【病例讨论】新英格兰杂志---29岁男性，发热及呼吸衰竭---最后死亡
发布于 2010-07-05 · 浏览 2791 · IP 天津天津
这个帖子发布于 14 年零 310 天前，其中的信息可能已发生改变或有所发展。
此为新英格兰杂志上得一个病例报道，先给大家看看病例简介，看看到底是什么病。因为英语水平有限，在翻译基础上，附原文。共同学习吧。
病例介绍：
Dr. Wilson Tak-Yu Kwong (Medicine): A 29-year-old man was admitted in July 2009 to the critical care unit of this hospital because of fever and respiratory failure.
29岁男性因发热及呼吸衰竭于2009-7被收入重症监护室。
The patient had been well until 9 days earlier, when a nonproductive cough and
myalgias in his legs developed. One week before admission, he had a temperature of 39.4°C, associated with headache. During the next week, sore throat and nasal congestion developed, the cough became productive of clear sputum, and he noted mild chest pain under his ribs during inspiration.
患者9天前，出现干咳，无痰，伴下肢肌痛。入院前1周，患者出现发热，体温39.4°C，伴头痛。接下来的1周，患者咽痛及鼻赛进行性发展，同时，开始出现咳痰，白痰。同时吸气时轻度胸痛。
Four days before admission, he was seen at the emergency department of another hospital. He did not have neck pain or photophobia. He reported finding a tick on his scalp 1 month earlier
入院前4天，患者就诊于外院急诊，当时患者无颈痛或畏光。患者自述1月前在头皮发现有一蜱。
. On examination, he appeared in mild distress. The temperature was 38.2°C and the pulse
106 beats per minute; the remainder of the examination was normal.
体检：轻度呼吸困难，体温38.2，脉搏 106，其余正常。
A rapid test of a specimen from a buccal swab was negative for inf luenza A and B antigens, and
no parasites were seen on a peripheral-blood smear; other test results are shown
in Table 1.
咽拭子示流感AB抗原阴性。外周血涂片未见寄生虫。其余检查见附表。
Acetaminophen, ketorolac, and ceftriaxone were administered, and normal saline was infused. Doxycycline was prescribed, and he was discharged.
给予患者对乙酰氨基酚，酮咯酸，头孢曲松，强力霉素治疗，患者出院。
The patient returned the next afternoon because of persistent fever, cough, myalgias, low back pain, and new scrotal pain. The temperature was 39.0°C, and the other vital signs were normal. There were rhonchi in the left lower lung field, and the remainder of the examination was normal. A test for Lyme disease, sent the day before, was negative. Other test results are shown in Table 1. A chest radio-graph showed incomplete segmental consolidation of the apical posterior segment of the right upper lobe and right hilar prominence, features suggestive of pneu-
monia and lymphadenopathy, respectively. Levofloxacin was prescribed, and he was
sent home.
患者因持续性发热，咳嗽，肌痛，后背痛及头皮痛于第二天下午返诊，体温39度，生命体征正常。左肺下部可闻及啰音。检查除外LYME病，胸片：右肺上叶尖后段不完全实变，右肺门突出。---肺炎，淋巴结肿大。给予左氧氟沙星后，患者离院。
During the next 2 days, nausea and vomiting developed, with blood-tinged emesis. One day before admission to this hospital, the patient returned to the other hospital. The temperature was 38.6°C, the blood pressure 135/70 mm Hg, the pulse 113 beats per minute, the respiratory rate 34 breaths per minute, and the oxygen saturation 88% while he was breathing 4 liters of oxygen by nasal cannula. A chest radiograph revealed progression of the process in the right upper lobe and patchy air-space disease in the right lower lobe and the middle and lower lobes on the left side.
