炎症病例讨论.docx

炎症病例讨论.docx

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炎症病例讨论

Case29-2010:

A29-Year-OldWomanwithFeverandAbdominalPain

PresentationofCase

Dr.VernonA.Rayford（Medicine–Pediatrics）:

A29-year-oldwomanwasadmittedtothehospitalbecauseoffeverandincreasingabdominalpain.

Thepatienthadspasticquadriplegiaduetocerebralpalsybuthadbeeninherusualstateofhealthuntilapproximately2weeksbeforeadmission,whenintermittentfevers,withtemperaturesupto37.7°C,developed.Onedaybeforeadmission,painintheleftflankandleftlowerquadrantdeveloped,andshenotedfoul-smellingurine.Duringthenightbeforeadmission,theoraltemperatureroseto39.1°C,associatedwithnauseaandpaininthechest,bothlegs,andtheabdomen,whichradiatedtotheback,bothflanks,andthemidscapularregion.Shetookibuprofen,andherparentsbroughthertotheemergencydepartmentatthishospitalintheearlyafternoon.

Thepatientratedthepainat8onascaleof1to10,with10indicatingthemostseverepain.Shehadcerebralpalsywithspasticquadriplegia,obesity,iron-deficiencyanemia,polycysticovarysyndromewithirregularmenses,recurrenturinarytractinfections,andnephrolithiasis.Aureteralstenthadbeenplacedtemporarily10yearsearlierbecauseofanobstructingstoneintheleftureter.Shedrankalcoholsociallyanddidnotsmokeoruseillicitdrugs.Shelivedwithherparentsandasiblinginanurbanarea,andshehadrecentlybrokenupwithherboyfriend.Sheusedawheelchairandrequiredassistancecuttingfood.Shefollowedalow-oxalatediet.Shereportednocontactwithsickpersonsandnoexposuretoticks,andshewasnotsexuallyactive.Herfatherandpaternalgrandfatherhaddiabetesmellitus,herfatherhadreactivearthritis（formerlyknownasReiter’ssyndrome）,onegrandfatherhadrelapsingpolychondritis,andtwograndparentshadcoronaryarterydisease.

Onexamination,thepatient,whowasinawheelchair,wasalertandcommunicative.Thetemperaturewas37.5°C,thebloodpressure119/63mmHg,thepulse108beatsperminute,andtheoxygensaturation96%whileshewasbreathingambientair.Therewasmildtendernessofthesternum,whichwasreproducedwithdeepinspirations,andtendernessoftheleftcostovertebralangle.Theabdomenwassoftandtendertopalpationontheleftside,withthemostseveretendernessintheleftlowerquadrant;therewasnoreboundorguarding.Radialpulseswere2+.Theremainderoftheexaminationwasconsistentwithspasticquadriplegia.

Theplateletcountandlevelsofserumelectrolytes,glucose,calcium,phosphorus,magnesium,totalprotein,albumin,globulin,amylase,andlipasewerenormal,asweretestsofrenalfunction;othertestresultsareshowninTable1.Reviewoftheperipheralbloodsmearrevealedanisocytosis红细胞大小不均（2+）,polychromatocytosis多染细胞增多症（1+）,hypochromatocytosis色素过少性血细胞增多症（2+）,andmicrocytosis小红细胞症（3+）.Urinalysisrevealedclearamber琥珀色urinewithaspecificgravityof1.025,apHof6.0,2+bilirubin,1+protein,andtraceamountsofketonesandurobilinogen;aculturewassterile.

Whilethepatientwasintheemergencydepartment,narcoticanalgesiawasadministeredintravenously,andherpaindecreasedtoascoreof7outof10.Eighthoursafterarrival,thepatientvomitedonce;ondansetronwasadministered.Computedtomography（CT）oftheabdomenwasperformedaftertheoralandintravenousadministrationofcontrastmaterial,butitwascomplicatedbyextravasationofthecontrastmaterialattheintravenoussiteintherightarm.Thestudyshowedmalrotationoftheleftextrarenalpelvis,multiplecorticaldefectsintheleftkidneythatwereconsistentwithscarring,andaurinarycatheterintheurethra.Thespleenwasmildlyenlarged（14.8cminthecraniocaudaldimension;upperlimitofthenormalrange,12to13）.Therewereprominentperiportal,mesenteric,inguinal,andretroperitoneallymphnodes,upto1.4cmindiameter,withtracefreefluidinthepelvis.Thepatientwasadmittedtothehospitalearlythenextmorning.

Onthedayofadmission,thetemperaturewas38.1°C.Thepain（ratedas8outof10）persisted,andnarcoticanalgesiawasadministeredintravenously.Nauseaandvomitingrecurredbutlessenedaftertheadministrationofprochlorperazine丙氯拉嗪（中枢神经系统药物）.Treatmentwithdalteparinsodium达肝素钠（抗凝血药）wasbegun.Arepeatcultureoftheurinegrewraremixedbacteria.Thechestradiographshowedlowlungvolumesandnoopacities混浊thatweresuggestiveofpneumonia.Thenextday,ultrasonographyofthekidneysandthevenoussystemofthelowerextremitieswasnormal,withnoevidenceofhydronephrosisordeepvenousthrombosis.

