Partie 2: Phénomènes cliniques

Infections et thromboses

Fortbildung
Édition
2021/05
DOI:
https://doi.org/10.4414/phc-f.2021.10366
Prim Hosp Care Med Int Gen. 2021;21(05):161-165

Affiliations
a Medizinische Universitätsklinik, Infektiologie und Spitalhygiene, Kantonsspital Baselland, Bruderholz, Universität Basel; b Medizinische Universitätsklinik, Notfallzentrum, Kantonsspital Baselland, Bruderholz, Universität Basel; c Medizinische Universitätsklinik, Kardiologie, Kantonsspital Baselland, Bruderholz, Universität Basel; d FMH Innere Medizin, Allschwil BL; e FMH Innere Medizin, Medix toujours, Basel; f Service de Médecine interne générale et Service d’Angiologie, Hôpital Fribourgeois; g Medizinische Universitätsklinik, Klinik für Angiologie, Universitätsspital Basel, Universität Basel; h Medizinische Universitätsklinik, Klinik für Hämatologie, Universitätsspital Basel, Universität Basel; i Universitätsklinik für Allgemeine Innere Medizin, Inselspital, ­Universitätsspital Bern, Universität Bern; j Interdisziplinäre Notfallstation, Universitätsspital Basel, Universität Basel

Publié le 04.05.2021

La relation complexe entre infections et thromboses s’observe dans divers phénomènes captivants dans la pratique clinique quotidienne. Les infections peuvent également provoquer des thromboses artérielles: par exemple, environ un.e patient.e sur 12 atteint.e d’une pneumonie à pneumocoques souffre également d’un infarctus du myocarde. Nous présentons des conseils pratiques concernant les relations pathophysiologiques, le diagnostic différentiel parfois complexe de l’infection et de la thrombose et l’indication de l’anticoagulation.

Série Infectiologie

Dans la pratique, les infections et les défenses immu­nitaires sont des thèmes centraux. Ils offrent d’ex­cellentes opportunités de ­collaboration interdisciplinaire, de vérification de concepts courants et d’intégration de méthodes des médecines complémentaires. Philip Tarr est interniste et infectiologue à ­l’hôpital cantonal de Bâle-­Campagne, et il mène un programme national de recherche PNR 74 sur le scepticisme vis-à-vis des vaccins. Il attache beaucoup d’importance à une médecine centrée sur les patients ainsi qu’à des ­articles pertinents pour la pratique, que nous allons publier régulièrement dans cette série du Primary and Hospital Care.

Infections et thromboses artérielles

Les infections provoquent-elles aussi des thromboses artérielles?

Oui, la pneumonie est associée à un risque accru de syndrome coronarien aigu (SCA) [10, 190, 217–220]. Par exemple, environ 7–8% des patients atteints d’une pneumonie à pneumocoques présentent un SCA concomitant [205, 221]. Ces événements cardiaques passent souvent inaperçus et sont associés à une mortalité élevée [205]. Le risque de SCA accroît proportionnellement à la sévérité de la pneumonie et reste augmenté pendant des semaines ou des mois, même en cas d’évolution clinique favorable [190]. En outre, une prévalence accrue de SCA a été constatée en cas de grippe, d’infection urinaire et de bactériémie [222–228].

Comment une infection peut-elle provoquer un infarctus du myocarde?

Les médiateurs inflammatoires peuvent favoriser l’instabilité des plaques athéromateuses. Les granulocytes neutrophiles circulants, une fibrinolyse insuffisante, un dysfonctionnement du système de coagulation et une augmentation de l’activité plaquettaire pendant l’infection peuvent favoriser la formation de thrombus coronaires et donc l’infarctus du myocarde classique (type 1) [218, 227, 229]. Le stress, dû à la fièvre et à l’inflammation, augmente la demande métabolique des organes. En outre, une hypotension, une tachycardie ou une hypoxémie peuvent être présentes en cas d’infection. Tous ces facteurs peuvent entraîner une diminution de l’apport en oxygène et une augmentation de la demande en oxygène du myocarde. Cette divergence favorise l’infarctus du myocarde de type 2 [190, 205]. Les infections, en particulier la pneumonie à pneumocoques, peuvent déclencher une fibrillation auriculaire dans environ 5 % des cas, ce qui, en raison d’une éventuelle tachycardie avec raccourcissement consécutif de la durée diastolique, peut compromettre l’apport en oxygène du myocarde et entraîner un infarctus du myocarde de type 2 [190, 205, 220, 221, 230, 231].

