CASE-Report3 Pancreatitis associated with Strongyloides stercoralis infection i

一例长期接受皮质类固醇治疗的患者出现与粪类圆线虫感染相关的胰腺炎。

Strongyloides stercoralis [粪类圆线虫]

Strongyloides stercoralis is a nematode that is a ubiquitous parasite in man. Life-threatening infections can occur in immunocompromised patients. We report a case of a 64-year-old Puerto Rican gentleman treated chronically with corticosteroids for reactive airway disease, who presented to our institution with pancreatitis complicated by sepsis and acute lung injury requiring mechanical ventilation. The initial working diagnosis was gallstone pancreatitis; however, several days into his hospital course, he was found to have a history of strongyloidiasis. Subsequent examination of his stool revealed the parasite, and the patient was treated with ivermectin. This case highlights the occasional association between pancreatitis and strongyloidiasis and the importance of proper treatment and consideration of infection in patients from endemic regions, which include Central America, Africa, and Asia.粪类圆线虫是一种线虫，是人类中普遍存在的寄生虫。危及生命的感染可发生在免疫功能低下的患者中。我们报告了一例64岁的波多黎各男性患者，因反应性气道疾病长期接受皮质类固醇治疗，他在我们机构就诊时患有胰腺炎并发脓毒症和急性肺损伤，需要机械通气。初步工作诊断为胆石性胰腺炎；然而，在住院几天后，他被发现有类圆线虫病史。随后对其粪便的检查发现了寄生虫，患者接受了伊维菌素治疗。该病例强调了胰腺炎和类圆线虫病之间偶尔存在的联系，以及对来自流行地区（包括中美洲、非洲和亚洲）的患者进行适当治疗和考虑感染的重要性。

nematode【线虫】

ubiquitous【普遍存在的】

immunocompromised【免疫功能低下】

ivermectin.【伊维菌素】

A 64-year-old gentleman with a history significant for steroiddependent reactive airway disease was admitted to the hospital with abdominal pain, nausea, vomiting, shortness of breath, confusion, disorientation, and fever of less than 24 hours duration. The patient and his family denied any use of alcohol. There was no history of gallstones or pancreatitis. He had not begun any new medications recently. Chronic medications included albuterol, ipratropium and fluticasone/salmeterol inhalers, prednisone, montelukast, aspirin, and pantoprazole. The patient had lived in Puerto Rico, where he worked picking coffee beans for many years before he emigrated to the United States. He frequently returned to Puerto Rico, however, and did so most recently in the month prior to admission. 一名 64 岁的男性患者因腹痛、恶心、呕吐、呼吸急促、意识模糊、定向障碍和持续不到 24 小时的发烧而入院，其病史中存在明显的激素依赖性反应性气道疾病。患者及其家人否认酗酒。没有胆结石或胰腺炎病史。他最近没有开始服用任何新药。长期服用的药物包括阿布特罗、异丙托品和氟替卡松/沙美特罗吸入剂、强的松、孟鲁司特、阿司匹林和泮托拉唑。患者曾在波多黎各生活，多年来一直从事采摘咖啡豆的工作，后来移民美国。不过，他经常返回波多黎各，最近一次是在入院前一个月。

On physical examination, his vital signs were unremarkable. Bilateral expiratory wheezing was noted. His abdomen was somewhat tense and distended with maximum tenderness in the epigastric region. No rebound or guarding was noted, and there were positive bowel sounds. No rash was appreciated. The remainder of the examination was unremarkable. Abnormal laboratory values on admission included glucose 189 mg/dL, aspartate aminotransferase (AST) 52 IU/L, alanine aminotransferase (ALT) 64 IU/L, lactate dehydrogenase (LDH) 200 IU/L, amylase 4367 U/L, lipase >396 U/L, and white blood cell (WBC) 19 400/mm3. Manual differential showed neutrophils 47%, bands 8%, metamyelocytes 2%, lymphocytes 32%, monocytes 7%, and eosinophils 4%.体格检查时，他的生命体征无异常。双侧呼气性喘息。他的腹部有些紧张和膨胀，上腹部有最大压痛。未发现反跳或戒备，肠鸣音阳性。没有发现皮疹。其余检查结果均无异常。入院时的实验室异常值包括葡萄糖 189 mg/dL、天冬氨酸氨基转移酶（AST）52 IU/L、丙氨酸氨基转移酶（ALT）64 IU/L、乳酸脱氢酶（LDH）200 IU/L、淀粉酶 4367 U/L、脂肪酶 >396 U/L、白细胞（WBC）19 400/mm3。人工鉴别显示，中性粒细胞占 47%，带状粒细胞占 8%，偏嗜酸性粒细胞占 2%，淋巴细胞占 32%，单核细胞占 7%，嗜酸性粒细胞占 4%。

