ENDOCARDITIS BACTERIAL SUBACUTE

From Big Medical Encyclopedia

ENDOCARDITIS BACTERIAL SUBACUTE (Greek endon inside + kardia heart + - itis) — the infectious endocarditis arising at subacute (long) bacterial sepsis against the background of immune disturbances in an organism and leading usually to formation of valve heart disease. The subacute current is observed also lr the infectious endocarditis caused by pathogenic fungi (see the Endocarditis).

Nosological isolation E. the bp is discussed because of the insufficient clearness of criteria of distinguishing of acute and subacute disease. As such criterion use sometimes duration of a disease, including subacute an infectious endocarditis lasting more than 6 — 8 weeks. However to a large extent distinctions are defined by character and degree of manifestation of immune disturbances at acute and subacute forms of a current that in a certain measure depends on a type of a disease-producing factor. Traditional for domestic clinic was allocation of a long septic endocarditis (endocarditis septica lenta, or sepsis lenta), to-ry considered within features of impact on an organism of the green streptococcus (and - a streptococcus). A number of clinical physicians designates thus is generally long the current clinically soft and difficult recognizable forms inf. an endocarditis irrespective of a type of the activator. In a crust, time of the concept «long septic endocarditis» and «subacute bacterial endocarditis» are more often used as synonyms.

To the middle of 19 century the infectious endocarditis was not distinguished from rheumatic, including it malignant option of a current of the last. Gave to A. P. Langova in 1844 the detailed description of a clinical and pathoanatomical picture of a disease, pointing to a possibility of lack of communication of an endocarditis with rheumatism. In 1851 A. I. Polunin, sorting results of autopsy of the died patient with aortic incompetence and existence of multiple hems in a spleen and kidneys, came to conclusion that not rheumatism, but «purulent cachexia», i.e. sepsis was a basis of a disease in this case. A. A. Ostroumov and And. P. Langova designated a disease as endocarditis septica. After Vinge's detection (E. F. H. Winge, 1870) microorganisms in the struck valve of heart the concept about inf. to the nature of an endocarditis and its studying gained development in U. Osler's works (1885, 1909), to Zhakk { S. Jaccoud, 1885, 1888), Littena (M. of Litten, 1881), T. G. Lukina (1903), Shotmyuller (H. Schottmii-ller, 1910), etc.; the problem of a ratio of a rheumatic and septic endocarditis was studied by B. A. Chernogu-bov (1949).

AA. the bp can be primary, i.e. arising on an intact endocardium, but it is more often is secondary, i.e. develops against the background of already available heart disease at rheumatic heart diseases (40 — 60%), inborn heart diseases (is more often at patients with defect of an interventricular partition, an open arterial channel, a stenosis of a pulmonary trunk), is more rare at atherosclerotic damage of heart, a myocardial infarction, a hypertrophic cardiomyopathy with a sub-aortal stenosis, a prolapse of the mitral valve. At pathology of an aorta and large arteries with development of arteriovenous aneurisms the endothelium of arteries and an aorta can initially be surprised.

Statistics. 9. the bp makes more than 90% of all cases of an infectious endocarditis. At men it is noted by 2 — 3 times more often than at women. Age structure getting sick and some other statistical characteristics E. bps underwent essential changes for the last 30 — 35 years. Increase E is noted. bp at elderly people: if in 1948 among patients E. the bp of the person is more senior than 50 years made 11%, in 1960 60% of all revealed cases were the share of them. According to V. V. Serov with sotr. (1982), among infectious endocarditises considerably (up to 46%) the frequency of primary infectious endocarditis which made 10,2% in the 60th, and in the 70th — 29,2% increased; cases of the isolated defeat of the aortal valve — from 29% in 30 — to 53% in 60 — the 70th became frequent the 40th. The structure of the pathology of heart preceding a secondary endocarditis changes: frequency E increases. bp

against the background of inborn heart diseases at an urezheniya E. bp against the background of rheumatism; there were new forms secondary E. bp, arising after a commissurotomy, prosthetics of valves of heart, owing to hron. hemodialysis.

