Manifestações neurológicas nas endocardites infecciosas - revisão de 103 casos estudados - 84 casos do Hospital dos Servidores do Estado-R.J. (1947-1978) e 19 casos do Hospital Estadual São Sebastião-R.J. (1975-1978)

Gonçalves, Adrelirio José Rios; Carneiro, Raymundo Dias; Duarte, Francisco; Pinto, Ana Maria Miranda; Lazera, Marcia dos Santos; Barbosa, Luiz Sergio Guedes; Costa, Iranildo Cabral da; Barbosa, Niobe Furtado; Peçanha, Paulo Mendes; Teixeira, Carlos Roberto de Vasconcelos; Lagreca, Helena; Lopes, Paulo A.

doi:10.1590/S0037-86821980000100009

Resumos

Os autores fazem uma revisão de 103 casos de endocardites infecciosas, dos quais 52 apresentaram manifestações neurológicas. Dos 52 que não tiveram problemas neurológicos, 39 faleceram 175%), enquanto que dos 51 que não tiveram alterações do sistema nervoso, apenas 18 evoluíram para o óbito 135,3%). A endocardite infecciosa com manifestações neurológicas, na presente série, foi dominante no sexo masculino. Os grupos etários mais envolvidos foram as crianças, adolescentes e adultos jovens. Houve outro pico importante em pacientes acima de 50 anos. Os critérios para o diagnóstico de endocardite infecciosa utilizados no presente estudo, foram os clássicos, acrescidos de outros considerados de extrema utilidade, à medida que a experiência foi sendo acumulada, acompanhando paralelamente as modificações dos padrões etiológicos, assim como as alterações dos espectros clínicos da doença, conseqüentes a muitos fatores aqui discutidos. Os principais distúrbios neurológicos observados foram as manifestações meningeias, 25/52 148,1%), alterações do comportamento, 20/52 (38,4%), fenômenos motores (paralisias e paresias), 20/52 (38,4%). Alterações do nível de consciência (torpor ou coma), ao lado de outras menos comuns, como cefaléia 16/52 (26,9%), convulsões, 10/52 (19,2%), afasia 7/52 (13,5%) e manchas de Roth, 7/53 (13,5%). As manifestações neurológicas frequentemente foram múltiplas em um mesmo paciente. Nas formas de endocardite, foram em muitos casos praticamente as alterações que abriram e dominaram a cena clínica. As mais comuns foram: síndrome meningeia, síndrome vascular e encefalopatia tóxica. Foi difícil, em conseqüência de múltiplas manifestações neurológicas num mesmo paciente, estabelecer critérios entre a lesão neurológica e o prognóstico, embora o coma profundo, as convulsões, os distúrbios motores acentuados, a meningite e as alterações do comportamento, isoladamente ou em associação, façam com que o mesmo seja bem mais sério. O germe mais encontrado em nossa série foi oStaphylococcus aureus, relacionado com formas agudas da infecção endocárdica, aliado a processos destrutivos valvulares e a sérias alterações neurológicas tais como meningite, encefalite, infartos, hemorragias e abcessos cerebrais. Os principais achados neurológicos referentes à patologia, no estudo de 15 casos, são apresentados ao lado de conclusões tiradas de reflexões sobre o material analisado e da experiência vivida. Uma revisão da literatura é feita desde os trabalhos iniciais sobre a doença até os dias de hoje, ficando evidenciada a importância do tema pelas grandes contribuições apresentadas pelos diferentes autores.

The authors make a revision of 103 cases of infectious endocarditis, 52 of which brought about neurologic manifestations. In the 52 cases showing neurologic problems, 39 died (75%), while in the other 51 cases showing no alterations of the nervous system only 18 evolved to death (35,3%). The present series of infectious endocarditis with neurologic manifestations was dominat in the mate sex. The more affected age groups were children, adolescents and young adults. Another significant peak was shown by patients more than 50 years old. For the diagnosis of infectious endocarditis in the present study, classical criteria were adopted in addition to a few other ones which were recognized to be extremely useful in the process of accumulating experience, as paralel observation was applied to those changes of etiological patterns and to those alterations of clinical specters of the disease, which resulted from many of the factors here described. The major neurologic diserders detected were meningeal manifestations, 25/52 (48,1%), behavior alterations, 20/52 (38,4%) motor phenomena (paralysis and paresis), 20/52 (38,4%), alterations of the level of consciousness (torpor or coma), plus a few less commonones, such as cephalea, 16/52 (30,7%), alterations of cranial pai rs, 14/52 (26,9%), convulsions, 10/52 (19,2%),aphasia, 7/52 (13,5%). Multiple neurologic manifestations were frequent in the same patient. These alterations were practically the opening and dominant feature of the clinical scene in many cases of acute endocardites. Most common were: meningeal syndrome, vascular syndrome and toxic encephalopathy. Due to multiple neurologic manifestations in the same patient it was difficult to establish criteria linking the neurologic lesion to the prognostic although in states of profound coma, convulsion, pronounced motor disorders, meningitis and behavior alterations, isolated or in association, this prognostic becomes rather more serious. The germ more often found in our series was the staphylococcus aureus, related to acute forms of endocardiac infection, associated with valve destructive process and serious neurologic alterations, such as meningitis, encephalitis, infarcts, hemorrhages and cerebral abscesses. A description is given of the major neurologic findings related to the pathology and of the conclusions draw upon reflexion over the material analysed and the experience collected. A review of the existing literature on the disease, from the initial to the lates studies, clearly points out to the importance of the theme to which different authors have made remarkable contributions.