接下来的2天，患者出现恶心，呕吐，呕吐物有少许血。入院前1天，患者在此返回原就诊医院，体温38.6度，血压135/70 mm Hg，脉搏113，呼吸34次/分。氧饱和度88%（鼻导管吸氧4L/min），胸片提示右肺病变进展。右中下肺及左下可见斑片状实变。
Nucleic acid testing for Babesia microti and Anaplasma phagocytophilum and testing for serum antibodies to Borrelia burgdorferi, sent 3 days earlier, were negative. A rapid screening test for pharyngitis due to group A streptococcus and review of a blood smear for parasites were negative; He was admitted to the hospital. Doxycycline,levof loxacin, genta micin, ibuprofen, acetaminophen, ondansetron, guaifenesin–codeine cough syrup, and ranitidine were administered. Respiratory distress worsened. Testing for antibodies toFrancisella tularensis was negative. Approximately 14 hours after admission, he was transferred to this hospital by helicopter and admitted to the critical care unit.
Babesia microti，Anaplasma phagocytophilum，Borrelia burgdorferi抗体检测阴性。收入病房。给予左氧氟沙星，强力霉素，止咳等对症治疗。入院大约14小时，患者呼吸困难加重，转至ICU.
The patient reported transient arthralgias in his ankles and knees, which had resolved; he had
not had rash, lymphadenopathy, visual symptoms,diarrhea, dysuria, hematuria, or bruising. He had
been well before the illness.
患者曾有短暂腕关节及膝关节痛，已愈。无皮疹、淋巴结肿大、视觉改变、腹泻、排尿困难、血尿、瘀斑。既往体健。
He lived with his wife in a rural area in southern New Englandthat has a high rate of tickborne illness. Two weeks earlier, he had been exposed to a child with an upper respiratory infection who had been visiting from the southeastern United States;there were no other exposures to ill persons and no recent travel. He worked indoors and outdoors, and except for the tick, he had no recent history of insect bites or exposure to animals.
他和妻子居住在新西兰南部的农村，那里蜱病发病率极高。2周前，患者和一个上感小孩有过接触（该患儿曾到过美国南部）。无其他疾病患者接触，近期无外出旅行。工作环境否认蜱接触。无昆虫及动物叮咬史。
spiratory rate 29 breaths per minute, and the oxygen saturat ion 92 to 95% while he was breathing
50% inspired oxygen. There were rhonchi in both lung bases and occasional wheezes; the remain-
der of the examination was normal. Tests for tularemia agglutination, Rocky Mountain spotted fever, typhus, heterophile antibodies, and anti-bodies to the human immunodeficiency virus and B. burgdorferi were negative, as was nucleic acid testing for anaplasma and ehrlichia. Multiple tests of nasopharyngeal secretions for inf luenza viruses, parainfluenza virus, respiratory syncytial virus, and adenovirus and tests of the
urine for legionella and histoplasma antigens were negative. Testing for antibodies to toxoplasma was suggestive of past infection. No malarial or babesial forms were seen on peripheral-blood smears. Cultures of specimens of blood, urine, and sputum were sterile.
在吸氧50%情况下，患者血氧饱和度在92-95%。查体：双肺可及湿性啰音，散在哮鸣音。流感病毒、军团菌、弓形虫等检查阴性，血尿痰培养未见异常。给予万古霉素、庆大霉素，口服左氧氟沙星+奥司他韦治疗。
During the f irst 6 hours, dyspnea and respiratory distress worsened; the respiratory rate was
24 to 26 breaths per minute, with 85 to 90% oxygen saturation while he was breathing 100% oxygen through a face mask that prevents rebreathing. Nine hours after arrival, computed tomography (CT) of the chest, without the administration of contrast material, showed extensive bilateral multifocal asymmetric consolidation involving all lobes, trace pleural effusion on the right, and multiple enlarged mediastinal or hilar lymph nodes (up to 1.3 cm in diameter). Within 18 hours after arrival, tachypnea increased further; the partial pressure of oxygen was 58 mm Hg while he was breathing high-f low oxygen, and the trachea was intubated. The partial pressure of oxygen rose to 83 mm Hg while the patient was being ventilated with 100% oxygen.