Bilateral expiratory wheezing[双侧呼气性喘息]

rebound or guarding[反跳痛]

A computed tomogram (CT) of the abdomen showed a normal appearing gallbladder and biliary tree. The pancreas was edematous with a small peripancreatic fluid collection but without evidence of abscess or pseudocyst. An initial working diagnosis of gallstone pancreatitis was made. Ranson’s score on admission was 2/5. On the first day of hospitalization, the patient decompensated and required tracheal intubation with mechanical ventilation. He was admitted to the surgical intensive care unit (ICU) for further treatment. A single blood culture grew Streptococcus viridans. A right upper quadrant ultrasound and magnetic resonance cholangiopancreatography (MRCP) failed to demonstrate any evidence of gallstones. Chest x-ray at the time of ICU admission revealed bilateral perihilar and bibasilar infiltrates. 腹部计算机断层扫描（CT）显示，胆囊和胆管外观正常。胰腺水肿，胰周有少量积液，但没有脓肿或假性囊肿的迹象。初步诊断为胆石性胰腺炎。入院时的兰森评分为 2/5。住院第一天，患者出现失代偿，需要气管插管和机械通气。他被送入外科重症监护室（ICU）接受进一步治疗。一次血液培养发现了病毒性链球菌。右上腹超声波检查和磁共振胰胆管造影术（MRCP）均未显示任何胆结石迹象。入住重症监护室时的胸部X光检查显示双侧肺周和双肺叶浸润。

tracheal intubation 【气管插管】

Streptococcus viridans【链球菌】

Further review of his medical history revealed that S stercoralis infection had been incidentally discovered approximately 2 years earlier when a polyp removed during a routine screening colonoscopy tested positive for the parasite. Additional questioning of his family revealed that he had not completed treatment for the infection. A stool sample obtained in the ICU tested positive for S stercoralis. Central nervous system involvement was excluded by cerebral spinal fluid examination, which revealed clear, colorless fluid with normal protein (22 mg/dL), glucose (77 mg/dL), WBC (0/mm3), and red blood cell (RBC, 1/mm3) counts and resulted in a negative culture. The patient was initially placed on bowel rest with parenteral nutritional support. The S stercoralis infection was treated with oral ivermectin, 18 mg given once daily. Although the treatment was briefly interrupted by bouts of emesis, he did complete a cumulative 5-day course. The patient also completed a 12-day course of ceftriaxone for Escherichia coli ventilator-associated pneumonia and possible Streptococcus viridians bacteremia. Because only 1 positive blood culture result was obtained, endocarditis was thought to be unlikely and thus echocardiography was not pursued. Steroid medication given in the ICU was initially intravenous methylprednisolone, but this was subsequently tapered down to his previous maintenance dose of oral prednisone, 10 mg daily. He was successfully extubated on hospital day 12. After his abdominal pain improved and his pancreatic enzymes trended down, he was started on clear liquids and subsequently advanced to a regular diet. He was discharged to a rehabilitation facility in stable condition on hospital day 19. Three separate stool specimens collected at 3-month follow-up failed to reveal any evidence of residual parasitic infection.进一步回顾他的病史后发现，大约两年前，他在一次常规结肠镜检查中被切除的息肉经检测发现寄生虫呈阳性，从而意外发现感染了带状孢子虫。对其家人的进一步询问显示，他尚未完成对感染的治疗。在重症监护室采集的粪便样本检测结果呈阳性。脑脊液检查排除了中枢神经系统受累的可能，检查结果显示脑脊液清澈无色，蛋白质（22 mg/dL）、葡萄糖（77 mg/dL）、白细胞（0/mm3）和红细胞（RBC，1/mm3）计数正常，培养结果为阴性。起初，患者在肠道休息的同时接受肠外营养支持。患者感染了盘尾丝虫，接受了伊维菌素口服治疗，每天一次，每次 18 毫克。虽然治疗曾因阵发性呕吐而短暂中断，但他还是完成了累计 5 天的疗程。由于只获得了一个阳性血培养结果，因此认为患者不太可能患有心内膜炎，因此没有对其进行超声心动图检查。重症监护室最初使用的类固醇药物是静脉注射甲基强的松龙，但后来逐渐减少到之前每天口服 10 毫克强的松的维持剂量。他在住院第 12 天成功拔管。在他的腹痛有所改善、胰酶呈下降趋势后，他开始进食清流食，随后转为正常饮食。住院第 19 天，他病情稳定，出院前往康复机构。在三个月的随访中，分别采集的三份粪便标本均未发现任何残余寄生虫感染的证据。

S stercoralis infection 【丝虫感染】

bouts of emesis【阵发性呕吐】

ceftriaxone【头孢曲松】

methylprednisolone【甲强龙】

tapered down 【下降】

extubate【脱机拔管】

rehabilitation facility【康复机构】