转"发热--疑难病例"

http://www.dxy.cn/bbs/post/view?bid=112&id=954276&sty=1 by junehill
发热待查－疑难病例
病史资料简介：患者女性，13岁，学生。反复发热12个月。
患者于2003年4月初出现咽痛，予“阿齐霉素、阿莫西林”口服后好转，2003年4月18日出现发热（T38℃），伴畏寒、咳嗽、咳痰，仍予以“阿齐霉素、开瑞坦、利巴韦林”口服后咳嗽症状好转，但是仍有发热（T38-39℃）。2003年5月21日查肥达氏反应抗“O”1: 160阳性，拟“伤寒”住院治疗，仍有低热。期间查B超显示“肝右叶占位”“PPD试验++”，6月5日行“肝中叶部分切除术”，病理报告为“肝中叶局灶结节状增生，周围肝组织汇管区淋巴细胞浸润”『此后多位病理科专家会诊结论相同』，术后患者体温正常。03-6-29日体温再次升高（T38-39.5℃），骨髓穿刺提示“增生性骨髓象粒系增生为主”，此后患者先后应用头孢拉定等药治疗，体温仍为37.5-38.5℃，03-9查“巨细胞病毒IgG（+），COX-IgM混合型（+），VCA-IgA（+），粪常规为人芽囊原虫（+），骨髓穿刺为骨髓增生活跃，粒红比减低，粒、红、巨三系增生活跃”，予“甲硝唑、头孢哌酮、阿昔洛韦”治疗后体温正常。3天后再次发热（T37.5-38.6℃），仍予以甲硝唑、头孢哌酮、阿昔洛韦无效，此后未予特殊处理。2004-2胸骨、髂前上棘骨髓穿刺以及两次髂后上棘骨髓活检均显示“增生性骨髓象，可见少量异形淋巴细胞（0.5-1%）和分类不明的幼稚白细胞（0.5%），NAP49%（+），积64分”。外周血淋巴细胞单克隆基因重排检测均为阴性，T细胞亚群比例正常。2004-3体温持续（38.6-39）至今。
查体：患者一般情况良好，全身浅表淋巴结未及肿大；巩膜、皮肤未见瘀点；颈软，心、肺无殊；腹部平软，未及肿块。患者食欲、睡眠、两便正常。
其他辅助检查：三大常规、肝肾功能基本正常；ESR、RF、CRP、抗“O”均为阴性；ANA等多种自身抗体检测均为阴性；AFP等肿瘤标记基本正常；泌乳素、生长激素正常。
影像学检查：肝、胆、胰、脾、肾、子宫、卵巢、后腹膜B超未见异常（多次查肝脏原有的占位性病变消失）。2003-8和2004-2头颅MRI均显示“垂体饱满”，放射科、神经外科专家会诊认为没有临床意义。肠镜正常。
患者目前状况：患者仍有发热，一般情况良好。
存在问题：1）敬请各位专家同行出谋献策，协助明确诊断；
2）在诊断不明的情况下，选择最佳的对症处理措施。

Fever of undetermined origin----A case to be discussed

Patient: 13 years old , a female student.
Brief complaint: recurrent fever for 11 months.
The patient got throat pain in April,2003 and got better after taking Amoxycillin & Azithromycin. On April 18 2003,she began to have a fever with cough、chilly & expectoration. She got better after taking Azithromycin、Clarinase & Ribavirin, but still fever(38-39℃).On may 21 2003,Widal’s reaction showed anti-O 1:160,so admitted to hospital as”typhoid?”.After one week treatment, it turned negative, but still fever(about 38℃).Because B-ultrasonic showed” right leaf of liver has space occupied lesion” and PPD++ , the patient was accepted a surgery called ”liver part middle lobectomy of liver” and pathological report showed: liver meddle period local nodal hyperplasia, peripheral liver tissue portal area lymphocyte infiltration .
After the surgery, body temperature is normal. On Jun 29 2003,temperature again elevate to 38-39.5℃ and offered with Ceforadine, temperature remain within 37.5-38.5℃.
After taking Metronidazole,Cefoperazone,Aciclovir,temperature became normal,but re-higher after 3 days with 37.5-38.6℃.It showed ineffective after use Metronidazole,Cefoperazone,Aciclovir again. No treatment was taken then.
Physical examination: general condition is OK without big LN, no rash, lung 、 heart
& abdomen are normal .nerve exam is normal.
Lab examination: blood urine & stool routines are Ok;
Liver & kidney function are normal;
ESR、RF、CRP、anti-O are negative
ANA and other auto-antibodies are negative
AFP and other tumor marks are normal
growth hormone are normal
CMV-IgG(+),COX-IgM mixtural type (+),VCA_IgA(+)
Protozoon in stool(+)
BM puncture: hyperplasia activity,the ratio of granulocyte and red
series is low.
BM biopsy : hyperplastic myelogram with a few heteromorphic
lymphocyte(0.5-1%)and unclassified
korocyte (0.5%),NAP49%(+),added up
to 64 scores.
Peripheral LC mono-clone gene rearrange test is negative.
T-cells subgroup ratio is normal
Imaging examination: MRI---pituitary satiety
EEG---blood vessel headache
B-ultrasonic---liver、gall、pancreas、spleen、kidney、matrix、
Ovary & posterior peritoneum are all
normal(former liver space
Occupied lesion disappear)
enteroscopy result---normal
The Patient’s status at present: remain febrile, headache, a slight addicted to
sleep, general condition is OK
Presenting problem1) to definitely diagnose
(2) to select a prior treatment even before definitely diagnosed