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Jingdong book

风湿免疫科疑难病诊断:协和医生临床思维例释(第4集)

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风湿免疫科疑难病诊断:协和医生临床思维例释(第4集)

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《风湿免疫科疑难病诊断:协和医生临床思维例释(第4集)》总结在病房工作期间最有意义的十几个病例报告给大家,这些病例中有危重病人治疗成功的范例,有病情复杂诊断困难、经过艰苦工作明确诊断的病例,也有不成功的经验教训病例。通过大家对这些病例的回顾和分析,我们都从中受到很多启发。我们提供给大家的病例主要是这些病例中的一部分,希望能为读者提供一定的帮助。
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第一章 循序渐进
第1例 咯血-下肢肿痛-结节红斑
第2例 发热-小腿红肿溃破-心内占位
第3例 发热-皮疹-肌痛-心脏杂音
第4例 进行性肌无力-肌萎缩-慢性丙型肝炎
第5例 关节痛-反复发热-双胎妊娠
第6例 关节痛-多发淋巴结增大-发热-血小板减少
第7例 脓血涕-发热-急性肾功能衰竭-咯血
第8例 发热-腰腿痛-血三系下降-ANA阳性

第二章 临床病例分析
第9例 发热-嗜酸性粒细胞增多-饮水呛咳
第10例 血小板减少-椎体压缩性骨折-水肿-憋气
第11例 皮疹-憋气-皮下气肿
第12例 下颌肿物-口干-夜尿增多
第13例 反复头晕-肾功能不全-意识障碍
第14例 白色萎缩-肌痛-多发腹腔动脉瘤
第15例 肌无力-反复胸闷憋气
第16例 肌无力-气短-排便困难
第17例 多关节肿痛-趾坏疽-手足麻木-心肌病变
第18例 眼红-腿痛-皮疹-耳郭红肿
第19例 发热-胸闷-腰髋痛
第20例 出血倾向-腹痛-血管杂音-下肢疼痛
第21例 面部红斑-急性肾功能不全-皮肤水疱-癫痫
第22例 发热-腹胀-腹痛-肌酸激酶升高
第23例 雷诺现象-咯血-高钙血症并异位钙化
第24例 多关节痛-皮肤硬肿-左踝溃疡
第25例 腹泻-皮肤变硬-水肿-反复晕厥
第26例 水肿-皮肤变硬-腹胀
第27例 系统性硬化症并发肠道溃疡
第28例 雷诺现象-皮肤变硬-头痛
第29例 脓血便-发热-下肢疼痛
第30例 多发黏膜溃疡-咯血-发热-肺内团块空洞
第31例 下肢水肿-夜尿增多-阴囊肿大

第三章 协和内科大查房
第32例 水肿-发热-截瘫
第33例 雷诺现象-水肿-憋气

英文略语简解
Book Abstract

沈敏医师(风湿免疫科):经过多科积极努力,患者最终诊断为:结核感染(亚急性血行播散型肺结核,脑脊髓结核脓肿),系统性红斑狼疮(狼疮性肾炎Ⅳ+V型)。本次发热和截瘫系结核感染所致。2007年内科大查房曾由呼吸科提供过类似结核性脑脊髓脓肿的病例。该患者肺部主要表现为磨玻璃影,以及下肺结节影部分融合。该患者因肢体无力,行头颅及脊髓MRI显示颅内及脊髓多发环形强化“葡萄样”病灶,符合结核脓肿(图32-7)。主治医师张弘医师在当时总结了2000~2007年血行播散型肺结核累及中枢神经系统共16例患者,发现所有患者均出现脑膜刺激征表现。神经科关鸿志医师总结了2007年前共12例结核性脑脓肿患者,其中仅有1例合并出现脊髓脓肿。我们通过病案室资料检索了从北京协和医院建院至2011年3月住院病例,其中血行播散型肺结核合并中枢神经系统结核感染共50例,单纯颅内结核感染23例,合并脊髓结核感染者仅3例。由此可见脊髓结核非常罕见。
在风湿免疫科,SLE合并脑结核脓肿的情况又如何呢?北京协和医院风湿免疫科徐东、徐燕医师曾总结1995~2001年北京协和医院收治4130例狼疮患者中,脑脓肿共15例,其中10例(66.7%)最终诊断为结核,3例奴卡菌,1例非结核分枝杆菌,另1例可能为普通细菌。10例结核感染患者中有6例从痰或组织中获得确凿病原学证据。该15例SLE患者原发病均稳定,所有患者均出现脑脊液蛋白质增多,MRI表现为环形强化病灶或脑膜强化。我们形象地将这种结核脓肿环形强化病灶称为颅内的“葡萄”。
……

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