Duringthethird,fourth,andfifthhospitaldays,theserumiron-bindingcapacityandlevelsofiron,ferritin铁蛋白,folate,andvitaminB12werenormal;otherlaboratory-testresultsareshowninTable1.Onthethirdday,thetemperatureroseto38.5°C.Urinalysisrevealedleukocytes（>100whitecellsperhigh-powerfield）,andaurineculturegrewProteusmirabilis奇异变形杆菌andEscherichiacoli;bloodculturesremainedsterile.Ciprofloxacin环丙沙星wasadministered.Thenextday,acherry-redrashdevelopedonthepatient’sfeetandresolvedspontaneouslyafterseveralhours.Ultrasonographyoftheabdomenwasnormal.Low-gradefeversoccurredintermittentlythereafter,andsevereabdominalpain（8outof10）persisted;itwasgreatestintheleftupperquadrant,withradiationtotheleftflank,andwasassociatedwithnauseaandintermittentvomiting.

Onthefifthday,testingforantibodiestoBorreliaburgdorferi伯氏疏螺旋体,cytomegalovirus（CMV）,andhepatitisBandCviruseswasnegative,asweretestsforantinuclearantibody,CMVantigenemia抗原血症,andheterophileantibody;othertestresultsareshowninTable1.ACTscanoftheabdomen,aftertheintravenousadministrationofcontrastmaterial,showedpersistentmildsplenomegalywithperipheralwedge-shapedareasofhypoattenuation低衰减thatwereconsistentwithinfarcts;otherfindingswereunchangedfromtheCTperformedonadmission.

Testsformalariaandantibodiestothehumanimmunodeficiencyvirus（HIV）andheparin–plateletfactor4werenegative,aswerenucleicacidtestingforehrlichia,Coombs’directantibodytest,cold-agglutininscreening,andtestingforlupusanticoagulant;hemoglobinelectrophoresis血红蛋白电泳andlevelsoffibrinogen,homocysteine高半胱氨酸,lipoprotein（a）,β2-glycoproteinI,antithrombinIII,andproteinC（functional）werenormal.OthertestresultsareshowninTable1.Bloodculturesremainedsterile.Transthoracicechocardiographywasnormal,withnoevidenceofvalvularvegetations.

Onthe10thday,diagnostictestresultswerereceived.

DifferentialDiagnosis鉴别诊断

Dr.DanielP.Hunt:

Iamawareofthediagnosis.Mydifferentialdiagnosiswillfocusoncluesearlyinthecourseofthispatient’sillnessthatmightleadtoanearlypresumptivediagnosisthatcouldbeefficientlyconfirmedwithminimallaboratorytesting.

Twoweeksbeforeadmission,feverdevelopedinthispatient,withnootherreportedsymptoms.Itwouldbeessentialfortheadmittingphysiciantoexploresymptomsthatmightlocalizeasourceforthefever.Specifically,weshouldbesurethatshehadnotnotedsymptomsofrespiratoryorurinaryinfection.Inviewofthehistoryofrecurrenturinarytractinfections,weshouldalsobesurethatshehadnotinitiatedtreatmentwithantibioticsbeforeshepresentedatthehospital.Afterthissmolderingillness,shehadarelativelysuddenonsetofacuteabdominalpain,flankpain,andfoul-smellingurine.Theinitialexaminationrevealedfever,mildtachycardia,tendernessofthesternum胸骨andleftcostovertebralangle,andleftsidedabdominaltenderness,particularlyintheleftlowerquadrant.

Abdominalpain腹痛分析

位置含义：

Inpatientspresentingtoanoutpatientclinicwithanewonsetofabdominalpain,thelocationofthepainmayormaynotbepredictiveoftheunderlyingpathologicfeatures.Inonestudy,sensitivitywashighforpainintheepigastricregion上腹部,indicatinggastroduodenalprocesses;forrightsubcostal肋骨下的pain,indicatinghepatobiliarydiseases;andformid-to-lowerabdominalpain,indicatinggynecologic妇科学的diseasesamongwomen.Thisstudysuggeststhatweprobablyshouldnotfocusourdifferentialdiagnosisonorgansintheleftlowerquadranttotheexclusionofotherabdominalorgans.

可能诊断：

However,weneedtostartsomewhere,sowewillbeginwiththemostlikelycausesofpainintheleftlowerquadrant左下象限,左下腹部inayoungwoman:

salpingitis输卵管炎,ectopicpregnancy,irritablebowelsyndrome,inflammatoryboweldisease,inguinalhernia腹股沟疝,nephrolithiasis肾结石,anddiverticulitis憩室炎.Themedicalhistoryindicatesthatthepatientisnotsexuallyactive,makingsalpingitisandectopicpregnancyunlikely.Theabsenceofclinicallysignificantbowelsymptomslessens减少thelikelihoodofirritablebowelsyndromeorinflammatoryboweldisease.Aninguinalherniawouldhavetobeincarcerated箝闭的,狭窄的togeneratethedescribeddegreeofpain,andthisshouldhavebeenevidentonexamination.Weareleftwithdiverticulitisandnephrolithiasis,anddiverticulitisislesslikelythannephrolithiasisinarelativelyyoungwoman.

Thepresenceoffever,tendernessintheleftcostovertebralangle,andleft-sidedabdominaltenderness腹部压痛,particularlyintheleftlowerquadrant,suggestsarecurrentureteralstonewithassociatedpyelonephritis肾盂肾炎,particularlyinviewofthepatient’shistory.Itwouldbehelpfultoknowwhetherthepainwascolicky疝气痛的,asithadbeenduringherpreviousepisodes发作ofnephrolithiasis,andwhetherithadbeenpresentinalesserdegreeduringher2-weekillness.Akidneystonewithpyelonephritis肾盂肾炎isunlikelybecauseofthenormalwhite-cellcountandtheabsenceofdysuria排尿困难.Theresultsoftheinitialurinalysis尿分