Pourquoi une nouvelle fibrillation auriculaire (FA) peut-elle survenir lors d’une infection?

La cause semble être une dilatation préalable de l’oreillette suivie d’un déclenchement de la FA suite au sepsis [232]. Les raisons d’un atrium «malade» peuvent être des conditions cardiovasculaires préexistantes telles que l’hypertension ou le diabète, qui conduisent progressivement à un remodelage de l’atrium avec une activation des fibroblastes et une augmentation de la fibrose et de la dilatation atriale [233–235]. Ces facteurs, associés à des modifications du volume sanguin, peuvent favoriser la dilatation de l’oreillette [232, 236–238]. La libération de différentes cytokines peut conduire à un état inflammatoire, lequel semble être en partie responsable de la FA et donc de l’aggravation de la fonction cardiaque [239–242]. D’autres éléments déclencheurs liés à l’infection, tels que les troubles électrolytiques (par exemple l’hypokaliémie, l’hypomagnésémie), les modifications de l’activité nerveuse parasympathique ou sympathique, le dysfonctionnement d’organes ou l’administration de vasopresseurs peuvent contribuer à l’apparation d’une FA [231, 232, 236, 243].

Comment se développe une thromboembolie en cas de FA?

La FA peut affecter les trois mécanismes de la triade de Virchow [244]. Par manque de contraction auriculaire synchronisée, une stase sanguine peut se former, en particulier dans l’auricule de l’oreillette gauche, qui est aggravée par la dilatation auriculaire souvent concomitante [244–246]. D’autre part, la FA semble endommager indirectement l’endothélium, entraînant des modifications fibrineuses et œdémateuses dans le tissu auriculaire et des modifications myocytaires avec en conséquence des propriétés électrophysiologiques modifiées [244–246]. Ces changements pourraient faire évoluer la composition du sang vers un état procoagulant, par exemple en augmentant le facteur von Willebrand (vWF) et l’activité plaquettaire [244–246]. Cela pourrait expliquer en partie pourquoi la FA paroxysmale peut également être associée à un risque accru de thromboembolie.

Ma patiente qui présente un bref épisode de FA asymptomatique documenté lors d’une pneumonie à pneumocoques doit-il prendre une anticoagulation orale à vie?

Il n’existe actuellement aucune recommandation explicite à ce sujet. En effet, l’existence d’une FA «secondaire» est très disputée [247, 248]. Les recommandations de l’ESC et de l’AHA (sociétés de cardiologie européenne et américaine, respectivement) recommandent généralement une anticoagulation à vie pour les hommes et les femmes ayant un score CHA2DS2-VASc de 1 ou 2 points en présence d’une FA [249, 250]. Cette directive est en contradiction avec l’expérience clinique qui montre que la FA déclenchée par une ­infection transitoire disparaît avec le traitement de l’infection. Il semble exister une prédisposition à la FA (voir ci-dessus): chaque infection pourrait donc ­entraîner une récidive de la FA, qui peut rester ­asymptomatique, et augmenter le risque d’AVC [243, 251, 252]. De plus, plusieurs études on démontré que le risque d’embolie reste comparable, que la FA soit ­paroxysmale ou permanente et qu’elle soit déclenchée ou non par une infection. En conclusion, la FA semble être un marqueur d’une oreillette «malade», qui augmente le risque de thromboembolie et rend donc ­l’anticoagulation raisonnable, quel que soit le facteur déclencheur.

Thrombose septique

Quelle est la définition de la thrombose septique et quand dois-je y penser?