Etiology and pathogeny. In emergence and development E. bps matter property of the activator (as infekt and sensibilizator), change immunol. reactivity of an organism and, quite often, existence of the previous pathology of an endocardium.

From activators E. the leading place belongs to bp and - to a streptococcus, about the Crimea generally and connected development of the picture of long sepsis reflected in classical descriptions of a disease. After widespread introduction in a wedge, practice of antibiotics these-ol. a role and - a streptococcus value of golden staphylococcus, epidermal (white) staphylococcus, enterokokk decreased and increased a little; more rare activators E. bps are an anaerobic streptococcus and gram-negative bacteria — colibacillus, klebsiyella, a pyocyanic stick, proteas, etc. Big etiol. value staphylococcus, enterococci and gram-negative bacteria have at E. bp, developing after heart operations, after venipunctures, in particular at addicts. Leader etiol. the role and - a streptococcus remains at E. bp against the background of the bacteremia connected with activation of the centers hron. infections (especially in almonds, teeth, in respiratory tracts). Bacteremia in itself is not a sufficient condition as for development of sepsis (passing bacteremia is observed at almost healthy people after extraction of tooth in 50% of cases), and for implementation of an infekt in an endocardium if the last is not damaged and there are no disturbances of immunity.

In an experiment at intravenous administration of bacteria an animal the infectious endocarditis, as a rule, does not arise. V. K. high-HIV (1885) showed that it can be caused at zhivotnkh by introduction of streptococci and stafilokokk, but only after a preliminary small injury of the valve of heart by the probe. Further it was established that development of an endocarditis at intravenous administration of a streptococcus is promoted not only by direct damage of fabric of the valve, but also change of conditions of a hemodynamics with increase in cordial emission, acceleration of a blood flow, defiant these or those changes of an endocardium (e.g., after imposing to dogs of the arteriovenous shunt). In other experiments the infectious endocarditis was caused introduction of bacteria and without damage of the valve, but with presensitization of an organism of an animal foreign proteins.

From the beginning of fixing of microbes in an endocardium a pathogeny E. the bp includes development of at least three patol. the processes defining as a result formation of the leading displays of a disease. First, in places of implementation of microorganisms the infectious inflammation develops (see) with lines of giperergichesky — actually the endocarditis, and microbes fixed on valves can get for the second time to a blood channel, causing metastasises of an infection. Development of infectious process is expressed by fervescence, acceleration of ROE, change of cellular composition of blood. Secondly, the microbes and products of an inflammation fixed on valves play a role of the sensibilizing factors and cause immune disturbances, including the adjournment of the circulating cell-bound immune complexes leading to damage of various bodies and fabrics (nephrite, myocarditis, hepatitis, arthritises, vasculites). In an active phase E. bps at the vast majority of patients (90 — 95%) find the circulating cell-bound immune complexes in blood, in kidneys often find deposits them on basal membranes disappearing after successful treatment. 90% of patients have cryoglobulins, at a half — anti-cardial antibodies. The maintenance of IgM, and then and IgG increases; at V3 of patients the rhematoid factor, decrease in a caption of a complement is defined. Function of macrophages and monocytes increases; at the same time sensitivity of lymphocytes to mitogens decreases. Thirdly, on the surface of the damaged valves deposits of fibrin and blood clots are formed, to-rye quite often are sources of an embolism of various vascular areas (see the Embolism).

Ratio listed patol. processes in a pathogeny of each specific disease can be various owing to what a wedge, manifestations E. p, have specific features.

Pathological anatomy. In most cases preferential the valve of an aorta is surprised, mitral is more rare. Localization of an inflammation on the three-leaved valve is observed seldom and usually, according to N. K. Permyakov (see t. 29, additional materials), at primary infectious endocarditis against the background of genital sepsis or at sepsis of an injection origin, especially at addicts.

