炎症病例讨论.docx

1、炎症病例讨论Case 29-2010: A 29-Year-Old Woman with Fever and Abdominal PainPresentation of CaseDr. Vernon A. Rayford (MedicinePediatrics): A 29-year-old woman was admitted to the hospital because of fever and increasing abdominal pain.The patient had spastic quadriplegia due to cerebral palsy but had been

2、 in her usual state of health until approximately 2 weeks before admission, when intermittent fevers, with temperatures up to 37.7C, developed. One day before admission, pain in the left flank and left lower quadrant developed, and she noted foul-smelling urine. During the night before admission, th

3、e oral temperature rose to 39.1C, associated with nausea and pain in the chest, both legs, and the abdomen, which radiated to the back, both flanks, and the midscapular region. She took ibuprofen, and her parents brought her to the emergency department at this hospital in the early afternoon. The pa

4、tient rated the pain at 8 on a scale of 1 to 10, with 10 indicating the most severe pain. She had cerebral palsy with spastic quadriplegia, obesity, iron-deficiency anemia, polycystic ovary syndrome with irregular menses, recurrent urinary tract infections, and nephrolithiasis. A ureteral stent had

5、been placed temporarily 10 years earlier because of an obstructing stone in the left ureter. She drank alcohol socially and did not smoke or use illicit drugs. She lived with her parents and a sibling in an urban area, and she had recently broken up with her boyfriend. She used a wheelchair and requ

6、ired assistance cutting food. She followed a low-oxalate diet. She reported no contact with sick persons and no exposure to ticks, and she was not sexually active. Her father and paternal grandfather had diabetes mellitus, her father had reactive arthritis (formerly known as Reiters syndrome), one g

7、randfather had relapsing polychondritis, and two grandparents had coronary artery disease. On examination, the patient, who was in a wheelchair, was alert and communicative. The temperature was 37.5C, the blood pressure 119/63 mm Hg, the pulse 108 beats per minute, and the oxygen saturation 96% whil

8、e she was breathing ambient air. There was mild tenderness of the sternum, which was reproduced with deep inspirations, and tenderness of the left costovertebral angle. The abdomen was soft and tender to palpation on the left side, with the most severe tenderness in the left lower quadrant; there wa

9、s no rebound or guarding. Radial pulses were 2+. The remainder of the examination was consistent with spastic quadriplegia.The platelet count and levels of serum electrolytes, glucose, calcium, phosphorus, magnesium, total protein, albumin, globulin, amylase, and lipase were normal, as were tests of

10、 renal function; other test results are shown in Table 1. Review of the peripheral blood smear revealed anisocytosis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+), and microcytosis小红细胞症(3+). Urinalysis revealed clear amber琥珀色urine with a specific gravity of 1.025, a

11、pH of 6.0, 2+ bilirubin, 1+ protein, and trace amounts of ketones and urobilinogen; a culture was sterile.While the patient was in the emergency department, narcotic analgesia was administered intravenously, and her pain decreased to a score of 7 out of 10. Eight hours after arrival, the patient vom

12、ited once; ondansetron was administered. Computed tomography (CT) of the abdomen was performed after the oral and intravenous administration of contrast material, but it was complicated by extravasation of the contrast material at the intravenous site in the right arm. The study showed malrotation o

13、f the left extrarenal pelvis, multiple cortical defects in the left kidney that were consistent with scarring, and a urinary catheter in the urethra. The spleen was mildly enlarged (14.8 cm in the craniocaudal dimension; upper limit of the normal range, 12 to 13). There were prominent periportal, me

14、senteric, inguinal, and retroperitoneal lymph nodes, up to 1.4 cm in diameter, with trace free fluid in the pelvis. The patient was admitted to the hospital early the next morning.On the day of admission, the temperature was 38.1C. The pain (rated as 8 out of 10) persisted, and narcotic analgesia wa

15、s administered intravenously. Nausea and vomiting recurred but lessened after the administration of prochlorperazine丙氯拉嗪（中枢神经系统药物）. Treatment with dalteparin sodium达肝素钠（抗凝血药） was begun. A repeat culture of the urine grew rare mixed bacteria. The chest radiograph showed low lung volumes and no opacit

16、ies混浊that were suggestive of pneumonia. The next day, ultrasonography of the kidneys and the venous system of the lower extremities was normal, with no evidence of hydronephrosis or deep venous thrombosis.During the third, fourth, and fifth hospital days, the serum iron-binding capacity and levels o

17、f iron, ferritin铁蛋白, folate, and vitamin B12 were normal; other laboratory-test results are shown in Table 1. On the third day, the temperature rose to 38.5C. Urinalysis revealed leukocytes (100 white cells per high-power field), and a urine culture grew Proteus mirabilis奇异变形杆菌 and Escherichia coli;

