CAZ CLINIC BIOCHIMIE CLINICA
IONESCU VALERIAN STEJAREL Gr. 5, Seria A
Pacienta
A.G., in varsta de 10 ani edi! r!ra" Se #re$inta in !r%enta
&tive"e internarii '!reri
retr&sterna"e retr&sterna"e c! c! iradiere iradiere in !(ar!" dre#t 'is#nee !s&ara, a#ar!ta c! ) $i"e inaintea internarii
Antecedente *ered&+c&"atera"e si antecedente #ers&na"e #at&"&%ice nese(nicative
C&nditii de viata si de (!nca e"eva
Ist&ric!" -&"ii Pacienta
A.G. in varsta de 10 ani, din (edi!" r!ra", c! antecedente*ered&+c&"atera"e si antecedente #ers&na"e #at&"&%ice nese(nicative, se internea$a avand !r(at&are"e ac!$e d!reri retr&sterna"e c! iradiere in !(ar!" dre#t, dis#nee !s&ara. Si(#t&(at&"&%ia a a#ar!t in a#r&/i(ativ c! ) $i"e inaintea internarii.
E/a(en c"inic "a internare Gre!tate
+ 5% Inai"ti(e + 151 c( IC+ 25 Stare de n!tritie s!#ra#&ndera-i"itate severa Stare %enera"a a"terata, s!-3e-ri"a ),5 C 4acies si(etric, erite( "a nive"!" #&(eti"&r Te%!(ente n&r(a" c&"&rate !c&ase n&r(a" c&"&rate
E/a(en c"inic "a internare 4anere
n&r(a" i(#"antate Tes!t c&n!nctiv+adi#&s -ine re#re$entat Siste( %an%"i&nar 3ara aden&#atii dece"a-i"e c"inic Siste( (!sc!"ar n&r(&t&n, n&r(&tr&3, n&r(&inetic Siste( &ste&+artic!"ar inte%r!, artic!"atii "i-ere, ned!rer&ase, 3ara t!(eeri artic!"are
E/a(en c"inic "a internare A#arat res#irat&r 'is#nee (i/ta !s&ara !r(!r ve$ic!"ar !s&r di(in!at "a -a$a *e(it&race"!i stan% 4ara ra"!ri A#arat cardi&vasc!"ar AV 6a"!ra ventric!"ara7 c! 100 -atai8(in 9%&(&te cardiace rit(ice, -ine -at!te, 3ara s!:!ri TA; 1108<0 ((=%
E/a(en c"inic "a internare A#arat di%estiv A-d&(en s!#"!, de#resi-i", cat si s#"ina ne#a"#a-i"e A#arat !r&%enita" L&e rena"e "i-ere
E/a(en -i&c*i(ic =e(&"e!c&%ra(a
dece"ea$a tr&(-&cit&#enie, "e!c&cit&$a c! ne!tr&e"ie, 3ara sindr&( ane(ic =- ; 11,2%8d" 6VN 12+15%8d"7 =t ; )),1> 6VN )5+?5>7 VE ; @5,?: 6VN @+5:7 =E ; 2@,<#% 6VN 2<+)2#%7 C=E ; )),5%8d" 6VN )2+)<%8d"7 L ; 10108((c 6VN ?000+10,5008((c7
E/a(en -i&c*i(ic LB
; 1<,> 6VN 50+0>7 N ; <@,@> 6VN 25+?0>7 Tr ; 1510008((c 6VN 150000+?000008((c7 4r&ti! #eri3eric ne!tr&"e c! n!c"e! #&"i"&-at VS= ; 52((81*, 6VN+1181*7 4i-rin&%en ; ?(% 61?0+)<0(%7 CRP ; ,@) (%8d" 60+1(%8d"7 ASLO ; 511UI8(" 6)20UI8("7 Pr&-e rena"e n&r(a"e
Investi%atii i(a%istice Radi&%rae #!"(&nara Trans#arenta #!"(&nara in "i(ite n&r(a"e C&rd!" c! dia(etr!" transvers !s&r cresc!t Ec&%rae a-d&(ina"a S#"ina (arita c! dia(etr!" "&n%it!dina" de 1),5 c(, 3ara "ic*id in cavitatea #erit&nea"a
Investi%atii i(a%istice Ec&%rae cardiaca 4E ; 50>, 4S ; )0>, se#t interatria" si interventric!"ar intacte, "a(a na de "ic*id in #ericard 65 ((7 Pericardita EG ta*icardie sin!sa"a, 3ara (&dicari a"e se%(ent!"!i ST si !ndei T
'ia%n&stic #re$!(tiv Pericardita