The picture of a polipozno-malignant endocarditis is characteristic. On the struck valves, tendinous chords, and sometimes and a pristenochny endocardium the ulcer defects which are usually closed by massive polipoobrazny or spherical trombotichesky imposings are visible to-rye have yellow-white color and the dry crumbling consistence. In them lime in the form of small grains is often laid. Since the disease has a long recurrent current, on valves at the same time meet fresh, partially or completely organized trombotichesky imposings. Perforations or aneurisms of shutters are found. The centers of necroses are surrounded with the infiltrates consisting of lymphoid cells, histiocytes and multinucleate colossal cells. Among cells of infiltrate, necrotic and trombotichesky masses bacterial colonies are often visible though less than at an acute infectious endocarditis. Granulyatsionny fabric at the maturing scleroses and deforms shutters in cases of primary endocarditis or strengthens these changes at a secondary endocarditis. Noticeable gistol. distinctions between these two forms are not found, though it is noted that at primary form typical granulomas of Ashoff — Tala-layeva characteristic of a rheumatic endocarditis do not meet (see Rheumatism), only granulemopodobny infiltrates are found. In addition to the described changes in valves at a subacute bacterial endocarditis the centers of disorganization, limfomakrofagalny infiltration and small warty imposings that reflects, perhaps, an abacterial (allergic) stage of a disease, edge, according to A. M. Vikhert can meet (see t. 10, additional materials), can precede a bacterial stage. Apparently, it is connected with the nature of immunocomplex damages at a bacterial endocarditis.

Clinical picture. The main displays of a subacute bacterial endocarditis consist of symptoms of infectious intoxication, endocarditis (usually in the form of manifestations of insufficiency of the struck valve of heart), to-rye are quite often combined with symptoms of the accompanying myocarditis, sometimes and a pericardis, and also signs of a vasculitis and defeat of parenchymatous bodies (most often kidneys, a spleen, a liver) in connection with septic process and tromboembolic episodes.

The onset of the illness often has no peculiar features and is characterized by a febricula, fatigue, a loss of appetite, constant or periodic subfebrile condition, and patients quite often continue to work, without seeing a doctor sometimes within several weeks. At certain patients the first address to the doctor is connected with emergence of already tromboembolic episodes, napr, the heart attack of a kidney which is followed by a back pain and a hamaturia. At more acute onset of the illness infectious intoxication is expressed by fever, oznoba, plentiful sweats, arthralgias, mial-giya, quickly increasing muscular weakness, fatigue. In process of stabilization of a septic state expressiveness of these symptoms changes, other symptoms of a disease join, creating various wedge, options of displays of subacute sepsis (see). Various types of fever (see) — remittiruyushchy, intermittent, wrong, constant, etc. are possible, chilling, perspiration, weight loss are often noted. Early acceleration of ROE, a disproteinemia with increase in fractions of coarse-dispersion proteins come to light; more than a half of patients has an anemia. Pallor of skin, sometimes its easy yellowness (is noted at excess hemolysis); at long infectious intoxication skin gets an earthy shade or «coffee with milk» color. Existence of petechias on skin and mucous membranes, especially on a transitional fold of a lower eyelid (Lukin's symptom — Liebman), emergence of petechias on places of squeezing of the skin collected pleated (a positive symptom of a pinch), or under the cuff squeezing a shoulder is considered characteristic (see Konchalovsky — Rumpelya — Leede a symptom); drain hemorrhagic rash is sometimes noted. More specific symptom of a skin septic vasculitis — Osler's small knots (painful, size from a prosyany kernel to a pea red small knots on skin of palms, a bottom part of feet, under nails); in recent years they meet considerably less than it was noted in classical descriptions of a disease in the first half of 20 century. In typical cases it is long current E. bps are observed changes of trailer phalanxes of fingers in the form of drum sticks (see. Drum fingers) and nails as clock glasses (see Hippocrates a nail).

Signs of damage of heart at primary E. bps come to light in several weeks, sometimes in several months after the beginning of a disease. Approximately at V3 of the diseased the valvulitis is limited to the isolated defeat of the valve of an aorta. Emergence of systolic noise is considered the earliest symptom, to-ry it is best of all listened in Botkin's point. Consider that it can be caused by emergence of polypostural educations on the valve of an aorta. Further aortic incompetence develops (see the Heart diseases acquired). The isolated defeat of the mitral valve is observed at 35 — 40% of the diseased. The mitral insufficiency arising at the same time is diagnosed hardly as a systolic apex murmur, characteristic of it, at E. the bp can be caused by other reasons (myocarditis, anemia). Only in rather exceptional cases sudden emergence of a musical systolic apex murmur gives the grounds to connect it with perforation of a shutter of the valve owing to infectious process. Recognition of septic defeat of valves is complicated

