁氏菌等并做排除诊断,这些问题在以后的临床工作中应注意。
关于布鲁氏菌心内膜炎的治疗,目前仍有争议。抗生素和手术联合治疗通常具有较好的效果,也有少数报道称单纯的药物治疗可以治愈[2,8-13]。如果患者没有临床症状或者症状较轻,可以考虑保守治疗;如果患者存在心衰加重、循环衰竭、赘生物、栓塞、瓣膜损伤、瓣周脓肿、人工瓣膜等,则应考虑手术治疗[14]。关于术前抗生素使用时间,Hadjinikolaou等[15]在开始抗生素1周后对患者进行手术,而Mustafa等[16]则建议术前使用抗生素4~6周。如果出现栓塞症状,建议在72 h内进行外科干预[17]。本患者入院时赘生物侵犯多个瓣膜,且治疗过程中出现心衰、右上肢栓塞,具有明确的手术指征。术后抗生素使用时间需要根据临床症状及化验等共同决定,推荐2~13个月[18]。所选的抗生素种类应具有杀菌效果。2015年欧洲心脏病学会关于感染性心内膜炎治疗指南中关于布鲁氏菌感染性心内膜炎推荐抗生素方案:多西环素、利福平和链霉素或者复方新诺明至少两种以上的抗生素联合治疗[19]。也有报道称头孢哌酮、舒巴坦钠在布鲁氏菌病的治疗中效果确切[20]。该患者使用敏感抗生素头孢哌酮钠舒巴坦钠联合左氧氟沙星抗感染方案使病情得到控制。
患者入院时查体发现肝脾大、下肢水肿等右心衰指征,可能与长期主动脉窦瘤破裂、室间隔缺损引起的心内分流加重右心负荷有关;之后出现的急性心衰考虑是心内膜炎引起二尖瓣、主动脉瓣瓣膜功能障碍,继而引起左心衰、全心衰所致。患者术后的心衰是由残余破裂窦瘤引起,再次心衰的可能性大,应密切随访,择期封堵破裂窦瘤。
虽然随着现代技术的进步和对该病认识的提高,BE的诊断和治疗有了很大改善,但其死亡率仍然很高。所以在临床工作中,对于可疑患者,应争取早发现、早诊断、早治疗,降低栓塞、心衰等发生率,以获得较好的预后。
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(收稿日期:2017-10-25)
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