La combinaison rare d’une thrombose avec des hémocultures positives correspond en principe à une thrombose septique également appelée thrombophlébite suppurée [88, 90, 93, 204, 253–255]. Cependant, ce terme est controversé car il peut suggérer que la thrombose est la cause de la septicémie. En présence d’une thrombose associée à une bactériémie, la thrombose n’est pas nécessairement considérée comme le foyer primaire de l’infection – ce qui soulève la question du facteur déclencheur et de la conséquence. Le/La médecin expérimenté doit y penser si la fièvre persiste malgré 72 heures d’antibiothérapie[88] ou si les hémocultures restent positives sans autre foyer infectieux endovasculaire tel qu’une endocardite [204].

Ma patiente a un accès veineux périphérique, un «venflon». Une rougeur douloureuse et un gonflement, c’est-à-dire une phlébite, sont maintenant apparus au point d’injection. Est-ce une thrombose septique?

Non, une phlébite d’une veine périphérique n’entraîne que très rarement une bactériémie ou une thrombose septique. Diverses études indiquent une fréquence de 0,2–2% [204, 256, 257]. Cette affection peut être traitée par des mesures topiques telles que le gel d’héparine ou de diclofénac ou, sauf contre-indications, par des AINS. L’anticoagulation n’est pas recommandée [16].

Comment se développe une thrombose ­septique?

La thrombose septique est fréquemment associée à l’utilisation de drogues par voie intraveineuse [92, 253, 258–261] ou de cathéters intravasculaires [88, 90, 98, 262]. L’agent pathogène le plus fréquent est Staphylococcus aureus [92, 93, 261, 263]. Dans les veines centrales et celles des extrémités, ces thromboses sont généralement facilement mises en évidence par une échographie duplex [88, 92, 98]. Les thromboses septiques survenues en l’absence de cathéter veineux ni utilisation de drogues par voie intraveineuse sont rares. Il s’agit principalement d’infections non-vasculaires qui entraînent une thrombose des veines locales [115], par exemple une diverticulite suivie d’une pyléphlébite (thrombose de la veine porte ou de ses veines afférentes) ou une sinusite suivie d’une thrombose septique de la veine sinusale [115], 118, 264–267] (Encadré 4). Ce genre de thrombus, en revanche, n’est pas toujours facile à identifier par échographie, CT-scan ou IRM – il est préférable de discuter au préalable du diagnostic différentiel avec le/la radiologue [92, 115, 118, 264, 267–269].
Encadré 4: Thromboses septiques – où se trouvent-elles?
Illustration: © Randy DuBurke, Binningen BL, randyduburke.com

Pourquoi est-il important de savoir s’il y a «seulement» une bactériémie ou également une thrombose septique?

Les bactériémies avec preuve de thrombose sont considérées comme plus difficiles à traiter [90, 98, 100, 204]. La durée recommandée de l’antibiothérapie est plus longue que pour une bactériémie sans thrombus. En cas de thrombose septique associée à un cathéter veineux central ou en présence d’une endocardite [88, 204], une durée de 4 à 6 semaines est recommandée. En revanche, une simple bactériémie à S. aureus sans thrombose septique ni endocardite peut être traitée par un antibiotique intraveineux pendant 14 jours dans le meilleur des cas [93, 100, 204, 270].

Quelle est la relation entre l’endocardite et les embolies septiques?

Les embolies septiques sont des complications redoutées de l’endocardite [89, 271–275]. En cas de bactériémie ou de fièvre dont le foyer n’est pas clair, il faut envisager une endocardite. L’agent causal le plus courant de l’endocardite est également S. aureus [89, 271, 273]. Les abcès cérébraux emboliques septiques [276], les «anévrismes mycotiques» [275, 277] et les abcès extracardiaques, par exemple dans la rate ou les reins, sont des séquelles connues d’embolies septiques provenant des valves cardiaques [272, 275, 278, 279].

Quand faut-il penser à une thrombose septique chez un utilisateur de drogues par voie intraveineuse?