ac!ta c! !r(at&are"e ar%!(ente e/a(en!" c"inic D d!reri #rec&rdia"e, dis#nee, ta*icardie sin!sa"a E/a(ene #arac"inice D sindr&( i(:a(at&r, dia(etr! transvers a" c&rd!"!i !s&r (arit #e radi&%raa #!"(&nara, #re$enta de "ic*id #ericardic "a ec&%raa cardiaca in cantitate (ica D 5((
Trata(ent initia" &/i%en&+tera#ie &nit&ri$are
6te(#erat!ra, TA, AV, Sa O2, 4R,
di!re$a7 Anti-i&tice A/etine 650 (% "a @ &re i.v.7, Genta(icina 6?0(% "a @ &re7, si(#t&(atice
'ia%n&stic!" di3erentia" a. &"i in3ecti&ase end&cardita in3ecti&asa
ac!ta sa! s!-ac!ta 6a-senta s!:!ri"&r cardiace7, #ericardita TC 6inr(ata #e -a$a I'R ne%ativ si a radi&%raei #!"(&nare n&r(a"e7, #ericardite vira"e, -acteriene, (Bc&#"as(e etc. -. Pericardite #rin c&nti%!itate 6in -&"i #"e!ra"e, #ne!(&nii7F
c. &"i de c&"a%en der(at&+(i&$ita,
sc"er&der(ie, "!#!s erite(at&s siste(ic n! s+a e/c"!s dat&rita #re$entei a d&!a criterii erite( "a nive"!" #&(eti"&r, "a(a na de "ic*id in #ericard7F d. Artrita re!(at&ida !veni"a 6e/c"!sa #e -a$a a-sentei sindr&(!"!i 3e-ri" #re"!n%it si artritei7F e. Vasc!"ite i(!ne, #&"iarterita n&d&asaF 3. Pericardita din re!(atis(!" artic!"ar
S+AU RECOLTAT PENTRU 'IAGNOSTICUL 'I4ERENTIAL Antic&r#i
antin!c"eari #re$enti, #attern #atat n 6in "!cr! "a (&(ent!" e/ternarii7, 3act&rre!(at&id 11 UI8(" 6N107, C&(#"e(ent C) 1),? (%8d" 6N;0+1@07, Antic&r#i anti+cc# 6anti#e#tide cic"ice citr!ni"ate7 0,5 U8(" 6ne%ativ #ana "a U8("7
'ia%n&stic #&$itiv initia" Cardita
re!(atis(a"a D 3&r(a !s&ara Ar%!(ente Criterii J&nes !n criteri! (a&r D cardita c! #ericardita, d&!a criterii (in&re reactanti de 3ara ac!ta #&$itivi 6VS=, CRP, -rin&%en7, d&vada in3ectiei stre#t&c&cice 6titr! ASLO cresc!t7
TRATAENTUL CURATIV 1. Eradicarea in3ectiei stre#t&c&cice #enici"ina G
[email protected] UI "a < &re i.v.7+ 10 $i"e 2. Trata(ent!" carditei c&rtic&tera#ie D Prednis&n <0 (%8$i 62(%8%c8$i7 initiat in D ) sa#ta(ani d&$a de atac, a#&i ) sa#ta(ani c! scaderea #r&%resiva a d&$e"&r ). Trata(ent ad!vant c&rtic&tera#iei 6aa"&/, Ranitidina, ca"ci! "actic7 ?. Pr&"a/ia sec!ndara #revenirea
Ev&"!tia s!- trata(ent a investi%atii"&r #arac"inice VS=
; 10((8* 6VN10((8*7 CRP ; 0.)@(%8d" 6VN 0,5(%8d"7 ASLO ?5 UI8(" 6VN )20 UI8("7 Ec&%rae cardiaca 3ara "ic*id in #ericard
'ISCUTII S+a
inter#retat ca$!" ca ind cardita ac!ta re!(atis(a"a 3&r(a !s&ara 6#ericardita i$&"ata 3ara se(ne de ins!cienta cardiaca, titr! ASLO cresc!t, sindr&( -i&"&%ic in:a(at&r7 N! s+a #!t!t e/c"!de #er!cardita din cadr!" c&"a%en&$e"&r 6AAN #&$itivi+ H#attern #atat s+ a! re"!at, "a (&(ent!" e/ternarii nd in "!cr!7. S!- trata(ent a ev&"!at c! re(isia si(#t&(at&"&%iei c"inice, a sindr&(!"!i -i&"&%ic in:a(at&r si dis#aritia "ic*id!"!i #ericardic "a e/a(inarea ec&%raca.