在治疗的起初6小时内，患者呼吸困难，呼吸窘迫症状加重，呼吸频率在24-26，给予面罩纯氧时，血氧饱和度在85-90%。胸部CT:两肺多发实变，右侧少量胸水，纵隔及肺门多发淋巴结肿大。给予气管插管，患者氧合略有改善。
On the second day, hypoxemia (Table 2) and renal failure (Table 1) developed and urine output fell to 20 to 30 ml per hour. Transthoracic echocardiography showed an ejection fraction of
50% and was otherwise normal. Microscopical examination of the urine sediment revealed white cell casts and granular casts, with tubular cells and nondysmorphic red cells. Continuous veno venous hemof iltration was begun, complicated by catheter-related thrombosis. Heparin was administered.
第二天，患者出现肾衰，尿量减少，20-30毫升/小时，超声心动：射血分数50%，尿中可见管型。给予血透治疗。
On the third day, a test for antinuclear antibodies was positive at a dilution of 1:40, in a
speckled pattern, and negative at dilutions of 1:80 and 1:160 (reference range, negative at 1:40 and 1:160); a test for antibodies to double-stranded DNA was negative; and levels of lactic acid, complement (C3 and **), and methemoglobin were normal. Hypotension developed with a mean systemic arterial pressure between 40 mm Hg and 50 mm Hg; pressors were administered, methylprednisolone was added, and heparin was discontinued.
第三天，患者1：40稀释时，抗核抗体阳性，在稀释到1：80及1：160时阴性，C3 ** DSDNA阴性，同时患者低血压加重，平均平均动脉压在40-50 mm Hg，给予升压药同时给予甲强龙。。
On the evening of the third day, the right pupil became eccentric, irregular, and dilated to 8 mm in diameter, without reactivity to light; the left pupil was round, 5 mmin diameter, and reactive to light to 3 mm, and there was no papilledema on funduscopic examination. The patient was considered too unstable for imaging studies of the brain to be obtained Hypertonic saline, mannitol, and ceftriaxone were administered.
当天晚上，患者出现右侧瞳孔不规则扩大，8mm，光反射消失，左侧瞳孔圆形，直径5mm，光照后缩到3mm，眼底检查无乳头水肿。给予高渗盐水，甘露醇，头孢曲松治疗，患者症状有所好转。
病例介绍：
Dr. Wilson Tak-Yu Kwong (Medicine): A 29-year-old man was admitted in July 2009 to the critical care unit of this hospital because of fever and respiratory failure.
29岁男性因发热及呼吸衰竭于2009-7被收入重症监护室。
The patient had been well until 9 days earlier, when a nonproductive cough and
myalgias in his legs developed. One week before admission, he had a temperature of 39.4°C, associated with headache. During the next week, sore throat and nasal congestion developed, the cough became productive of clear sputum, and he noted mild chest pain under his ribs during inspiration.
患者9天前，出现干咳，无痰，伴下肢肌痛。入院前1周，患者出现发热，体温39.4°C，伴头痛。接下来的1周，患者咽痛及鼻赛进行性发展，同时，开始出现咳痰，白痰。同时吸气时轻度胸痛。
Four days before admission, he was seen at the emergency department of another hospital. He did not have neck pain or photophobia. He reported finding a tick on his scalp 1 month earlier
入院前4天，患者就诊于外院急诊，当时患者无颈痛或畏光。患者自述1月前在头皮发现有一蜱。
. On examination, he appeared in mild distress. The temperature was 38.2°C and the pulse
106 beats per minute; the remainder of the examination was normal.
体检：轻度呼吸困难，体温38.2，脉搏 106，其余正常。
A rapid test of a specimen from a buccal swab was negative for inf luenza A and B antigens, and
no parasites were seen on a peripheral-blood smear; other test results are shown
in Table 1.
咽拭子示流感AB抗原阴性。外周血涂片未见寄生虫。其余检查见附表。
Acetaminophen, ketorolac, and ceftriaxone were administered, and normal saline was infused. Doxycycline was prescribed, and he was discharged.