18、 blood cultures remained sterile. Ciprofloxacin环丙沙星was administered. The next day, a cherry-red rash developed on the patients feet and resolved spontaneously after several hours. Ultrasonography of the abdomen was normal. Low-grade fevers occurred intermittently thereafter, and severe abdominal pai

19、n (8 out of 10) persisted; it was greatest in the left upper quadrant, with radiation to the left flank, and was associated with nausea and intermittent vomiting.On the fifth day, testing for antibodies to Borrelia burgdorferi伯氏疏螺旋体, cytomegalovirus (CMV), and hepatitis B and C viruses was negative,

20、 as were tests for antinuclear antibody, CMV antigenemia抗原血症, and heterophile antibody; other test results are shown in Table 1. A CT scan of the abdomen, after the intravenous administration of contrast material, showed persistent mild splenomegaly with peripheral wedge-shaped areas of hypoattenuat

21、ion低衰减 that were consistent with infarcts; other findings were unchanged from the CT performed on admission. Tests for malaria and antibodies to the human immunodeficiency virus (HIV) and heparin platelet factor 4 were negative, as were nucleic acid testing for ehrlichia, Coombs direct antibody test

22、, cold-agglutinin screening, and testing for lupus anticoagulant; hemoglobin electrophoresis 血红蛋白电泳and levels of fibrinogen, homocysteine高半胱氨酸, lipoprotein( a), 2-glycoprotein I, antithrombin III, and protein C (functional) were normal. Other test results are shown in Table 1. Blood cultures remaine

23、d sterile. Transthoracic echocardiography was normal, with no evidence of valvular vegetations.On the 10th day, diagnostic test results were received.Differential Diagnosis鉴别诊断Dr. Daniel P. Hunt: I am aware of the diagnosis. My differential diagnosis will focus on clues early in the course of this p

24、atients illness that might lead to an early presumptive diagnosis that could be efficiently confirmed with minimal laboratory testing.Two weeks before admission, fever developed in this patient, with no other reported symptoms. It would be essential for the admitting physician to explore symptoms th

25、at might localize a source for the fever. Specifically, we should be sure that she had not noted symptoms of respiratory or urinary infection. In view of the history of recurrent urinary tract infections, we should also be sure that she had not initiated treatment with antibiotics before she present

26、ed at the hospital. After this smoldering illness, she had a relatively sudden onset of acute abdominal pain, flank pain, and foul-smelling urine. The initial examination revealed fever, mild tachycardia, tenderness of the sternum胸骨 and left costovertebral angle, and leftsided abdominal tenderness,

27、particularly in the left lower quadrant. Abdominal pain 腹痛分析位置含义：In patients presenting to an outpatient clinic with a new onset of abdominal pain, the location of the pain may or may not be predictive of the underlying pathologic features. In one study, sensitivity was high for pain in the epigastr

28、ic region上腹部, indicating gastroduodenal processes; for right subcostal 肋骨下的pain, indicating hepatobiliary diseases; and for mid-to-lower abdominal pain, indicating gynecologic 妇科学的diseases among women. This study suggests that we probably should not focus our differential diagnosis on organs in the

29、left lower quadrant to the exclusion of other abdominal organs. 可能诊断：However, we need to start somewhere, so we will begin with the most likely causes of pain in the left lower quadrant左下象限,左下腹部 in a young woman: salpingitis输卵管炎, ectopic pregnancy, irritable bowel syndrome, inflammatory bowel diseas

30、e, inguinal hernia腹股沟疝, nephrolithiasis肾结石, and diverticulitis憩室炎. The medical history indicates that the patient is not sexually active, making salpingitis and ectopic pregnancy unlikely. The absence of clinically significant bowel symptoms lessens减少 the likelihood of irritable bowel syndrome or in

31、flammatory bowel disease. An inguinal hernia would have to be incarcerated箝闭的,狭窄的 to generate the described degree of pain, and this should have been evident on examination. We are left with diverticulitis and nephrolithiasis, and diverticulitis is less likely than nephrolithiasis in a relatively yo

32、ung woman. The presence of fever, tenderness in the left costovertebral angle, and left-sided abdominal tenderness腹部压痛, particularly in the left lower quadrant, suggests a recurrent ureteral stone with associated pyelonephritis肾盂肾炎, particularly in view of the patients history. It would be helpful t

33、o know whether the pain was colicky疝气痛的, as it had been during her previous episodes发作 of nephrolithiasis, and whether it had been present in a lesser degree during her 2-week illness. A kidney stone with pyelonephritis肾盂肾炎 is unlikely because of the normal white-cell count and the absence of dysuria排尿困难. The results of the initial urinalysis尿分