抗生素相关过度抗凝揭开由氟脱氧葡萄糖-正电子发射断层扫描/计算机断层扫描（FDG-PET/CT）诊断的人工瓣膜心内膜炎

摘要(中文译文)

维生素K拮抗剂（VKAs）仍是接受机械瓣膜置换术患者的标准抗凝治疗；尽管其在该临床情境中有效，但其治疗窗非常狭窄，这一因素使其与较高的出血风险相关。其广泛参与凝血级联反应以及与多种常用药物的相互作用，可导致抗凝过度。此外，人工瓣膜感染性心内膜炎是一种严重的并发症，其诊断具有挑战性，尤其当超声心动图检查结果不明确时。我们报告一例50岁男性患者，因重度主动脉瓣狭窄行机械主动脉瓣置换术，正在接受醋硝香豆素抗凝治疗，表现为严重抗凝过度，伴多处出血并发症，包括血胸、慢性硬膜下血肿以及累及髂腰肌和大腿深部肌群的广泛肌内血肿。这些并发症的发生在时间上与因上呼吸道感染而使用含阿莫西林的抗生素方案相关。住院期间，持续发热以及从中央和外周血培养中分离出病原体，引起了对可能感染性心内膜炎的怀疑；然而，经胸和经食管超声心动图均未发现明确的赘生物。因此，进行了氟脱氧葡萄糖（FDG）正电子发射断层扫描（PET）联合计算机断层扫描（CT）检查，显示主动脉瓣人工瓣环周围局灶性高代谢摄取，与人工瓣膜心内膜炎相符；随即启动针对性抗微生物治疗，随后患者被转诊接受外科瓣膜置换术，该手术在抗生素治疗完成后进行，临床进展令人满意。本病例突出了与VKAs相关的抗凝不稳定所带来的广泛临床后果，尤其是因药物相互作用导致的风险呈指数级增加，如本病例中与抗生素治疗相关的情况。此外，本病例强调了FDG-PET/CT在诊断人工瓣膜心内膜炎中的价值，尤其是当超声心动图检查结果不明确时。

Abstract

Vitamin K antagonists (VKAs) remain the standard anticoagulation therapy in patients undergoing mechanical valve replacement; despite their efficiency in this clinical context, they are associated with a very narrow therapeutic window, a factor that links them to a major risk of bleeding. Their broad involvement in the coagulation cascade and their interactions with multiple commonly used drugs can lead to supratherapeutic anticoagulation. Furthermore, prosthetic valve infective endocarditis is a serious complication that poses a diagnostic challenge, especially when echocardiographic findings are inconclusive. We present the case of a 50-year-old man with a mechanical aortic valve prosthesis secondary to severe aortic stenosis, on anticoagulation therapy with acenocoumarol, who presented with severe over-anticoagulation, with multiple hemorrhagic complications, including hemothorax, chronic subdural hematoma, and extensive intramuscular hematomas involving the iliopsoas muscle and deep compartments of the thigh. The onset of these complications was temporally associated with the administration of an antibiotic regimen containing amoxicillin, secondary to an upper respiratory tract infection. During his hospital stay, persistent fever and the isolation of from central and peripheral blood cultures raised suspicion of probable infective endocarditis; however, both transthoracic and transesophageal echocardiograms were inconclusive for vegetations. Therefore, positron emission tomography (PET) with fluorodeoxyglucose (FDG) combined with computed tomography (CT) was performed, revealing focal hypermetabolic uptake around the prosthetic aortic valve annulus, consistent with prosthetic valve endocarditis; targeted antimicrobial therapy was initiated, and the patient was subsequently referred for surgical valve replacement, which was performed after the completion of antibiotic treatment with satisfactory clinical progress. This case highlights the vast clinical consequences of anticoagulation instability associated with VKAs, and especially the exponential increase in risk due to drug interactions, as in this case, linked to antibiotic therapy. Furthermore, it emphasizes the value of FDG-PET/CT in the diagnosis of prosthetic valve endocarditis, particularly when echocardiographic findings are inconclusive.

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