给予患者对乙酰氨基酚，酮咯酸，头孢曲松，强力霉素治疗，患者出院。
The patient returned the next afternoon because of persistent fever, cough, myalgias, low back pain, and new scrotal pain. The temperature was 39.0°C, and the other vital signs were normal. There were rhonchi in the left lower lung field, and the remainder of the examination was normal. A test for Lyme disease, sent the day before, was negative. Other test results are shown in Table 1. A chest radio-graph showed incomplete segmental consolidation of the apical posterior segment of the right upper lobe and right hilar prominence, features suggestive of pneu-
monia and lymphadenopathy, respectively. Levofloxacin was prescribed, and he was
sent home.
患者因持续性发热，咳嗽，肌痛，后背痛及头皮痛于第二天下午返诊，体温39度，生命体征正常。左肺下部可闻及啰音。检查除外LYME病，胸片：右肺上叶尖后段不完全实变，右肺门突出。---肺炎，淋巴结肿大。给予左氧氟沙星后，患者离院。
During the next 2 days, nausea and vomiting developed, with blood-tinged emesis. One day before admission to this hospital, the patient returned to the other hospital. The temperature was 38.6°C, the blood pressure 135/70 mm Hg, the pulse 113 beats per minute, the respiratory rate 34 breaths per minute, and the oxygen saturation 88% while he was breathing 4 liters of oxygen by nasal cannula. A chest radiograph revealed progression of the process in the right upper lobe and patchy air-space disease in the right lower lobe and the middle and lower lobes on the left side.
接下来的2天，患者出现恶心，呕吐，呕吐物有少许血。入院前1天，患者在此返回原就诊医院，体温38.6度，血压135/70 mm Hg，脉搏113，呼吸34次/分。氧饱和度88%（鼻导管吸氧4L/min），胸片提示右肺病变进展。右中下肺及左下可见斑片状实变。
Nucleic acid testing for Babesia microti and Anaplasma phagocytophilum and testing for serum antibodies to Borrelia burgdorferi, sent 3 days earlier, were negative. A rapid screening test for pharyngitis due to group A streptococcus and review of a blood smear for parasites were negative; He was admitted to the hospital. Doxycycline,levof loxacin, genta micin, ibuprofen, acetaminophen, ondansetron, guaifenesin–codeine cough syrup, and ranitidine were administered. Respiratory distress worsened. Testing for antibodies toFrancisella tularensis was negative. Approximately 14 hours after admission, he was transferred to this hospital by helicopter and admitted to the critical care unit.
Babesia microti，Anaplasma phagocytophilum，Borrelia burgdorferi抗体检测阴性。收入病房。给予左氧氟沙星，强力霉素，止咳等对症治疗。入院大约14小时，患者呼吸困难加重，转至ICU.
The patient reported transient arthralgias in his ankles and knees, which had resolved; he had
not had rash, lymphadenopathy, visual symptoms,diarrhea, dysuria, hematuria, or bruising. He had
been well before the illness.
患者曾有短暂腕关节及膝关节痛，已愈。无皮疹、淋巴结肿大、视觉改变、腹泻、排尿困难、血尿、瘀斑。既往体健。
He lived with his wife in a rural area in southern New Englandthat has a high rate of tickborne illness. Two weeks earlier, he had been exposed to a child with an upper respiratory infection who had been visiting from the southeastern United States;there were no other exposures to ill persons and no recent travel. He worked indoors and outdoors, and except for the tick, he had no recent history of insect bites or exposure to animals.
他和妻子居住在新西兰南部的农村，那里蜱病发病率极高。2周前，患者和一个上感小孩有过接触（该患儿曾到过美国南部）。无其他疾病患者接触，近期无外出旅行。工作环境否认蜱接触。无昆虫及动物叮咬史。
spiratory rate 29 breaths per minute, and the oxygen saturat ion 92 to 95% while he was breathing
50% inspired oxygen. There were rhonchi in both lung bases and occasional wheezes; the remain-
der of the examination was normal. Tests for tularemia agglutination, Rocky Mountain spotted fever, typhus, heterophile antibodies, and anti-bodies to the human immunodeficiency virus and B. burgdorferi were negative, as was nucleic acid testing for anaplasma and ehrlichia. Multiple tests of nasopharyngeal secretions for inf luenza viruses, parainfluenza virus, respiratory syncytial virus, and adenovirus and tests of the
urine for legionella and histoplasma antigens were negative. Testing for antibodies to toxoplasma was suggestive of past infection. No malarial or babesial forms were seen on peripheral-blood smears. Cultures of specimens of blood, urine, and sputum were sterile.
