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Prezentare de caz - UMF

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Universitatea <strong>de</strong> Medicina si Farmacie “Iuliu Hatieganu”<br />

Cluj-Napoca<br />

<strong>Prezentare</strong> <strong>de</strong> <strong>caz</strong><br />

G. Gusetu<br />

Clinica <strong>de</strong> Cardiologie – Recuperare


G.I., B, 54 ani, Cluj<br />

Motivele internării (16 mai 2012 – Cardiologie-Recuperare)<br />

- durere retrosternala constrictiva<br />

- febra (38-39 0 C)<br />

AHC - nesemnificative<br />

APP - obezitate (2002)<br />

CVM - fumator, 1 pachet/zi, 20 ani<br />

IBA<br />

- <strong>de</strong>but <strong>de</strong> ~ 3 zile<br />

- febra continua<br />

- fatigabilitate<br />

- durere retrosternala cvasicontinua<br />

accentuata <strong>de</strong> miscarile respiratorii si <strong>de</strong> tuse<br />

- <strong>de</strong> o zi: tuse seaca


Ex. obiectiv:<br />

- obezitate (I=1.73, G=103 Kg, IMC= 34.4)<br />

- tegumente cal<strong>de</strong> (t=38.6 0 C)<br />

- zg. cardiace ritmice, AV=95/min<br />

- zg. aspru, “superficial”, sistolo-diastolic, intensitate medie,<br />

periapexian, (frecatura pericardica)<br />

- TA 115/75 mmHg<br />

Diagnostic <strong>de</strong> etapa:<br />

SINDROM PERICARDIC.<br />

SINDROM FEBRIL.<br />

OBEZITATE.


Investigatiiile <strong>de</strong> prima linie<br />

Tr 245 000 /mm 3 Uree 58.6 mg/dL<br />

Glc 368 mg/dL<br />

Probe biologice:<br />

Col 246 mg/dl<br />

TGL 189 mg/dl<br />

Hb 14.7 g/dl<br />

HDLc 34 mg/dl<br />

Ht 45.9%<br />

LDLc 172 mg/dl<br />

L 11 700 /mm 3<br />

PMN 56 %<br />

Lf 40 %<br />

Eo 3%<br />

Ba 1%<br />

VSH 52 mm/h<br />

CRP 4.8 mg/dl<br />

Ex <strong>de</strong> urina:<br />

d=1030, pH=5,<br />

AP-neg, Z++, sed.- c.cet.-<br />

Creat 0.99 mg/dL<br />

K 4.64 mEq/L<br />

Na 135 mEq/L<br />

CK 138 UI/L<br />

CK-MB 11 UI/L<br />

TnI 0.01 ng/ml<br />

ASAT 30 UI/L<br />

ALAT 24 UI/L


EKG :<br />

RS, AV=95 /min, ax QRS +30 grd, microvoltaj <strong>de</strong>riv standard, T negativ V1-V6


Rx toracica:


Ecocardiografie:


Investigatii <strong>de</strong> a doua linie<br />

Markeri virali serologici ??<br />

Markeri imunologici ai unei<br />

colagenoze ??


Alte investigatii<br />

Profil glicemic Ora 7.00 – 287 mg/dl<br />

Ora 12.00 – 321 mg/dl<br />

Ora 18.00 – 275 mg/dl<br />

Ora 21.00 – 337 mg/dl<br />

Ora 24.00 – 246 mg/dl<br />

Ora 03.00 – 291 mg/dl<br />

HbA1c<br />

Screening complicatii cronice DZ


Diagnostic final:<br />

Pericardita acuta idiopatica.<br />

Obezitate grd I.<br />

Dislipi<strong>de</strong>mie mixta.<br />

Diabet zaharat tip II nou <strong>de</strong>pistat <strong>de</strong>zechilibrat.


Pericardita acuta<br />

– date teoretice -


Pericardita acuta<br />

Inci<strong>de</strong>nta ? ~ 1%<br />

5 % din durerile toracice non – coronariene<br />

(UPU - SUA)<br />

1 % din cauzele <strong>de</strong> supra<strong>de</strong>niv. <strong>de</strong> segment ST<br />

(UPU - SUA)


