심실중격결손에의한감염성심내막염환자의치과치료 양정현 현홍근 김영재 김정욱 장기택 이상훈 한세현 김종철 서울대학교치과대학소아치과학교실및치학연구소 국문초록 감염성심내막염은치과치료로부터발생할수있는심각한심장질환합병증이며, 생명을위협하는치명적인상황을초래할수있다. 따라서심내막염예방을위하여위험군에속하는환자에서침습적술식을행하기에앞서예방적항생제를전투여한다. 본증례는영구치근관치료후발생한감염성심내막염을주소로내원한환아로서심실중격결손으로인해예방적항생제를투여했음에도불구하고심내막염이발병하여, 항생제요법후의심되는원인치아를발거하고심장수술을시행하였다. 이에다소의지견을얻었기에보고하는바이다. 주요어 : 감염성심내막염, 예방적항생제, 선천성심장질환 Ⅰ. 서론 감염성심내막염은, 심장의구조적결함이있는사람에게서심내막염을유발하는미생물에의한감염발생시심장판막과심내막등에일어나는염증반응으로정의된다. 원인균으로는 streptococci가가장우세하며, staphylococci, enterococci 순으로자주발견된다 1). 각종기저심장질환에서고속의제트류나좁은구멍을통하는고속의혈류등혈역학의국소적변화가발생하면이러한혈류가닿는부위에혈관내피의손상이발생하게된다. 손상된내피세포에혈소판과섬유소의복합체가부착하면비세균성혈전성심내막염 (nonbacterial thrombotic endocarditis; NBTE) 이형성되며, 이부위가감염성심내막염이시작되는부위이다. NBTE가감염성심내막염으로발전하기위해서는심내막염의원인균이 NBTE에도달하여야하는데, 이를가능하 교신저자 : 김종철 서울특별시종로구연건동 275-1 서울대학교치과대학소아치과학교실 Tel: 02-2072-3819 E-mail: Kimcc@plaza.snu.ac.kr 게하는것이균혈증이다. 균혈증은각종질병이나시술등을통하여발생하며, 구강점막이나치주에손상이생기는시술을할때가장높은빈도로균혈증이발생한다. 본격적인심내막염이발생하기위해서는세균이 NBTE에부착하여증식하여심장내막으로전파및확산되어야한다. 균혈증의세균이 NBTE에부착하는능력은 dextran, fibronectin, glycocalyx 등세균의여러가지요소들에의하여결정된다. 일단세균이부착되어증식하기시작하면증식증 (vegetation) 이생기고세균들은증식증내에서인체면역반응으로부터보호받게된다 2). 감염성심내막염의전신증상으로는발열, 오한, 무력감, 체중감소, 호흡곤란, 피로감등이있고심장소견으로는심잡음, 심부전, 급성심근경색, 심근농양, 진균성동맥류등이있다. 또한근골격계및말초혈관에서는점상출혈, Roth spot, Osler 결절, Janeway 병변, 손톱선상출혈, 곤봉상수지, 근육통, 관절통을보이며, 신경계에서는색전에의해뇌경색이일어날수있다. 미국심장학회 (American Heart Association; AHA) 에서는각종기저심장상태를심내막염위험정도에따라세부류로분류하고, 심내막염에대한항생제예방지침을발표하여예방적항생제의사용에대한기준을제시하였다 (Table 1, 2, 3). 기 461
J Korean Acad Pediatr Dent 34(3) 2007 Table 1. Cardiac conditions associated with endocarditis Endocarditis prophylaxis recommended High-risk category Prosthetic cardiac valves, including bioprosthetic and homograft valves Previous bacterial endocarditis Complex cyanotic congenital heart disease (e.g., single ventricle states, transposition of the great arteries, tetralogy of Fallot) Surgically constructed systemic pulmonary shunts or conduits Moderate-risk category Most other congenital cardiac malformations (other than above and below) Acquired valvar dysfuction (e.g., rheumatic heart disease) Hypertrophic cardiomyopathy Mitral valve prolapse with valvar regurgitation and/or thickened leaflets Endocarditis prophylaxis not recommended Negligible-risk category (no greater than the general population) Isolated secundum atrial septal defect Surgical repair of atrial septal defect, ventricular septal defect or patent ductus arteriosus (without residual beyond 6mos.) Previous coronary artery bypass graft surgery Table 2. Dental procedures and endocarditis prophylaxis Dental procedures and endocarditis prophylaxis recommended Dental extractions Periodontal procedures including surgery, scaling, and root planing, probing and recall maintenance Dental implant placement and reimplantation of avulsed teeth Endodontic(root canal) instrumentation of surgery only beyond the apex Subgingival placement of antibiotic fibers