Manifestações neurológicas nas endocardites infecciosas - revisão de 103 casos estudados - 84 casos do Hospital dos Servidores do Estado-R.J. (1947-1978) e 19 casos do Hospital Estadual São SebastiãoR.J. (1975-1978)

Adrelirio José Rios Gonçalves^I; Raymundo Dias Carneiro^II; Francisco Duarte^III; Ana Maria Miranda Pinto^IV; Marcia dos Santos Lazera^IV; Luiz Sergio Guedes Barbosa^V; Iranildo Cabral da Costa^V; Niobe Furtado Barbosa^VI; Paulo Mendes Peçanha^VI; Carlos Roberto de Vasconcelos Teixeira^VI; Helena Lagreca^VII; Paulo A. Lopes^VIII

^IChefe do Serviço de Cardiologia do H.S.E.

^IIChefe de Clínica do Serviço de Anatomia Patológica do H.S.E.

^IIIMédicas do Hospital Estadual São Sebastião

^IVMédicos do H.S.E. (Serviço de Clínica Médica)

^VMédicos Residentes do Serviço de Clínica Médica do H.S.E.

^VIMédica Residente do Serviço de Anatomia Patológica do H. S. E.

^VIIProfessor Departamento de Medicina Preventiva da Faculdade de Medicina, U. F. R.J. Chefe de Clínica do Hospital Estadual São Sebastião

RESUMO

Os autores fazem uma revisão de 103 casos de endocardites infecciosas, dos quais 52 apresentaram manifestações neurológicas. Dos 52 que não tiveram problemas neurológicos, 39 faleceram 175%), enquanto que dos 51 que não tiveram alterações do sistema nervoso, apenas 18 evoluíram para o óbito 135,3%).

A endocardite infecciosa com manifestações neurológicas, na presente série, foi dominante no sexo masculino. Os grupos etários mais envolvidos foram as crianças, adolescentes e adultos jovens. Houve outro pico importante em pacientes acima de 50 anos. Os critérios para o diagnóstico de endocardite infecciosa utilizados no presente estudo, foram os clássicos, acrescidos de outros considerados de extrema utilidade, à medida que a experiência foi sendo acumulada, acompanhando paralelamente as modificações dos padrões etiológicos, assim como as alterações dos espectros clínicos da doença, conseqüentes a muitos fatores aqui discutidos.

Os principais distúrbios neurológicos observados foram as manifestações meningeias, 25/52 148,1%), alterações do comportamento, 20/52 (38,4%), fenômenos motores (paralisias e paresias), 20/52 (38,4%). Alterações do nível de consciência (torpor ou coma), ao lado de outras menos comuns, como cefaléia 16/52 (26,9%), convulsões, 10/52 (19,2%), afasia 7/52 (13,5%) e manchas de Roth, 7/53 (13,5%).

As manifestações neurológicas frequentemente foram múltiplas em um mesmo paciente. Nas formas de endocardite, foram em muitos casos praticamente as alterações que abriram e dominaram a cena clínica. As mais comuns foram: síndrome meningeia, síndrome vascular e encefalopatia tóxica. Foi difícil, em conseqüência de múltiplas manifestações neurológicas num mesmo paciente, estabelecer critérios entre a lesão neurológica e o prognóstico, embora o coma profundo, as convulsões, os distúrbios motores acentuados, a meningite e as alterações do comportamento, isoladamente ou em associação, façam com que o mesmo seja bem mais sério.

O germe mais encontrado em nossa série foi oStaphylococcus aureus, relacionado com formas agudas da infecção endocárdica, aliado a processos destrutivos valvulares e a sérias alterações neurológicas tais como meningite, encefalite, infartos, hemorragias e abcessos cerebrais.