and at secondary E. the bp when dynamics of auskultativny symptoms of heart disease is less noticeable and is quite often interpreted as manifestation of a returnable rheumatic carditis. At the infectious endocarditis arising after heart operation the fitted a prosthesis valve (irrespective of character of a prosthesis) quite often is surprised that it is not always followed by the expressed dynamics of auskultativny signs. In rare instances of defeat at primary E. bps of the three-leaved valve usually appear symptoms of its insufficiency — systolic noise at the left edge of the bottom of a breast, then expansion of borders of heart to the right, a positive venous pulse, etc. (see the Heart diseases acquired).

Along with defeat of an endocardium the myocarditis (see) caused by a vasculitis is often observed. Clinically it can be shown by increase of heart failure, emergence of disturbances of a heart rhythm or endocardiac conductivity, delay a cut comes to light at every sixth diseased E. bp. Increase at E is noted. the bp of cases of a myocardial infarction (see), to-ry can proceed as with symptoms, characteristic of this disease (the anginous status, etc.), and is atypical. Approximately at 10% of patients E. the bp is observed an acute shaggy pericardium (see), to-ry arises, on-vidimokhmu, as a result of adjournment in a pericardium of cell-bound immune complexes. In rare instances the shaggy pericardium leads to an obliteration of a pericardiac cavity.

Damage of other internals at E. the bp is found with a different frequency and depends as on migration of the activator and immune destruction of cells of bodies, and, in an essential measure, on prevalence of a vasculitis with disturbance of passability of arteries and arterioles owing to the thromboses and thromboembolisms leading to developing of heart attacks (is more often in a spleen, kidneys, lungs, heart, a brain, is more rare — in abdominal organs and extremities). Approximately at a half of patients with tromboembolic episodes havingt place combined defeat of several vascular areas.

Increase in a spleen is found in 30 — 40% of cases E. bp; sometimes it is followed by symptoms of a hypersplenism (a leykotsitope-niya, thrombocytopenia, anemia). Also increase in a liver is quite often noted, a cut it can be connected both with stagnation of blood, and with hepatitis. The last proceeds rather easily, being characterized by moderate increase in transaminases, bilirubin, and only in exceptional cases there is jaundice and a liver failure.

Often at E. the bp is noted damage of kidneys. In half of cases the diffusion glomerulonephritis (see) which is shown a hamaturia, a proteinuria, the cylindruria moderated by arterial hypertension, sometimes hypostases is observed. The expressed nephrotic syndrome (see) develops seldom. Damage of kidneys usually slowly progresses and can lead to development hron. a renal failure, edge becomes a cause of death of certain patients. Focal nephrite (see) it is shown by generally passing changes of urine (a microhematuria, a small proteinuria), quickly disappearing at effective treatment. The heart attack of kidneys is shown by pains in lumbar area, a dysuria, a hamaturia with existence in urine of not changed erythrocytes; at a big heart attack the passing azotemia is possible. However at a part of patients the heart attack of kidneys proceeds a low-symptom - but also it is found only on section in the form of multiple hems in kidneys. Approximately at 3% of patients E. 6. the item at the long course of a disease develops an amyloidosis of kidneys.

Almost at 1/3 patients E. the bp comes to light damage of lungs in the form of a heart attack (see the Thromboembolism of pulmonary arteries), pneumonia (see), the pulmonary vasculitis which is shown atypical pneumonia (see the Pneumonitis), sometimes a pneumorrhagia.

Defeat of a nervous system is usually characterized by symptoms of infectious and toxic encephalopathy — a headache, sleeplessness, an adynamy, apathy (or euphoria). At a part of patients more expressed pathology is observed:

thromboembolisms of arteries of a brain or a rupture of the vascular wall which underwent a septic necrosis with clinic according to ischemic or a hemorrhagic stroke are possible (see); development of meningitis (see), encephalitis (see Encephalitis).