or strips Initial placement of orthodontic bands but not brackets Intraligamentary local anesthetic injection Prophylactic cleaning of teeth or implants where bleeding is anticipated Dental procedures and endocarditis prophylaxis not recommended Restorative dentisty(operative and prosthodontic) with or without retraction cord Local anesthetic injections(nonintraligamentary) Intracanal endodontic treatment; post placement and build up Placement of rubber dams Postoperative suture removal Placement of removable prosthodontic or orthodontic appliance Taking of oral impressions Fluoride treatments Taking of oral radiographs Orthodontic appliance adjustment Shedding of primary teeth 462
본이되는제제는 amoxicillin으로소아의경우 kg당 50mg의 amoxicillin을시술한시간전에경구투여하도록추천하였다 3). 본증례는선천선심실중격결손으로정기적검사를받고있는환아로서치과치료전예방적항생제를투여했음에도불구하고감염성심내막염이발병하여항생제요법후원인치아를발거하고심장수술을시행하였기에보고하는바이다. Ⅱ. 증례보고 8세 7개월된여아로서구강내통증과전반적치은부종을주소로감염성심내막염의구강내감염원확인을위하여서울대병원소아과에서본원으로의뢰되었다. 의과적병력상환아는출생시부터선천성심실중격결손으로정기적검사를받아오던중 7주전인근병원에서술전한시간에환아의체중에맞추 어 1200mg의 amoxicillin을경구복용한후상악우측제 1유구치를발거하고하악좌측제 1대구치의근관치료를받은경력이있었으며, 사흘뒤부터 acetaminophen에반응하지않는미열과고열이반복되고, 심장초음파상으로 2 2cm의증식증 (vegetation) 이관찰되었으며항생제요법에도불구하고혈액배양결과원인균인 Enterococcus faecalis가지속적으로동정되고있었다. 첫내원당일전반적인치은발적과부종을관찰할수있었고방사선사진상으로치수병변이나깊은치아우식병소는관찰할수없었으며제 1대구치들특히하악좌측제 1대구치의근단이아직미완성상태임을확인할수있었다. 근관충전상태는 underfilling이었다 (Fig. 1, 2). 소아과주치의의계획하에 Enterococcus faecalis에대하여 ampicillin과 gentamycin의복합항생제요법을시작하였고급 Table 3. Drugs for antibiotic prophylaxis(aha 1997 Standard regimen guidelines) Situation Agent Regime Adults : 2.0g Standard general Amoxicillin Children : 50mg / kg prophylaxis orally 1 hour before procedure Adults : 2.0g Unable to take oral Ampicillin Children : 50mg / kg medications IM or IV within 30 minutes before procedure Adults : 600mg Allergic to penicillin Clindamycin Children : 20mg / kg orally 1 hour before procedure Allergic to penicillin Adults : 600mg and unable to take Clindamycin Children : 20mg / kg oral medications IV within 30 minutes before procedure Fig. 1. Initial panoramic view. 463
J Korean Acad Pediatr Dent 34(3) 2007 Fig. 2. Initial periapical view. Fig. 3. Extracted tooth. Fig. 4. Extracted tooth(open apex). Fig. 5. Panoramic view of 6 months after treatment. 성증상이진정된후감염원제거위해원인치아로추정되는하악좌측제 1대구치를발거하였다 (Fig. 3, 4). 그러나항생제요법시작후 2주가경과한뒤심장초음파검사결과잔여증식증 (vegetation remnant) 이 7mm정도관찰되어전신마취하에소 아과에서 vegetectomy와 ventricular septal defect(vsd) patch closure를시행하였다. 이후검진시심내막염의임상증상은나타나지않았으며치과적으로도별다른소견이관찰되지않았다 (Fig. 5, 6). 464