Etiologia:<br />

1. Idiopatica (80-90%)<br />

2. Infectioasa<br />

1. Virala (Echo, Coxackie, CMV)<br />

2. Bacteriana (Str, Sf, Mycoplasma,Borellia)<br />

3. TBC<br />

3. IMA<br />

4. LES, PAR, SD<br />

5. Medicamente (izoniazida, hidralazina, procainamida)<br />

6. Radiatii<br />

7. Neoplazica<br />

8. Post-cardiotoracotomie<br />

Dupa Braunwald’s Heart Disease, 9 th Ed., 2012


FH Netter, Atlas of Human<br />

Anatomy, 5 th Ed., 2010


Dupa RA Lange et al. Acute Pericarditis N Engl J Med 2004; 351:2195-2012<br />

T. clinic - simptomele<br />

1. Durerea<br />

- Brusca, severa, <strong>de</strong> durata, caracter ascutit<br />

- Variabila cu respiratia, pozitia toracelui<br />

- Localizare, Iradiere<br />

2. Febra<br />

3. Dispneea<br />

4. Tusea<br />

5. Simptome generale - inf. virala<br />

6. Miocardita <strong>de</strong> acompaniament


Ex. obiectiv<br />

1. Frecatura pericardica<br />

- caracter aspru (“zapada inghetata”,”matase”)<br />

- “sperficiala”<br />

- 3 componente<br />

- variabila in dinamica<br />

2. Anxietate<br />

3. Pozitie antialgica<br />

4. Respiratie superficiala


Diagnostic diferential:<br />

1. Ischemia miocardica (IMA, API)<br />

2. Disectia <strong>de</strong> Ao<br />

3. Embolia si infarctul pulmonar<br />

4. Pneumonia cu pleurezie<br />

5. Pneumotoracele<br />

6. Costocondrita<br />

7. Herpes-zoster<br />

8. Reflux GE<br />

Dupa Braunwald’s Heart Disease, 9 th Ed., 2012


Diagnostic diferential:<br />

Al durerii toracice:<br />

Sdr. coronarin acut (factorii <strong>de</strong> risc, localizarea durerii)<br />

Pneumonie (febra, tuse)<br />

Esofagita, spasm esofagian<br />

Al formelor etiologice:


Tratament<br />

Obiective:<br />

1. Combaterea durerii si a febrei<br />

2. Retrocedarea colectiei pericardice<br />

3. Prevenirea complicatiilor<br />

4. Tratamentul conditiilor asociate


Tratament:<br />

Repaus la pat ?<br />

Dieta: hiposodat, hipocaloric (1900 kcal), hipolipidic<br />

Medicatia: Ibuprofen 400 mg, 1-1-1-1<br />

Bisoprolol 5 mg, 1-0-1<br />

Colchicina 0.5 mg, 1-0-1<br />

Paracetamol 500 mg, 1-0-1<br />

Atorvastatina 20 mg/zi<br />

Insulatard 16 UI seara<br />

Siofor 2 x 1000 mg


Complicatiile pericarditei acute – date din literatura:<br />

• Colectia pericardica mare<br />

• Tamponada cardiaca (3,1 %)<br />

• Pericardita constrictiva (1.5%)<br />

- multe din <strong>caz</strong>urile complicate – etiologie specifica<br />

(i<strong>de</strong>ntificabila)<br />

B Maisch et al. Diagnosis and management of pericardial diseases Eur Heart J 2004; 25:587


Evolutia<br />

Recidiva – 15-30 % din p. ac. idiopatice<br />

Femei, cei cu raspuns incomplet la AINS<br />

Episoa<strong>de</strong> recurente <strong>de</strong> durere pericardica<br />

Uneori persistenta, <strong>de</strong>bilitanta<br />

Reevaluare pentru o caua specifica (autoimuna)<br />

Prognosticul pe termen lung e bun:<br />

cele mai multe remit (chiar daca 8 ani)<br />

pericardita constrictiva e rara<br />

Recurentele dureroase pot crea confuzie <strong>de</strong> diagnostic cu SCA


Tratamentul durerii recurente post - p. acuta<br />

AINS: 2 saptamani<br />

Colchicina: 2-3 mg incarcare, apoi 1 mg/zi, 6 sapt – 3 (6) luni<br />

(<strong>de</strong> la inceput sau dupa AINS initial)<br />

10-15 % intoleranta digestiva la colchicina<br />

Prednison: cure scurte (1 saptamana) la fiecare recidiva<br />

Daca recidivele sunt frecvente – cure lungi cu doza minima<br />

eficienta (0.2-0.5 mg/Kgc)


Afebrilitate din ziua a 3 a<br />

Ecografie control 18 iun 2012


Prognostic:<br />

Remisiunea completa: regula, pt etiologia virala<br />

Recurenta: posibila pana la 20-30 %<br />

Al bolilor asociate: riscul cardiovascular f. inalt<br />

poate fi redus – sa<strong>de</strong>rea in G<br />

- control dislipid<br />

- control diabet


Concluzie:<br />

Pericardita acuta - realitate in practica clinica<br />

Recunoasterea – clinic si EKG<br />

Diferentierea <strong>de</strong> alte conditii acute, in special cardiovasculare<br />

Importanta pentru tratamentul <strong>de</strong> urgenta al acestor pacienti


Particularitatea <strong>caz</strong>ului<br />

Durere toracica anterioara care survine la<br />

un pacient cu factori <strong>de</strong> risc CV si care<br />

poate crea confuzii <strong>de</strong> diagnostic.


Va multumesc

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