Os principais achados neurológicos referentes à patologia, no estudo de 15 casos, são apresentados ao lado de conclusões tiradas de reflexões sobre o material analisado e da experiência vivida. Uma revisão da literatura é feita desde os trabalhos iniciais sobre a doença até os dias de hoje, ficando evidenciada a importância do tema pelas grandes contribuições apresentadas pelos diferentes autores.

ABSTRACT

The authors make a revision of 103 cases of infectious endocarditis, 52 of which brought about neurologic manifestations. In the 52 cases showing neurologic problems, 39 died (75%), while in the other 51 cases showing no alterations of the nervous system only 18 evolved to death (35,3%).

The present series of infectious endocarditis with neurologic manifestations was dominat in the mate sex. The more affected age groups were children, adolescents and young adults. Another significant peak was shown by patients more than 50 years old. For the diagnosis of infectious endocarditis in the present study, classical criteria were adopted in addition to a few other ones which were recognized to be extremely useful in the process of accumulating experience, as paralel observation was applied to those changes of etiological patterns and to those alterations of clinical specters of the disease, which resulted from many of the factors here described.

The major neurologic diserders detected were meningeal manifestations, 25/52 (48,1%), behavior alterations, 20/52 (38,4%) motor phenomena (paralysis and paresis), 20/52 (38,4%), alterations of the level of consciousness (torpor or coma), plus a few less commonones, such as cephalea, 16/52 (30,7%), alterations of cranial pai rs, 14/52 (26,9%), convulsions, 10/52 (19,2%),aphasia, 7/52 (13,5%).

Multiple neurologic manifestations were frequent in the same patient. These alterations were practically the opening and dominant feature of the clinical scene in many cases of acute endocardites. Most common were: meningeal syndrome, vascular syndrome and toxic encephalopathy. Due to multiple neurologic manifestations in the same patient it was difficult to establish criteria linking the neurologic lesion to the prognostic although in states of profound coma, convulsion, pronounced motor disorders, meningitis and behavior alterations, isolated or in association, this prognostic becomes rather more serious.

The germ more often found in our series was the staphylococcus aureus, related to acute forms of endocardiac infection, associated with valve destructive process and serious neurologic alterations, such as meningitis, encephalitis, infarcts, hemorrhages and cerebral abscesses.

A description is given of the major neurologic findings related to the pathology and of the conclusions draw upon reflexion over the material analysed and the experience collected. A review of the existing literature on the disease, from the initial to the lates studies, clearly points out to the importance of the theme to which different authors have made remarkable contributions.