Une thrombose septique doit être envisagée si le.a patient.e présente des abcès locaux en plus de la fièvre, en particulier s’il y a un gonflement du bras ou de la jambe et des hémocultures positives [92, 261]. L’administration de drogues avec une technique d’injection inadéquate augmente le risque de thromboembolie veineuse (TEV) de plusieurs façons, par exemple, par une inflammation locale, des lésions tissulaires et endothéliales [280], ou l’introduction de bactéries et autres matières contaminantes [258, 261]. Les veines déjà oblitérées et l’immobilisation liée à la maladie favorisent encore plus la stase veineuse [92]. Lorsque l’état veineux s’aggrave, le consommateur se tourne souvent vers les veines proximales, plus grosses, ce qui favorise les thromboses et embolies septiques, notamment dans les poumons [92, 259, 261].

Mon patient consomme des drogues par voie intraveineuse et a de la fièvre. Que dois-je faire?

Ces patients présentent souvent une pneumonie, un abcès au point d’injection, une bactériémie ou une endocardite [92, 258, 259]. Il est recommandé de réaliser une radiographie du thorax, des hémocultures [58, 62] et d’envisager une hospitalisation pour une antibiothérapie intraveineuse visant à traiter S. aureus [255], par exemple amoxicilline-acide clavulanique. En cas de gonflement des extrémités ou de fièvre persistante, la présence d’une thrombose septique doit être envisagée et un diagnostic échographique est recommandé [88, 92, 261, 281, 282].

Quel est le meilleur traitement pour une thrombose septique?

La thrombose septique est traitée par une antibiothérapie empirique intraveineuse initiée rapidement [90, 115]. Il faut viser une durée de traitement de 4 à 6 semaines. Après 2 à 3 semaines d’administration intraveineuse, le passage à une antibiothérapie orale peut être envisagé [88, 92, 93, 204]. Il est important de pondérer entre les avantages d‘une administration intraveineuse en matière d’observance thérapeutique et le risque d’utilisation abusive d’un cathéter intraveineux pour l’injection de drogues [93].

Quel est le rôle de l’anticoagulation dans le traitement de la thrombose septique?

Le nombre d’études à ce sujet est faible [98, 204, 253]. Le risque d’embolie septique suite à une anticoagulation nouvellement établie, pouvant conduire à une embolie pulmonaire septique, a été discuté[92]. L’anticoagulation est recommandée principalement pour des localisations spécifiques et rares (encadré 4) et uniquement en cas d’absence de réponse au traitement antibiotique [260, 269, 285], c’est-à-dire en cas de persistance de la fièvre après 4-5 jours d’ une antibiothérapie appropriée [253].
En cas de thrombose septique associée à un cathéter, une anticoagulation pendant au moins 6–12 semaines est recommandée [88, 90, 253], selon si le cathéter peut être retiré ou non [88, 204, 286] – voir également les recommandations américaines [16]. Une anticoagulation pendant au moins 3 mois est également recommandée en cas de thrombose avérée associée à l’utilisation de drogues par voie intraveineuse [92, 259].
La gestion de l’anticoagulation en cas d’endocardite est un challenge et les études sont controversées, notamment en ce qui concerne les deux risques concurrents d’embolie septique et d’hémorragie intracérébrale. Certains experts déconseillent l’anticoagulation en raison de la possibilité d’embolies septiques cérébrales avec transformation hémorragique secondaire potentielle. Enfin, le bénéfice et le risque de l’anticoagulation en cas d’endocardite dépendent de nombreux facteurs différents (par exemple: présence d’une valve mécanique, infarctus ischémique du SNC avec ou sans hémorragie intracérébrale, presence ou absence de S. aureus, risque hémorragique spécifique au patient) et doivent être discutés individuellement pour chaque patient [271, 275, 276, 284, 288, 289].

La thrombose septique peut-elle aussi être traitée chirurgicalement?

En principe, oui, car la veine concernée pourrait être excidée chirurgicalement avec le thrombus [255]. Cependant, une telle procédure est une rareté absolue et, selon les recommandations, ne devrait être envisagée que si des veines superficielles sont impliquées, si l’inflammation s’étend aux tissus environnants ou si l’antibiothérapie a échoué [204, 253, 254, 290].

