Türk Beyin Damar Hast Derg. 2022; 28(1): 63-67 | DOI: 10.5505/tbdhd.2021.31549

Ýnfektif endokardite baðlý septik embolide intravenöz trombolitik tedavi uygularsak ne olur? Olgu sunumu

Gülsüm Saruhan, Ayse Güler, Hadiye Þirin, Neþe Çelebisoy
Ege Üniversitesi Týp Fakültesi, Nöroloji Anabilim Dalý, Ýzmir

Ýnfektif endokardit (ÝE), endokardýn bakteriyel, viral veya fungal mikroorganizmalara baðlý geliþen enfeksiyonudur. Tipik bulgularý üfürüm, splenomegali, osler nodülleri, splinter hemoraji, janeway lezyonlarýdýr. Bu yazýda ateþ yüksekliði sonrasýnda akut inme ile prezente olan IV rtPA uygulanan multipl serebral-serebellar hemoraji geliþen bir ÝE olgusunun sunulmasý amaçlanmýþtýr. 35 yaþýnda bilinen DM ve HT öyküsü olan erkek hasta multipl serebral ve serebellar hemoraji nedeni ile kliniðimize yatýrýldý. Öyküsünde 2 hafta önce ateþ yüksekliði (39-40 derece) geliþmesi üzerine farenjit tanýsý ile antibiyotik tedavisi aldýðý, ateþ yüksekliðinden 1 hafta sonra sað yan güçsüzlüðü geliþtiði öðrenildi. Sað yan güçsüzlüðü ile baþvurduðu merkezde çekilen Beyin Bilgisayarlý Tomografi (BT) ve Beyin Magnetik Rezonans Görüntüleme (MRG) normal saptanan hastaya akut iskemik inme tanýsý ile Ýntravenöz-Alteplaz (IV rtPA) uygulanmýþ. Çekilen kontrol beyin BT de multipl serebral ve serebellar hemoraji odaklarý saptanmasý ve hastanýn nörolojik skorunda kötüleþme geliþmesi üzerine hastanemize sevk alýndý. Ateþ yüksekliði etyolojisi net aydýnlatýlamamýþ olan ve multipl hemorajik odaðý olan hastada infektif endokardite sekonder septik emboli düþünülerek kardiyoloji tarafýndan ekokardiografi (EKO) yapýldý. EKO sonucunda mitral kapak anteriorunda 1,1x0.7 cm vejetasyon izlenmesi üzerine uygulanan Transözefageal EKO de 1,9x0,9 cm vejetasyon saptandý. Enfeksiyon hastalýklarý tarafýndan antibiyotik tedavisi düzenlendi. Kalp Damar Cerrahisine operasyon açýsýndan danýþýldý. Operasyon sýrasýnda yüksek doz heparin kullanýmý gerekeceði için hematom rezorpsiyonuna kadar operasyon planlanmadý. Ýzleminde ateþ yüksekliði olmayan kontrol EKO larýnda vejetasyon boyutlarýnda küçülme izlenen hastanýn izlem kranial BT lerinde hemorajilerinde rezorpsiyon izlendi. Acil servise yüksek ateþ ve nörolojik defisit ile baþvuran hastalar deðerlendirilirken, septik embolizm öncelikle akla getirilmelidir ve ileri inceleme için görüntüleme yöntemleri kullanýlmalýdýr.

Anahtar Kelimeler: Endokardit, septik emboli, trombolitik tedavi.

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What happens when you treat septic cerebral emboli with intravenous thrombolytic treatment ? A case report

Gülsüm Saruhan, Ayse Güler, Hadiye Þirin, Neþe Çelebisoy
Ege University Faculty of Medicine, Department of Neurology, Ýzmir, Turkey

Infective endocarditis (IE) is the infection of the endocardial surfaces of the heart and intracardiac foreign bodies, and is caused by various microorganisms such as bacteria, fungus and viruses. Most common findings of IE include cardiac murmur, splenomegaly, Osler nodes, splinter hemorrhages, and Janeway lesions. Here, we aimed to present a IE case which was misdiagnosed as thromboembolic stroke, treated with intravenous (IV) thrombolytic treatment and developed multiple cerebral and cerebellar hemorrhages. A 35-year-old man with a history of diabetes mellitus (DM) and hypertension (HT) was admitted to our clinic with multiple cerebral and cerebellar hemorrhages. It was found out that the patient was given an antibiotic treatment due to high fever (39-40 oC) and pharyngitis two weeks before admission to our clinic, and a week later he developed right side weakness. As computerised tomography (CT) and diffusion-weighted magnetic resonance imaging (MRI) were normal at the clinic the patient applied with right sided weakness, he was diagnosed with acute ischemic stroke and was given intravenous thrombolytic treatment-alteplase (IV rTPA). Patient was referred to our clinic due to persistent fever, clinical worsening and multiple cerebral and cerebellar hemorrhages in follow-up CT scan. The patient was referred to the Cardiology clinic with the preliminary diagnosis of infective endocarditis. Echocardiography (ECO) showed a thrombotic vegetation measuring 1.1 x 0.7 centimeters (cm) on the anterior mitral valve, and transoesophageal ECO showed a thrombotic vegetation measuring 1.9 x 0.9 on the mitral valve. The patient was referred to Infctious Diseases clinic for initiation of antibiotherapy, and Cardiovascular Surgery clinic regarding the need for surgery. Yet, as the surgery required high-dose heparin application, an operation was not performed. After the treatment, hemorrhage areas were seen to be regressed in follow-up brain CT scan. While evaluating patients who admit to the emergency with high fever and neurological deficits, septic embolism should also be kept in mind at the first visit and imaging methods should be used for further evaluation.

Keywords: Endocarditis, septic embolism, thrombolytic treatment.

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