在吸氧50%情况下，患者血氧饱和度在92-95%。查体：双肺可及湿性啰音，散在哮鸣音。流感病毒、军团菌、弓形虫等检查阴性，血尿痰培养未见异常。给予万古霉素、庆大霉素，口服左氧氟沙星+奥司他韦治疗。
During the f irst 6 hours, dyspnea and respiratory distress worsened; the respiratory rate was
24 to 26 breaths per minute, with 85 to 90% oxygen saturation while he was breathing 100% oxygen through a face mask that prevents rebreathing. Nine hours after arrival, computed tomography (CT) of the chest, without the administration of contrast material, showed extensive bilateral multifocal asymmetric consolidation involving all lobes, trace pleural effusion on the right, and multiple enlarged mediastinal or hilar lymph nodes (up to 1.3 cm in diameter). Within 18 hours after arrival, tachypnea increased further; the partial pressure of oxygen was 58 mm Hg while he was breathing high-f low oxygen, and the trachea was intubated. The partial pressure of oxygen rose to 83 mm Hg while the patient was being ventilated with 100% oxygen.
在治疗的起初6小时内，患者呼吸困难，呼吸窘迫症状加重，呼吸频率在24-26，给予面罩纯氧时，血氧饱和度在85-90%。胸部CT:两肺多发实变，右侧少量胸水，纵隔及肺门多发淋巴结肿大。给予气管插管，患者氧合略有改善。
On the second day, hypoxemia (Table 2) and renal failure (Table 1) developed and urine output fell to 20 to 30 ml per hour. Transthoracic echocardiography showed an ejection fraction of
50% and was otherwise normal. Microscopical examination of the urine sediment revealed white cell casts and granular casts, with tubular cells and nondysmorphic red cells. Continuous veno venous hemof iltration was begun, complicated by catheter-related thrombosis. Heparin was administered.
第二天，患者出现肾衰，尿量减少，20-30毫升/小时，超声心动：射血分数50%，尿中可见管型。给予血透治疗。
On the third day, a test for antinuclear antibodies was positive at a dilution of 1:40, in a
speckled pattern, and negative at dilutions of 1:80 and 1:160 (reference range, negative at 1:40 and 1:160); a test for antibodies to double-stranded DNA was negative; and levels of lactic acid, complement (C3 and **), and methemoglobin were normal. Hypotension developed with a mean systemic arterial pressure between 40 mm Hg and 50 mm Hg; pressors were administered, methylprednisolone was added, and heparin was discontinued.
第三天，患者1：40稀释时，抗核抗体阳性，在稀释到1：80及1：160时阴性，C3 ** DSDNA阴性，同时患者低血压加重，平均平均动脉压在40-50 mm Hg，给予升压药同时给予甲强龙。。
On the evening of the third day, the right pupil became eccentric, irregular, and dilated to 8 mm in diameter, without reactivity to light; the left pupil was round, 5 mmin diameter, and reactive to light to 3 mm, and there was no papilledema on funduscopic examination. The patient was considered too unstable for imaging studies of the brain to be obtained Hypertonic saline, mannitol, and ceftriaxone were administered.
当天晚上，患者出现右侧瞳孔不规则扩大，8mm，光反射消失，左侧瞳孔圆形，直径5mm，光照后缩到3mm，眼底检查无乳头水肿。给予高渗盐水，甘露醇，头孢曲松治疗，患者症状有所好转。
最后编辑于 2010-07-06 · 浏览 2791
12 9 2