Erysipèle et thrombose

Quelle est la probabilité qu’un.e patient.e attaint.e d’un érysipèle développe simultanément une thrombose veineuse profonde (TVP)?

Selon de grandes études à ce sujet, le risque est de 2 à 3%; une seule étude parle d’environ 15% [291–295]. Cela signifie que la TVP ne se produit simultanément que chez environ un.e patient.e sur 30 à 50 atteints d’un érysipèle.

Pourquoi la distinction entre l’érysipèle et la TVP n’est-elle pas toujours facile dans la pratique clinique?

La présentation clinique de l’érysipèle et de la TVP est très similaire avec une rougeur locale et un gonflement ou une induration, généralement au niveau du membre inférieur [291, 292, 296]. La fièvre et l’élévation de la CRP ou des leucocytes sont également peu utiles pour distinguer l’érysipèle de la TVP [292, 297, 298].

Cette incertitude diagnostique s’applique-t-elle également à la pneumonie et à l’embolie pulmonaire?

Oui, la présentation clinique peut être similaire. La douleur thoracique et la dyspnée sont bien sûr plus évocatrices d’une embolie pulmonaire, tandis que la toux et la fièvre sont les principaux symptômes d’une pneumonie [299, 300]. Cependant, une élévation des D-dimères et une douleur pleurétique sont également observées en cas de pneumonie [301, 302]. La pneumonie est le diagnostic alternatif le plus fréquent en cas d’embolie pulmonaire non confirmée [212, 299, 303–305]. S’il n’y a pas d’amélioration clinique rapide de la pneumonie suspectée avec une antibiothérapie adaptée au profil de résistance, ou si une dyspnée et une hypoxie apparaissent également, la présence d›une embolie pulmonaire doit être envisagée.

La douleur est-elle un symptôme utile pour différencier l’érysipèle de la TVP?

Non [306, 307]. Le symptôme clinique le plus important qui tend à indiquer une thrombose est une augmentation de la circonférence du membre affecté [281, 282, 292, 308].

Chez quels patients souffrant d’un érysipèle dois-je réaliser une échographie duplex?

L’échographie duplex n’est pas réalisée systématiquement chez tous les patients, mais uniquement en présence de facteurs de risque de TEV [291, 292, 296, 308]. Une indication existe notamment en cas d’antécédents de TEV, d’hypercoagulabilité génétiquement déterminée [292] ou en cas d’absence de réponse à l’antibiothérapie [308].

Le score de Wells et les D-dimères m’aideront-ils à décider si ma patiente atteinte d’érysipèle a besoin d’une échographie duplex?

Ce n’est pas clair. En cas d’érysipèle, le score de Wells peut surestimer le risque de TVP [291, 292]. Les D-dimères sont souvent élevés en cas d’infection et n’ont pas de valeur prédictive [293, 294, 310, 311]. Les facteurs de risque de TEV et le gonflement des membres sont les critères les plus importants pour réaliser une échographie duplex en cas de suspicion de TVP ou un CT-scan en cas de suspicion d’embolie pulmonaire [291, 292, 308].

Points clés pour la pratique

• La pneumonie bactérienne augmente le risque de subir simultanément un infarctus du myocarde.
• Les infections peuvent déclencher une fibrillation auriculaire, qui favorise les accidents vasculaires cérébraux emboliques.
• L’érysipèle et la TVP se présentent souvent de manière similaire sur le plan clinique. Cependant, l’érysipèle ne s’accompagne d’une TVP chez seulement 2 à 3% des patient.e.s.
• Une thrombose septique, c’est-à-dire une thrombose accompagnée d’hémocultures positives, survient souvent en cas d’utilisation de cathéters veineux centraux ou de consommation de drogues par voie intraveineuse. Le pathogène le plus fréquent est S. aureus.
• La thrombose septique dans les infections non-vasculaires entraînant une thrombose des veines locales, comme le syndrome de Lemierre ou la pyléphlébite, est rare.
Prof. Dr. med. Philip Tarr
Medizinische ­Universitätsklinik
Kantonsspital Baselland
CH-4101 Bruderholz
philip.tarr[at]unibas.ch
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