RECOAN'ARI LA ETERNARE Re%i(
3ara sare C&ntin!area trata(ent!"!i c&rti$&nic, c! scaderea #r&%resiva a d&$e"&r, trata(ent ad!vant c&rtic&tera#ei 6aa"&/, CaK vita(ina '), As#acardin7 Pr&"a/ia end&carditei
'!#a
5 "!ni s+a reinternat #entr! d!reri "a nive"!" *e(it&race"!i stan%, 3ati%a-i"itate, si(#t&(at&"&%ie c! de-!t de & $i E/a(en!" c"inic "a internare G ;
In ev&"!tie 6a d&!a $i de "a internare7 A"terarea
starii %enera"e, #r&c&rdia"%ii6sen$atie de #resi!ne t&racica c! iradiere in !(ar!" stan%7, dis#nee (&derata, cian&$a discreta SaO2; 0> 3ara O2 4R;)08(in AV;<08(in TA; 08?0 ((=%, se trans3era in sectia de TI Se e3ect!ea$a de !r%enta Radi&%rae #!"(&nara care dece"ea$a cardi&(e%a"ie 6c&rd in Hcara3a Ec&%ra3!e cardiaca evidentia$a #ericardita6 @(( "ic*id7
TRATAENT S+a
initiat tera#ie c! S&"!(edr&" 125 (% "a < &re i.v. edr&" )2(% 1K1K0 Trata(ent c! Penici"ina G 61 UI "a < &re7 < $i"e (ai tar$i! a #re$entat Peri&ade c! -radicardie sin!sa"a )@8(in in c"in&statis(, "a ridicarea in &rt&statis( AV;<08(in, $%&(&te cardiace !s&r as!r$ite, sat!ratie O2;0> 63ara O27, accent!area erite(!"!i 3acia", EG c! -radicardie sin!sa"a, RS n&r(a"
INVESTIGATII IUNOLOGICE C&(#"e(ent
C) D 2,)2 %8" 6N0,+1,@7 C&(#"e(ent C?+ 0,5 %8" 6N0,1+0,?7 4act&r re!(at&id )@ UI8(" 6N 0+257 Antic&r#i antin!c"eari #&$itivi, #attern #atat, titr!181<0, antic&r#i anti+AN' d!-"! catenar 6N507 1@,?UI8(", ce"!"e "!#ice a-sente
N!