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Referências bibliográficas

1. ALAJOUANINE, T.; CASTALIGNE, P.; LHERMITTE, F.; CAMBIER, J. - The cerebral arteritis of bacterial endocarditis: its late complications (Abstract) JAMA, 170: 1858, 1959.
2. ANTEL, J. J.; ROME, H. P.; GERACI, J. E.; SAYRE, G. P. Toxic-organic psychosis as a presenting feature in bacterial endocarditis Proc. Mayo Clin. 30:45, 1955.
3. AUSTRIAN, R. Pneumococcal endocarditis, meningits and rupture of the aortic valve - Arch. Inst. Med., 99: 539, 1957.
4. BADEMOSI, C.; FALASE, A. O.; JAIYESIMI, F. and BADEMOSI, A. - Neuropsychiatric manifestations of infective endocarditis: a study of 95 patients at Ibadan, Nigéria - J. of Neur., Neuros. and Psychiat., 39:325, 1976.
5. BAWA, Y. S. and WAHI, P. L. - Subacute bacterial endocarditis: meningeal complications Texas Med., 57:159, 1961.
6. BELL, W. E. and BUTLER C. - Cerebral mycotic anerisms in children Neurology, 18:81, 1968.
7. BERGEN, S. S. and DERMKSIAN, G. - Meningeal manifestations of subacute bacterial endocarditis N. Y. State J. Med., 57:3683, 1957.
8. BRUETSCH, W. L. The histopathology of the psychoses with subacute bacterial and chronic verrucose rheumatic endocarditis Am. J. Psychiat., 95:335, 1938.
9. CANTU, R. C.; LE MAY, M. and WILINSON, H. A. The importance of repeated angiography in the treatment of mycotic-embolic intracranial aneurisms J. Neurosurg., 25:189, 1966.
10. CARPENTER, R. R.; PETERSDORF, R. G. The clinical spectrum of bacterial meningitis Am. J. Med., 33:262, 1962.
11. CATES, J. E. and CHRISTIE, R. V. Subacute bacterial endocarditie. A review of 442 patients - Q. J. Med., 20:93, 1951.
12. CLAUDE, H. and OURY, P. - Les accidents nerveux de l'endocardite maligne prolongueé Rev. de Méd., 39: 449, 1922.
13. Clinicopathologic conference: A case of staphilococcal septicaemia with endocarditis and cerebral abscess demonstrated at the Royal Postgraduate Medical School., Brits. Med. J., 479:482, 1967.
14. COOPER, E. S.; COOPER, J. W.; SHNABEL, T. G. Pitfalls in the diagnosis of bacterial endocarditis - Arch. Ind. Med., 118:55, 1966.
15. DE JONG, R. N. Central nervous system complications in subacute bacterial endocarditis J Nerv. e Ment. Dis. 85:397, 1937.
16. DILLON, J. C.; FEINGENBAUM H.; KONECKE, L. L et al. Echocardiographic manifestations of valvular vegetations Am. Heart. J., 86:698, 1973.
17. DOHERTY, W. B.; TRUBEK, M. Significant hemorrhagic retinal lesions in bacterial endocarditis (Roth's spots) - JAMA, 97:308, 1931.
18. DOWLING, H. F.; LEPPER, M.; CALDWELL, E. R. and SPIES, H. W. - Staphilococcal endocarditis: an analysis of 25 cases treated with antibiotics Medicine, 31:155, 1952.
19. FETTERMAN, J. L. and ASHE, W. F. - Cerebral debut of certain cases of cardiac disease OHIO M. J., 34: 1354, 1938.
20. FRIEDBERG, C. K. Subacute bacterial endocarditis: revision of diagnostic criteria and therapy JAMA, 144: 527,1950.
21. FRIEDBERG, C. K.; GOLDMAN, H. M.; FIELD, L. E. Study of bacterial endocarditis: comparisons in ninety- five cases Arch. Inter. Med. (Chicago) - 107:6, 1961.
22. GATES, E. M.; KERNOHAN, J. W.; CRAIC, W. M. Metastatic brain abscess Medicine (Balt.), 29:71, 1950.
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Datas de Publicação

Publicação nesta coleção
10 Jun 2013
Data do Fascículo
Dez 1980

Histórico

Aceito
10 Mar 1978
Recebido
10 Mar 1978

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[1] 1. ALAJOUANINE, T.; CASTALIGNE, P.; LHERMITTE, F.; CAMBIER, J. - The cerebral arteritis of bacterial endocarditis: its late complications (Abstract) JAMA, 170: 1858, 1959.

[2] 2. ANTEL, J. J.; ROME, H. P.; GERACI, J. E.; SAYRE, G. P. Toxic-organic psychosis as a presenting feature in bacterial endocarditis Proc. Mayo Clin. 30:45, 1955.

[3] 3. AUSTRIAN, R. Pneumococcal endocarditis, meningits and rupture of the aortic valve - Arch. Inst. Med., 99: 539, 1957.

[4] 4. BADEMOSI, C.; FALASE, A. O.; JAIYESIMI, F. and BADEMOSI, A. - Neuropsychiatric manifestations of infective endocarditis: a study of 95 patients at Ibadan, Nigéria - J. of Neur., Neuros. and Psychiat., 39:325, 1976.

[5] 5. BAWA, Y. S. and WAHI, P. L. - Subacute bacterial endocarditis: meningeal complications Texas Med., 57:159, 1961.

[6] 6. BELL, W. E. and BUTLER C. - Cerebral mycotic anerisms in children Neurology, 18:81, 1968.

[7] 7. BERGEN, S. S. and DERMKSIAN, G. - Meningeal manifestations of subacute bacterial endocarditis N. Y. State J. Med., 57:3683, 1957.

[8] 8. BRUETSCH, W. L. The histopathology of the psychoses with subacute bacterial and chronic verrucose rheumatic endocarditis Am. J. Psychiat., 95:335, 1938.

[9] 9. CANTU, R. C.; LE MAY, M. and WILINSON, H. A. The importance of repeated angiography in the treatment of mycotic-embolic intracranial aneurisms J. Neurosurg., 25:189, 1966.

[10] 10. CARPENTER, R. R.; PETERSDORF, R. G. The clinical spectrum of bacterial meningitis Am. J. Med., 33:262, 1962.

[11] 11. CATES, J. E. and CHRISTIE, R. V. Subacute bacterial endocarditie. A review of 442 patients - Q. J. Med., 20:93, 1951.

