Splintered hemorrhage under the finger or toenail

Introduction Finger and nail rupture flakes are one of the signs of infective endocarditis. Infective endocarditis (IE) is a direct infection of microorganisms (bacteria, fungi and other microorganisms such as viruses, rickettsia, chlamydia, spirochetes, etc.) to produce inflammation of the heart valve or ventricular wall, including Acute and subacute endocardial inflammation.

Cause

First, common pathogenic microorganisms

Common pathogenic microorganisms include:

1. Streptococcus and Staphylococcus each account for 65% and 25% of autologous valve endothelium pathogenic microorganisms.

2. The pathogens of acute IE are mainly Staphylococcus aureus, and a few are caused by pneumococci, gonococcal bacteria, group A streptococci and Haemophilus influenzae.

3. Subacute IE patients are most common with Streptococcus viridans, followed by Group D Streptococcus (Streptococcus bovis, Enterococcus), Staphylococcus epidermidis and other bacteria are rare.

4. Fungi, rickettsia and chlamydia are rare pathogenic microorganisms in autologous valve endocarditis.

Second, the incidence of subacute infective endocarditis

Hemodynamic factors

Subacute IE occurs mainly in patients with structural heart disease (heart valve disease and congenital cardiovascular disease). Rheumatic valvular disease, which is most prone to subacute infective endocarditis, especially the mitral and aortic valves. The common site of the neoplasm is the endocardium downstream of the abnormal blood flow, which may be associated with decreased pressure and intimal perfusion at these sites, which is beneficial to microbial deposition. High-speed jets can cause local damage to the intima of large blood vessels, which can cause infection, such as the left atrial wall facing the mitral regurgitation beam, and the endothelium of the pulmonary artery wall facing the unobstructed arterial catheter shunt. Less occurs when the pressure gradient is small, atrial fibrillation, and heart failure.

2. Non-bacterial thrombotic endocardial lesions

The endothelium of the endocardium is damaged, and the collagen fibers of the connective tissue are exposed. The platelets accumulate here to form platelet microthrombus and fibrin deposits, forming nodular aseptic neoplasms, called non-bacterial thrombotic endocardium. Inflammation is an important factor in the colonization of bacteria on the surface of the valve.

3. Temporary bacteremia

Skin and mucous membrane wounds caused by various infections or bacteria often cause temporary bacteremia. Infectious endocarditis can occur if bacteria in the circulation settle on aseptic neoplasms.

4. Bacterial infections Aseptic neoplasms: infection depends on:

(1) The frequency of bacteremia and the number of bacteria in the circulation.

(2) The ability of bacteria to adhere to platelet microthrombus and fibrin. Streptococcus mutans enters the bloodstream with many opportunities and strong adhesion, so it is the primary cause of subacute infective endocarditis. Escherichia coli has poor adhesion, although it is common bacteremia, but rarely causes heart Endometritis.

an examination

Related inspection

Electrocardiogram Doppler echocardiography M-mode echocardiography (ME)

Auxiliary examination and diagnosis

Blood culture

Blood culture is the most important method for diagnosing bacteremia and infective endocarditis. For subacute patients who are not treated with antibiotics, blood should be taken once every 1 hour at the first day for a total of three times. There was no bacterial growth the next day, and the blood was collected three times and started to be treated with antibiotics. Those who have used antibiotics should repeat the blood collection 2 to 7 days after stopping the drug. There is no need to collect blood when the body temperature rises, and 10 to 20 ml of blood is collected each time, and aerobic and anaerobic cultures are performed for at least 3 weeks. Special culture techniques are used when necessary.

2. Echocardiography

If neoplasms and periorbital complications are found, evidence of endocarditis is supported, which helps to confirm the diagnosis.

(1) Transthoracic ultrasonography can diagnose 50% to 75% of neoplasms. The sensitivity of transesophageal ultrasonography is as high as 95%, and it can detect <5mm neoplasms. However, IE cannot be excluded when no scorpion is found.

(2) Other abnormalities such as valvular disease, congenital heart disease, and pericardial effusion can be clarified. If the neoplasm is 10mm, the risk of arterial embolism is high.

3. Diagnostic criteria (emphasis)

The diagnostic criteria for IE (1995 Duke criteria) were developed in conjunction with clinical presentation, laboratory testing, and echocardiography.

(1) Main criteria

1 The blood culture was positive twice and the pathogens were completely consistent.

2 Echocardiography revealed neoplasms, or new valve insufficiency.

(2) Secondary criteria

1 History of basic heart disease or intravenous drug abuse.

2 fever, body temperature 38 ° C.

(3) vascular phenomenon: embolism, bacterial aneurysm, intracranial hemorrhage, conjunctival siltation, Janeway damage.

(4) Immune response: glomerulonephritis, Osler nodules, Roth plaques and rheumatoid factor positive.

(5) Blood culture is positive, but does not meet the main criteria.

(6) Echocardiography has the performance of IE, but does not meet the main criteria.

Differential diagnosis

Differential diagnosis of finger or toe nail flaky hemorrhage:

1. Nail visible transverse groove spinning: Mucocutaneous lymph node syndrome (MCLS), also known as Kawasaki disease, is an acute febrile rash pediatric disease characterized by systemic vasculitis becoming the main pathological feature. . During the recovery period, the nail can be seen in the transverse groove.

2, there are missing marks on the tip of the nail: the lack of marks on the tip of the nail refers to the symptom of the lack of marks on the tip of the nail.

3, nails thick and brittle and many cracks: nails thick and brittle and many cracks are suffering from the clinical manifestations of hypothyroidism.

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