In recent years cases with developed a wedge, a picture meet less often. Often the disease proceeds without fervescence or with low subfebrile condition; sometimes at high and long fever there are no wedge, signs of defeat of valves of heart; in some cases the disease long time proceeds behind a mask of hepatitis, nephrite, etc.

Current E. the bp is defined by a number of factors, including features of a disease-producing factor, age of the diseased, existence of the associated diseases influencing on immunol. reactivity of an organism, the nature of primary pathology of heart (at secondary E. bp) etc. At the endocarditis caused by staphylococcus, to enterococci, a pneumococcus multiple suppurative focuses in different bodies are more often observed, the course of a disease differs in big sharpness and more expressed displays of infectious intoxication.

At persons of advanced and senile age E. the bp especially often proceeds without fever. Secondary E.

the bp develops at them as in the presence of rheumatic heart disease, and is frequent against the background of atherosclerotic defeat, including after a myocardial infarction. Almost in all cases there are these or those associated diseases. In a wedge, a picture the frequency of a thromboembolic syndrome, disturbances of a heart rhythm and conductivity attracts attention.

Current E. the bp, arising in the remote terms after heart operations (a so-called late endocarditis), has no natural differences from usual options of a current E. bp. More hard the endocarditis arising in the first 1 — 2 months after operation (a so-called early endocarditis) differing in resistance to therapy and development of heavy complications, especially thromboembolic proceeds; at the same time the overall picture of a disease often corresponds not to a subacute, but acute infectious endocarditis.

The diagnosis in the first days of a disease is established seldom. Allow to suspect a disease of typical cases existence of fever or steady subfebrile condition with oznoba or chilling, astenisation, weight loss, petechias on skin, Lukin's symptom — Liebman, emergence or change of nature of noise over area of heart, increase in a spleen, symptoms of a thrombembolia, formation of a symptom of bar of bathing fingers.

From these laboratory blood analyses for E. bps are characteristic acceleration of ROE, is frequent to 70 — 80 mm an hour, anemia (more than at a half of patients), a disproteinemia with increase in ^-globulins, is more rare than a2-globulins and a hyperproteinemia that causes emergence of positive sedimentary proteinaceous tests: formolovy, timolovy, sublimate. Almost at all patients the circulating cell-bound immune complexes come to light. The number of leukocytes in blood often remains normal, but are possible both a leykotsitopeniya, and a moderate leukocytosis, especially in the presence of any complications during a disease. Decrease in number of thrombocytes can be observed, but the expressed thrombocytopenia is noted seldom. In cells of marrow the tendency to plasmatization is traced.

From changes in urine the hamaturia and a moderate proteinuria is most often noted different degree, it is frequent in combination with a cylindruria.

Diagnosis actually of an endocarditis is based on identification of signs of a valvulitis by auscultation of heart and phonocardiographic researches in dynamics, and also by means of an echocardiography (see). The one-dimensional or two-dimensional echocardiography allows more than in half of cases E. to determine by bp existence of vegetations on the valve of an aorta or on the mitral valve, is more rare — on the three-leaved valve. Indirect signs E. the bp can serve detection of a separation of a tendinous chord, gap or perforation of a shutter of the valve, change of nature of defect, especially increase of insufficiency that is specified at simultaneous use of a pulse doppler-echo-cardiography (see Doppler effect, the Echocardiography). The most characteristic echocardiographic signs are: strengthening of echo signals from shutters of the valve and their systolic or diastolic «fluttering» perpendicular to a flow of blood with a frequency of 80 — 125 Hz. It is necessary to consider, however, that echocardiographic signs inf. defeats of shutters can remain vaguely long time and are equally characteristic both for current, and of earlier postponed septic endocarditis.

Etiol. diagnosis E. the bp necessary for the purposeful choice of means of antibacterial therapy establish generally by results of repeated bacterial. crops of blood for the purpose of allocation of the activator. It is desirable to make blood sampling prior to treatment by antibiotics and to send for crops

of 4 — 5 portions of blood. For a research it is recommended to take

not less than 10 ml of blood, mixing it with a large amount of nutrient medium. If blood was taken in the period of treatment by antibiotics and by results of crops it was sterile, it is necessary to conduct a series of repeated researches, having cancelled antibiotics on 1 — 2 day. To allocate the activator E. the bp works well approximately in 60% of cases.