[12] 12. CLAUDE, H. and OURY, P. - Les accidents nerveux de l'endocardite maligne prolongueé Rev. de Méd., 39: 449, 1922.

[13] 13. Clinicopathologic conference: A case of staphilococcal septicaemia with endocarditis and cerebral abscess demonstrated at the Royal Postgraduate Medical School., Brits. Med. J., 479:482, 1967.

[14] 14. COOPER, E. S.; COOPER, J. W.; SHNABEL, T. G. Pitfalls in the diagnosis of bacterial endocarditis - Arch. Ind. Med., 118:55, 1966.

[15] 15. DE JONG, R. N. Central nervous system complications in subacute bacterial endocarditis J Nerv. e Ment. Dis. 85:397, 1937.

[16] 16. DILLON, J. C.; FEINGENBAUM H.; KONECKE, L. L et al. Echocardiographic manifestations of valvular vegetations Am. Heart. J., 86:698, 1973.

[17] 17. DOHERTY, W. B.; TRUBEK, M. Significant hemorrhagic retinal lesions in bacterial endocarditis (Roth's spots) - JAMA, 97:308, 1931.

[18] 18. DOWLING, H. F.; LEPPER, M.; CALDWELL, E. R. and SPIES, H. W. - Staphilococcal endocarditis: an analysis of 25 cases treated with antibiotics Medicine, 31:155, 1952.

[19] 19. FETTERMAN, J. L. and ASHE, W. F. - Cerebral debut of certain cases of cardiac disease OHIO M. J., 34: 1354, 1938.

[20] 20. FRIEDBERG, C. K. Subacute bacterial endocarditis: revision of diagnostic criteria and therapy JAMA, 144: 527,1950.

[21] 21. FRIEDBERG, C. K.; GOLDMAN, H. M.; FIELD, L. E. Study of bacterial endocarditis: comparisons in ninety- five cases Arch. Inter. Med. (Chicago) - 107:6, 1961.

[22] 22. GATES, E. M.; KERNOHAN, J. W.; CRAIC, W. M. Metastatic brain abscess Medicine (Balt.), 29:71, 1950.

[23] 23. HARRIS, G. A. Subacute bacterial endocarditis presenting with meningitis -Brit. Med. J., 2:1530, 1965.

[24] 24. HARRISON, M. J. G. and HAMPTON, J. R. Neurological presentation of bacterial endocarditis Nr. Med. J., 2:148, 1967.

[25] 25. JONES, H. R.; SIEKERT, R. G. and GERACI, J. E. Neurologic manifestations of bacterial endocarditis Ann. Int. Med. 71:21, 1969.

[26] 26. KAYE, D. Infective endocarditis University Park Press, 1976.

[27] 27. KERNOHAM, J. W.; WOLTMAN, H. W. and BARNES, A. R. Involvement of the nervous system associated with endocarditis Arch. Neurol. e Psychiat., 42:789, 1939.

[28] 28. KERR, A. Jr. Subacute bacterial endocarditis Springfield III, 1955. Charles C. Thomas.

[29] 29. KRINSKI, C. M. and MERRIT H. H. - Neurological manifestations of subacute bacterial endocarditis New Enql.J. Med., 218:563, 1938.

[30] 30. LAHOZ, H.; ASIM, M.; CORRAL, R. DEL; MENES, B. Complicaciones neurologicas de la endocarditis bacterianas Rev. Clin. Esp., 122:327, 1971.

[31] 31. LERNER, P. I. and WE INSTE IN L. - Infective endocarditis in the antibiotic era N. Engl. J Med., 274: 259, 1966.

[32] 32. L1BMAN, E. and FRIEDBERG, C. K. - Subacute bacterial endocarditis,, 2.a ed. New York, 1948, Oxford University Press.

[33] 33. LUPI, E.; HORWITZ S.; PAREDES, A.; ARROYO, L. S.; CONTRERAS, R. Transtornos Neurológicos de la endocarditis bacteriana Arch. Inst. Cardiol. Mex., 43:558, 1973.

[34] 34. MEAD, R. H. Staphylococcal bacteriana and endocarditis Circulation, 19:440, 1959.

[35] 35. MITCHELL, N. and ANGRIST, A. - Intracranial aneurysms: 3 report of thirtysix cases Ann. Int. Med. 19: 909,1943.

[36] 36. Mc DONALD, C. A. and KORB, M - Intracranial aneurysms Arch. Neur. e Psychiat., 42:298, 1939.

[37] 37. MORGAN, W. L. and BLAND, E. F - Bacterial endocarditis in the antibiotic era Circulation, 19:753, 1959.

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