384 X computed tomography: CT : 178cm 87 kg /78 mmhg 98/min 18/min3 Levine Roth Osler Janeway : C Creactive protein : CRP 9.0 mg/dl 12,600/ l
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1 J Cardiol 2007 Dec; 50 6 : Pulmonary Septic Embolism With Right Side Infectious Endocarditis and Ventricular Septal Defect: A Case Report Yoshifumi Mitsugu Yukiko Takuo Shunichi NAKAUCHI, MD TANIGUCHI, MD MIYAMURA, MD ISHISE, MD MIYAZAKI, MD, FJCC Abstract An 18-year-old man was diagnosed with ventricular septal defect after birth. He was asymptomatic until February He came to our hospital with remittent fever persisting for 2 months. Chest computed tomography showed multiple infiltrative shadows and -streptococcus was detected on blood cultures. Transesophageal echocardiography detected vegetation 1.3 cm on the right ventricle wall at the point of impact of the shunted bloodstream. We diagnosed pulmonary septic embolism and began to administer penicillin G and gentamicin. Sixteen days later, a new pulmonary septic embolism appeared, so antibiotic treatment was continued at a higher dose. Two weeks later, the vegetation and infiltrative shadow disappeared. Echocardiography showed the ratio of pulmonary to systemic blood flow was 1.2. These findings indicate that patch closure of ventricular septal defect may be necessary for prevention of recurrence of right side infectious endocarditis. J Cardiol 2007 Dec; 50 6 : Key Words Septal defects ventricular Pulmonary embolism septic Endocarditis right side infectious 10% :. : : : : Division of Cardiology, Department of Internal Medicine, Kinki University School of Medicine, Osaka Address for correspondence : NAKAUCHI Y, MD, Division of Cardiology, Department of Internal Medicine, Kinki University School of Medicine, Onohigashi 377 2, Osakasayama, Osaka ; yosipumi@hotmail.com Manuscript received May 25, 2007; revised July 30 and August 19, 2007; accepted August 23,
2 384 X computed tomography: CT : 178cm 87 kg /78 mmhg 98/min 18/min3 Levine Roth Osler Janeway : C Creactive protein : CRP 9.0 mg/dl 12,600/ l Fig. 1 Chest radiograph on admission showing a coin lesion in the left lower lung arrow PO mmhg 2.3ng/ml 5.0 ng/dl D 1.46 g/ml 0.5 g/ml 503 mg/dl mg/dl 108/ min ST-T X 47 % Fig. 1. CT Fig mm 41 mm M Simpson 134 ml 67 ml/m 2, 51ml 25.5 ml/m 2 62 % 5mm Qp/Qs cm Fig. 3 1cm Fig. 2 Chest computed tomography scans left, right on admission showing multiple infiltrative shadows in both lungs arrows J Cardiol 2007 Dec; 50 6 :
3 敗血症性肺塞栓症をきたした心室中隔欠損症 385 Fig. 3 Transesophageal echocardiograms showing a 1.3 cm vegetation on the right ventricle wall at the point of impact of the shunt bloodstream Right : Color Doppler LV RV shunt. V vegetation ; VSD ventricular septal defect ; RV right ventricle ; LV left ventricle. まず内科治療で炎症の沈静化を試み 治療に抵抗性で 疣贅の拡大が認められる場合には手術を考慮する方針 となった 入院後 抗生物質投与開始前の血液培養検 査によりα連鎖球菌が検出された subtype は同定でき ず 2003 年に発表された感染性心内膜炎の予防と治 療に関するガイドライン6 に基づき 感受性の結果を 待たずにエンピリ ック治療としてペニシリン G 2, U/day とゲンタマイシン 180 mg/day の大 量投与を開始した 投与開始 2 日後には解熱と CRP の 低下を認めた 薬剤感受性の結果 ペニシリン G とゲ ンタマイシンともに感受性が確認できたため 継続投 与とした 入院 18 日目に再び 39 台の発熱と右側胸部痛が出 Fig. 4 Clinical course PG penicillin G ; GM gentamicin ; AMPC amoxicillin ; WBC white blood cell ; CRP C-reactive protein. 現し CRP も 20 mg/dl まで再上昇した 胸部 CT で疼 痛部位と一致して右肺に胸膜に接する新たな浸潤影の 出現を認めた ペニシリン G を 3, U/day に も菌の発育や胸痛は認められなかったが 採血検査で ゲンタマイシンを 240 mg/day に増量し 2 週間継続投 CRP が 1.8 mg/dl 白血球数が 11,000/μl と軽度上昇し 与後には炎症は沈静化した 呼吸状態が安定していた 胸部 CT 検査より右上葉に新たに小さな浸潤影を認め ため 他症例で報告のある肺胞出血の合併を懸念し たため 入院時の血液培養検査により感受性が確認さ 肺梗塞に対する抗凝固剤の投与は行わなかった 経食 れていたアモキシシリン 1,000 mg/day の経口投与を開 道エコー図検査で疣贅はほぼ消失し 胸部 CT 検査で 始した 2 週間後には CRP は陰性化し 1 ヵ月間継続 も浸潤影の縮小を認めたため 入院より 46 日目に退 投与後の胸部 CT 検査ではすべての浸潤影はさらに縮 院となった Fig. 4 小または消失し 前回新たに認められた左上葉の浸潤 その後 症状なく経過し 退院 3 ヵ月後の外来での 心エコー図検査で疣贅は認められず 血液培養検査で J Cardiol 2007 Dec; 50 6 : 影も消失していた Fig. 5 その後の経過で 再発を 示唆する所見は認められていない
4 386 Fig. 5 Chest computed tomography scans 3 and 4 months after the discharge Left: A new infiltrative shadow appeared in the right lung arrow. Right : The infiltrative shadow disappeared after administration of amoxicillin for 1 month arrow. 50% 6 43 % 24% 7 8,9 CT CT CT 3 5 4,5,10 Mügge 11 1cm 18.9 % 1cm 46.8 % 1cm 1cm % 12 J Cardiol 2007 Dec; 50 6 :
5 cm G J Cardiol 2007 Dec; 50 6 : Chan P, Ogilby JD, Segal B: Tricuspid valve endocarditis. Am Heart J 1989; 117: ,,,,, : ; 41 : in Jpn with Eng abstr 3,,,,,,,, : 2004; 57 : ,,,,,, : VSD ; 53 : in Jpn with Eng abstr 5,,, : VSD MRSA ; 53 : in Jpn with Eng abstr 6 : Circ J 2003; 67 ; Robbins MJ, Soerio R, Frishman WH, Strom JA : Rightsided valvular endocarditis : Etiology, diagnosis, and an approach to therapy. Am Heart J 1986 ; 111: Webb DW, Thadepalli H: Hemoptysis in patients with septic pulmonary infarcts from tricuspid endocarditis. Chest 1979; 76 : Corzo JE, Lozano de León F, Gómez-Mateos J, López- Cortes L, Vázquez R, García-Bragado F : Pneumothorax secondary to septic pulmonary emboli in tricuspid endocarditis. Thorax 1992; 47: ,,,, : 3 : 1998; 46: in Jpn with Eng abstr 11 Mügge A, Daniel WG, Frank G, Lichtlen PR : Echocardiography in infective endocarditis: Reassessment of prognostic implications of vegetation size determined by the transthoracic and the transesophageal approach. J Am Coll Cardiol 1989 ; 14 : Otterstad JE, Erikssen J, Michelsen S, Nitter-Hauge S : Long-term follow-up in isolated ventricular septal defect considered too small to warrant operation. J Intern Med 1990; 228: J Cardiol 2007 Dec; 50 6 :
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