The differential diagnosis with other diseases makes an indispensable part diagnostikie. the bp also depends on dominance of these or those symptoms in a picture of a disease. At the acute beginning with fever and oznoba exclude acute infectious diseases — flu, a typhoid (see), etc., being guided by an epidemic situation, dynamics of symptoms of a disease and results of special diagnostic methods (microbiological, immunological). Differential diagnosis with a septicaemia without endocarditis can be promoted by a research in blood of the circulating cell-bound immune complexes, level to-rykh at E. the bp is much higher. In cases with steady subfebrile condition for differential diagnosis include in a circle of diseases also noninfectious diseases (a thyrotoxicosis, tumoral process, etc.), but most often, especially in the presence of signs of a valvulitis at secondary E. bp, rheumatism (see). From E. the bp a rheumatic carditis differs in a frequent combination to extracardiac displays of rheumatism (polyarthritis, serosites); the raised antiserum capacity to a hemolitic streptococcus at the beginning of an active phase of a disease; more expressed displays of myocarditis, including changes of an ECG, including low-characteristic for E. bp of disturbance of atrioventricular conductivity; more frequent formation of mitral defect, and combined type (insufficiency and stenosis). At the same time increase in a spleen, Lukin's symptom — Liebman, a symptom of drum fingers are not characteristic of a rheumatic carditis, to-rye can take place at E. bp. Also comparative assessment of effect of antibacterial therapy (it is inefficient at a rheumatic carditis) and anti-inflammatory drugs matters, to-rye are highly effective at rheumatism, but not at a septic endocarditis. If in a wedge, manifestations E. bps prevail signs of defeat of any one body, carry out the differential diagnosis with such forms of pathology, for to-rykh this defeat, napr, with a glomerulonephritis (see), hepatitis (see), nonspecific myocarditis is characteristic (see) it., based on results of the diagnostic testings necessary for establishment of the diagnosis of an estimated disease. At considerable difficulties in diagnosis in cases of the fever proceeding St. 10 days, even the assumption of its possible communication with E. the bp is considered the indication to performing vigorous antibacterial therapy for the purpose of the prevention of serious changes in the valve device of heart and decrease in risk of other heavy complications of a disease.

Treatment. In complex treatment of patients E. bp the main place is taken by antibacterial therapy, to-ruyu supplement with influence on immunol. reactivity of an organism of the patient and use of means of symptomatic therapy. If the activator is not identified yet, then after capture of blood for crops antibacterial therapy is begun with use of a combination of benzylpenicillin with streptomycin or other aminoglycoside, napr, gentamycin. At allocation in a hemoculture of the green streptococcus it is reasonable to continue therapy of a benzylpenalty fee-tsillinom having raised a dose (it can reach 60 000 000 PIECES and more in days). And a part of this dose is entered intravenously that is admissible for sodium salt of penicillin and it is unacceptable for potassium salt because of threat of potassium intoxication. At intolerance of benzylpenicillin appoint drop intravenous infusions of phosphate of erythromycin in isotonic solutions (sodium chloride, glucose) or antibiotics of group of cephalosporins, napr, cefalotin. At: AA. the bp caused by staphylococcus preference is given to polusinteti-chesky penicillin (Methicillinum, Oxacillinum) in combination with gentamycin; apply also Vancomycinum, cephalosporins. The same antibiotics, except for cephalosporins, should be used at allocation from blood of an enterokokk if the combination of benzylpenicillin and streptomycin is insufficiently effective. In cases, when activators E. bps are gram-negative bacteria, prefer as gentamycin in combination with ampicillin or karbenitsilliny or with cephalosporins. Use of the specific antibacterial serums considerably increasing efficiency of treatment of patients with sepsis, especially in the presence of antibiotics of activators, resistant to a row, in particular gram-negative flora is perspective. The general course of antibacterial therapy proceeds from 4 to 6 weeks.