s+a #!t!t e/c"!de "!#!s!" erite(at&s siste(ic dat&rita #re$entei a ) criterii erite( "a nive"!" #&(eti"&r, ser&$ita 6#ericardica7, antic&r#i antin!c"eari #&$itivi. S!- trata(ent ev&"!tia a 3&st 3av&ra-i"a c! re(isia si(#t&(at&"&%iei c"inice, re(isia sindr&(!"!i -i&"&%ic in:a(at&r, dis#aritia "ic*id!"!i #ericardic "a e/a(inarea ec&%raca Pe #arc!rs!" !r(at&are"&r trei internari #entr! -i"ant c"inic&+-i&"&%ic n! a #re$entat sindr&( in:a(at&r, #r&tein!rie 0,2%82?*, 3ara "ic*id #ericardic "a ec&%raa cardiaca
Pat&"&%ic
s+a evidentiat dis"i#ide(ie in cadr!" sindr&(!"!i C!s*in% iatr&%en, care s+a re(is s!- dieta si trata(ent c! aci$i %rasi O(e%a ) In ev&"!tie a #re$entat t!se cr&nica #entr! care s+ae3ect!at c&ns!"t #ne!(&3ti$i&"&%ic, test !anti4ERON ne%ativ 6s+a e/c"!s TC7 CT t&racic (ini(a in%r&sare de #ericard, (ini(a in%r&sare #"e!ra"a stan%a ? "!ni (ai tar$i! s+a internat #entr! (&tive"e dis#nee (i/ta, d!rere t&racica c! iradiere in !(ar!" stan%, t!se iritativa, #a"#itatii, ras* (a"ar. Se a:a in trata(ent c! edr&" 1<(%18?c#6?(%8$i7
La
) &re d!#a internare a #re$entat A"terarea starii %enera"e, 3e-ra )@C, verti, #a"#itatii, dis#nee (&derata, (&tive #entr! care s+a trans3erat in sectia de tera#ie intensiva Inre%istrarea EG a evidentiat !nde T ne%ative In AVL, AV4 si V2+MV< Ec&%raa cardiaca e3ect!ata a evidentiat na "a(a de "ic*id #ericardic 5 ((. S+a instit!it #!"s+tera#ie c! S&"!(edr&" 1% i.v. ) $i"e c&nsec!tiv
Ev&"!tie
3av&ra-i"a s!- trata(ent Re(isia sindr&(!"!i in:a(at&r 6"a internare L;1<.<008((c7 VS=;@0((8* CRP;1,0(% 4i-rin&%en;@)2(%, 3ara "ic*id "i-er in #ericard, n&r(a"i$area EG de c&ntr&" 'e (enti&nat 3act&r re!(at&id )5!8"6N 0+257, tr&(-&cit&#enie !s&ara 6101.0008((c7 si #r&tein!rie 0,515 %82?* 6n&r(a" 0,2%82?*7
Revi$!irea dia%n&stic!"!i Pe
-a$a date"&r ana(nestice, c"inice si #arac"inice a 3&st revi$!ita incadrarea in criterii"e ARA #entr! "!#!s erite(at&s siste(ic, ada!%and!+se a" #atr!"ea criteri!+ #r&tein!ria6inter(itenta in ca$!" n&str!7, a"at!ri de ce"e"a"te ) criterii ras*(a"ar, ser&$ita 6#ericardita7,antic&r#i AAN #&$itivi 6#attern #atat7 'e&arece tr&(-&cit&#enia n! s+a (ai re#etat, n! s+a c&nsiderat necesara rec&"tarea antic&r#i"&r antitr&(-&citari.
RECOAN'ARI LA ETERNARE Re%i(
3ara sare N&r(&+"i#idic N&r(&+%"!cidic Evitarea e/#!nerii "a s&are Evitarea (edica(ente"&r care inc"!de LES, edr&"61(8%c,c! scaderea tre#tata a d&$e"&r7 Trata(ent ad!vant c&rtic&tera#iei
CONCLU9II '&vada
in3ectiei stre#t&c&cice si a #ericarditei a &rientat initia" dia%n&stic!" catre cardita re!(atis(a"a. La de-!t!" -&"ii n! a! e/istat ce" #!tin ? criterii #entr! a deni dia%n&stic!" de "!#!" erite(at&s siste(ic A" #atr!"ea criteri! #&$itiv #entr! LES6#r&tein!ria7 este in ca$!" n&str! inter(itenta si n! #ersistenta D in viit&r #r&-a-i" va necesita #!nctie -i&#sie rena"a. 'at&rita tera#iei c&rti$&nice a de$v&"tat C!s*in% iatr&%en C&nsidera( acest ca$ c! c&(#"icatii #&tentia" severe dat&rita a3ectarii cardi&vasc!"are si rena"e
LUPUS ERITEATOS SISTEIC Este
& -&a"a a!t&i(!na (!"tisiste(ica de eti&"&%ie nec!n&sc!ta LES este rar inta"nit "a c&#ii, re!nind 15> din t&ta"!" ca$!ri"&r, c! #red&(inanta a3ectarii se/!"!i 3e(inin LES c! de-!t in c&#i"arie este (ai sever decat "a ad!"t, c! & incidenta (ai (are a ne3ritei, #ericarditei, *e#at&s#"en&(e%a"iei