Fig. 6. Intraoral view of 6 months after treatment. Ⅲ. 총괄및고찰상기환아는치료되지않은선천성심장기형으로중등도위험군에속하여 AHA의심내막염예방추천사항을따라 kg당 50mg의 amoxicillin을치과치료한시간전에복용하였다. 3 일의잠복기를갖고심내막염증상을보였는데침습적술식으로인한심내막염은 85% 가술후 2주이내, 90% 가최소 4주이내의짧은잠복기를갖고나타난다 4). 이환자에서발견된 Enterococcus faecalis는통성혐기성그람양성구균으로치은열구에서주로발견된다 5). 근관치료와연관하여서는 secondary, persistent root canal infection 시에발견되는세균으로서근관치료의실패와관련하여주목받는세균이다 6). 비교적항생제에도내성이강하여이세균에대한항생제요법시 penicillin계와 streptomycin, gentamicin 등 aminoglycoside계항생제의복합처방이필요한것으로알려져있다 7). 추천된예방적항생제투여의실패로심내막염이발생시에는주의깊은분석이필요한데, 이때에는원인이됐다고추정되는침습적술식과임상적징후가나타난사이의시간차, 심내막염을일으킨원인미생물, 원인이라고추정되는침습적술식이균혈증을일으켰을가능성, 환자가기저질환의존재와심도를알고있는지의여부와이사실을술전치과의사와상의하였는지여부등을고려해야한다 8). 본증례는잠복기가 3일에불과했고, 심내막염을일으킨원인균이 Enterococcus faecalis로유구치발치와하악영구치근관치료로인하여감염되었을가능성이매우높아치과치료로인하여발병된세균성심내막염으로사료된다. 1980년대초 AHA는심내막염예방이명백히실패한 52증례를분석하여발표하였는데, 52증례중 6증례는 AHA에서지시한항생제예방법을따랐음에도불구하고심내막염이발생한것으로알려졌다. 또이 6증례중 4증례는예방항생제에비교적감수성이있는 Streptococcus에의한것으로밝혀졌다 2). 또한 Dajani 등 8) 은모든세균이예방적항생제에민감할수 없으며사용된항생제가완벽히효과적일수도없으므로심내막염은적절한예방적항생제의사용에도불구하고발생할수있다고언급하였다. 따라서세균성심내막의위험이높은환자의치과치료를마친후심내막염과관련한임상증상들이나타나지않는지주의깊게관찰할필요가있다. 예방적항생제의투여와더불어치과치료전에 chlorhexidine이나 povidone iodine으로양치하는것이심내막염의원인균을감소시킴으로써균혈증의발생빈도와강도를낮출수있으므로추천되고있다 9). 치과치료에앞서 15ml의 chlorhexidine으로약 30초간가볍게양치하면된다 10). 그러나너무짧은간격으로빈번히사용하거나장기간사용할경우구강내정상세균총의변화를유발하여내성균을발생시킬수있으므로주의해야한다 11). Welbury와 Richard 12) 는심내막염위험군환자에서근관치료는매우성공률이높은치아에한해서시행해야한다고하였다. 심혈관계질환이있는환자에서다근치나유구치에행해지는근관치료는금기시되어야한다. 이에따르면곧은근관과완성된근첨을갖는영구전치에한해서단일내원하에근관치료를완료하는것만이적응증이된다. 심내막염위험군환자에서치수감염이나치근단감염등은감염원으로작용하므로되도록치수절단이나근관치료를행하지않고발치를행하며, 출혈문제가있는환자에게는가급적대수술을피하도록한다 13). 본증례는미국심장학회의지침에따라예방적항생제를투여하였으나감염성심내막염이발병한경우로, 미완성근첨을갖는미성숙영구대구치에근관치료를시행함으로써감염성심내막염의발병가능성을높였을가능성이있다. Ⅳ. 요약 1997년미국심장학회에서는선천성심장질환환자의치과시술시감염성심내막염의예방을위한최선의방법을제시하였다. 그러나모든세균이예방적항생제에민감할수없으며사용된항생제가완벽히효과적일수도없으므로심내막염은적절한예방적항생제의사용에도불구하고극히드물지만발생할수있다. 따라서세균성심내막염의위험이높은환자의치과치료전에는 chlorhexidine으로구강내를소독하고치과치료기구를철저히멸균해야하며, 구강내감염원을제거하기위해한단계공격적인치료를진행해야하고, 치과치료를마친후에는심내막염과관련한임상증상들이나타나지않는지주의깊게관찰할필요가있다고생각된다. 참고문헌 1. Tunkel AR, Mandell GL : Infective endocarditis. 2nd ed. Raven Pres, New York, 86, 1992. 2. Barco CT : Prevention of infective endocarditis: a 465
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Abstract INFECTIVE ENDOCARDITIS IN ANTIBIOTICALLY PROTECTED PATIENT WITH VENTRICULAR SEPTAL DEFECT Jung-Hyun Yang, Hong-Keun Hyun, Young-Jae Kim, Jung-Wook Kim, Ki-Taek Jang, Sang-Hoon Lee, Se-Hyun Hahn, Chong-Chul Kim Department of Pediatric Dentistry, College of Dentistry and Dental Research Institute, Seoul National University Infective endocarditis is a life-threatening disease, although it is relatively uncommon. Substantial morbidity and mortality result from this infection. Therefore, primary prevention of endocarditis whenever possible is very important. The American Heart Association updated recommendations for the prevention of infective endocarditis in individuals at risk for this disease in 1997. But, utilization of antibiotic prophylaxis for patients at risk does not provide absolute immunity from infection. This report presents the case of infective endocarditis that occurred in spite of appropriate antibiotic prophylaxis in the ventricular septal defect(vsd) patient. Key words : Infective endocarditis, Prophylactic antibiotics, Congenital heart disease 467