At the expressed clinical and laboratory signs of disturbance immunol. Prednisolonum or other glucocorticoids in equivalent doses are shown to reactivity of an organism (a giperergichesky vasculitis, a disproteinemia, a high level of the circulating cell-bound immune complexes in blood). Expediency of use at E is studied. bp of levamisole and a number of the immunomodulators stimulating systems T - or V-lymphocytes, function of macrophages, etc.

In predictively adverse cases of a current E. bps are made the attempts of operational treatment consisting in excision of the struck aortal valve and replacement with its prosthesis. The high lethality at this operation (60 — 70%) after all is lower, than in cases of resistance to massive antibacterial therapy at development in patients of heavy heart failure owing to destruction of the valve of an aorta. Operational treatment is shown also to patients E. bp with already available prosthesis of the valve and at the endocarditis caused by fungi.

The forecast in many respects depends on a disease-producing factor and on time of the beginning of antibacterial therapy. At a streptococcal etiology of a disease at patients without circulatory unefficiency of elimination of septic process it is possible to reach more than in 90% of cases, and at the endocarditis caused by stafilokokka and gram-negative bacteria — less than at 80% of patients. The correct tactics of antibacterial therapy at early diagnosis E. the bp considerably improves the forecast for life and working ability of the diseased since damage of heart does not reach deep degrees. At overdue or unsuccessful therapy in the tactical relation valve heart disease forms, extent of restriction of working ability of the patient after elimination of septic process, and sometimes and an outcome of a disease depends on expressiveness to-rogo. At a part of patients with the created heart disease palindromias are noted.

Worsen the forecast, including vital, development of a circulatory unefficiency, tromboembolic episodes and accession of the renal failure (in connection with a glomerulonephritis, heart attacks of kidneys) complicating antibacterial therapy. At the early and late endocarditis arising after heart operations, the forecast is not identical: at late — the lethality

makes 25 — 40%, and at early — it reaches 60 — 90%.

Prevention in general same as prevention of sepsis (see). It shall have purposeful character at patients with the acquired and inborn heart diseases, including with a prolapse of the mitral valve. At these patients careful sanitation of the centers of an infection is obligatory; during the carrying out at them such interventions as an odontectomy, surgery on urinogenital bodies, statement of a constant venous catheter, etc., to-rye can be followed by passing bacteremia, earlier recommended administration of penicillin, but in view of high risk of development of heavy medicinal complications it is better to apply with the same purpose other antibiotics, napr, erythromycin.

For increase in resistance to inf. the tempering procedures, exercises in admissible volume, the food enriched with vitamins are recommended to diseases.

Bibliography: Vikhert A. M. Compare

the telny characteristic postrevmatiche-sky and primary sepsis a tape, Arkh. patol., t. 20, No. 7, page 15, 1958; D e-

m and A. A. N and Dyomin Ave. And. Bacterial endocarditises, M., 1978; Serov V. V., etc. Kliniko-morfologichesky analysis of a septic (infectious) endocarditis, Arkh. patol., t. 44, No. 3, page 27, 1982; Smolensk V. S., Vedrov H. N and Namaka-n about in B. A. Antimicrobic therapy of a bacterial endocarditis, Cardiology, t. 20, No. 8, page 117, 1980; Tyurin V. P. Difficulties of diagnosis of subacute forms of a bacterial endocarditis at persons of advanced and senile age, Rubbed. arkh., t. 52, No. 8, page 33, 1980; C at to e r-m and G. I. N and d river. To a question of a possibility of surgical treatment of an infectious endocarditis in an active phase, Voshch revm., No. 3, page 42, 1981; Cabane J. and. lake of Fate of circulating immune complexes in infective endocarditis, Amer. J. Med., v. 66, p. 277, 1979; Garvey G. J. N e u H. C. Infective endocarditis — an evolving disease, Medicine (Baltimore), v. 57, p. 105, 1978; Heart disease, ed. by E. Braunwald, p. 1166, Philadelphia a. o., 1980; Martin R. P. a. o. Clinical utility of two diminsional echocardiography in infective endocarditis, Amer. J. Cardiol., v. 46, p. 379, 1980. See also bibliogr, to St. Endocarditis.

A. V. Sumarokov; A. B. Shekhter (stalemate. An.) „

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