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【病例讨论】白色的血液 [病例帖]

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这个帖子发布于10年零334天前，其中的信息可能已发生改变或有所发展。

In June, 2008, a 58-year-old woman was referred from a rural district hospital to our antiretroviral treatment (ART) clinic in Blantyre, Malawi, because of suspected ART failure. She was diagnosed with HIV in 2000 and had started the ART regimen of twice daily stavudine (30 mg), lamivudine (150 mg), and nevirapine (200 mg) in fixed dose tablets, according to national protocol, following a bacterial pneumonia in 2004. At the start of 2008 she began to lose weight, dropping from 45 kg to 34 kg. She also complained of numbness of the feet, polydipsia, and genital itching. ART failure was excluded (CD4 count 833 cells per μL, HIV-1 viral load <400 copies per mL), but diabetes mellitus was diagnosed (random blood glucose 25·8 mmol/L), and she was sent back to her district hospital with recommendations for treatment.
She did not attend follow-up at her local hospital, and returned to our centre in July, 2008, after her weakness, polydipsia, and polyuria had worsened. She was alert, emaciated, dehydrated, and had normal vital signs. Features of lipoatrophy in the face and extremities and mild abdominal distension were noted. At fundoscopy, lipaemia retinalis was present without signs of diabetic or HIV retinopathy (figure A). A blood sample was taken, but soon after the tube was left to stand, a white layer appeared on the surface (figure B). Laboratory test results showed: fasting glucose 119·9 mmol/L (normal 3·5—6·5 mmol/L), triglycerides 146 mmol/L (<2·0 mmol/L), cholesterol 24·0 mmol/L (< 6·5 mmol/L), sodium 119·6 mmol/L (126—145 mmol/L), amylase 141 U/L (50—220 U/L), lactate 7·0 mmol/L (0·5—2·0 mmol/L), aspartate aminotransferase 45 U/L (13—37 U/L), alanine-aminotransferase 80 U/L (8—32 U/L). Urinalysis showed marked glycosuria and trace of proteinuria. Abdominal ultrasonography and CT scans were normal. She was rehydrated and started on insulin treatment.

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概要：
患者女，58岁，因怀疑抗逆转录病毒治疗失败而由某社区医院转送至某三甲医院治疗。患者8年前被诊断为HIV感染，随后接受抗病毒治疗，治疗方案为：司他夫定30mg/d，拉米夫定150mg/d，奈韦拉平200mg/d。4年前曾患肺炎链球菌肺炎，并被治愈，治疗措施不详。患者于半年前开始发掘体重逐渐减轻（由45kg减轻为34kg），并感觉双腿麻木，多饮，外阴瘙痒。在当地医院检查：CD4＋细胞833/μL，HIV病毒载量<400拷贝/mL，随机血糖25.8 mmol/L。为接受任何治疗。
半年后至某三甲医院治疗，病情进一步加重，渴饮、多尿、体虚。患者思维清楚，面容憔悴，脱水。面部以及肢体末端脂肪萎缩，腹部膨隆。眼底镜发现脂性视网膜病变，但未见糖尿病视网膜病变以及HIV性视网膜病变（如图）。采集血液标本静置后发现上层血液呈絮状白色（如图）。其它实验室检查结果为：空腹血糖 119.9 mmol/L (参考范围3.5—6.5 mmol/L)，甘油三酯146 mmol/L (<2.0 mmol/L)，胆固醇24.0 mmol/L (< 6.5 mmol/L)，钠 119.6 mmol/L (126—145 mmol/L)，淀粉酶141 U/L (50—220 U/L)，乳酸7.0 mmol/L (0.5—2.0 mmol/L)，AST45 U/L (13—37 U/L)，ALT80 U/L (8—32 U/L)，尿糖＋＋＋，尿蛋白微量。腹部超声以及CT未见异常。
问题：
1,血液为什么呈现白色？高脂血症，糖尿病原因何在、如何处理？
2,当前以及进一步的处理措施？