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[ATS临床病例]:60岁男性肺炎持续不缓解(1/5)
2017年05月30日 临床话题, 模拟诊室 暂无评论

60-Year-Old Man with Non-resolving Pneumonia

Submitted by

Nicholas C. James, MD, Timothy N. Liesching, MD

Department of Pulmonary and Critical Care Medicine

Lahey Hospital & Medical Center

Burlington, Massachusetts

from https://www.thoracic.org/professionals/clinical-resources/clinical-cases/01-15.php

History 病史

A 60 year-old man with a past medical history for coronary artery disease requiring four vessel coronary artery bypass grafting, hypertension, hyperlipidemia, nephrolithiasis and cirrhosis related to alcohol abuse was deemed a liver transplant candidate after complications of several episodes of hepatic encephalopathy and esophageal variceal bleeding. He remained abstinent from alcohol.

一名60岁男性患者曾因冠心病接受冠脉搭桥手术(4根血管),此外,既往史包括高血压,高脂血症,肾结石及酒精性肝硬化。患者还曾数次发生肝性脑病及食道静脉曲张出血,因而等待肝移植。

He underwent a living donor liver transplant using the right hepatic lobe graft donated by his son. His immunosuppression regimen included sirolimus, mycophenolate, and prednisone. Valgancyclovir and trimethoprim/sulfamethoxazole included his prophylactic therapy. There were no peri-operative complications noted. Post-operatively, the patient noted mild dyspnea and a non-productive cough. His postoperative course was complicated by cholangitis secondary to biliary stricture necessitating percutaneous trans-hepatic cholangiography (PTC) and biliary dilation.  Work up for his cholangitis included an abdominal CT that incidentally demonstrated a dense pulmonary infiltrate of the right middle lobe (RML) (Figure 1). He also developed acute renal insufficiency, but did not require renal replacement therapy. It was determined by the surgical team that the patient had pneumonia and was treated amoxicillin/clavulanate. His respiratory symptoms resolved and followed up in clinic.

患者接受了活体肝移植(儿子捐献的肝脏右叶)。免疫抑制剂包括西罗莫司,麦考酚酯和强的松。同时预防性使用缬更昔洛韦和复方新诺明。术后,患者出现轻度呼吸困难及干咳。术后患者因胆道狭窄继发胆管炎行经皮经肝胆管造影(PTC)及胆管扩张。有关胆管炎的诊断检查包括腹部CT,CT检查意外发现右中叶(RML)致密性浸润影(图1)。患者还发生急性肾脏功能不全,但无需接受肾脏替代治疗。外科医生认为患者发生肺炎,并使用阿莫西林/克拉维酸治疗。患者呼吸道症状缓解,随后在门诊随访。

As an outpatient, the patient required one additional biliary dilation procedure for biliary stricture. A follow up chest CT (Figure 2) 7 weeks after initial imaging demonstrated a persistent RML infiltrate. The patient was completely without respiratory complaint at the time.  A pulmonary consultation is requested.

门诊随访期间,患者因胆道狭窄再次进行胆道扩张。7周后复查胸部CT(图2)显示RML浸润影持续存在。此时患者没有任何呼吸道主诉,遂请呼吸科医生会诊。

Physical Exam 体格检查

Physical examination revealed the patient to be afebrile with an oxygen saturation of 99% on room air. The remaining vitals were also unremarkable. The patient was not in acute distress and could talk in complete sentences.  Auscultation of the lungs was clear throughout and cardiac examination revealed a 3/6 systolic murmur. The extremities were void of edema and there was no clubbing.

体格检查显示患者不发热,吸入空气时氧饱和度99%。其余生命体征无明显异常。患者没有急性呼吸窘迫的症状,且能够说出完整的话。肺部听诊呼吸音清晰,心脏检查发现有3/6级收缩期杂音。四肢没有水肿,没有杵状指。

Figure 1: CT chest showing right middle lobe dense consolidation with associated ground glass opacities

图1:胸部CT显示右中叶致密实变影伴磨玻璃影

Figure 2: Persistent, more consolidated right middle lobe infiltrate with increased ground glass opacities

图2:右中叶浸润影持续存在且实变更明显,磨玻璃影加重

Question 1 问题1

What would be the next best diagnostic approach for this patient’s non-resolving opacity? 对于肺部病变,下一步应选择以下哪种诊断措施?

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References

1. Fishman, JA. Infection in Solid-Organ Transplant Recipients. NEJM. 2007;357:2601-14.

2. Garzoni C. Multiply resistant gram-positive bacteria methicillin-resistant, vancomycin-intermediate and vancomycin-resistant Staphylococcus aureus (MRSA, VISA, VRSA) in solid organ transplant recipients. Am J Transplant. Dec 2009;9 Suppl 4:S41-9.

3. Preiksaitis, JK, Keay, S. Diagnosis and Management of Psttransplant Lymphoproliferative Disorder in Solid-Organ Transplant Recipients. Clin Infect Dis. 2001; 33 (1): S38-46.

4. Johnson, PC, Hogg, KM, Sarosi, GA. The rapid diagnosis of pulmonary infections in solid organ transplant recipients. Semin respir infect. 1990; 5(1): 2-9.

5. Tuna, T., Ozkaya, S., Dirican, A. et al. Diagnostic Efficacy of Computed Tomography-guided Transthoracic Needle Aspiration and Biopsy in Patients with Pulmonary Disease. Onco Targets Ther. 2013;6: 1553-57.

6. Wiener, RS, Schwartz, LM, Woloshin, S. et al. Population-Based Risk Complications After Transthoracic Needle Lung Biopsy of a Pulmonary Nodule: An Analysis of Discharge Records. Ann Intern Med. 2011; 155(3): 137-44.

7. Rano, A., Agusti C., Jimenez, P., et al. Pulmonary infiltrates in non-HIV imunocompromisesd patients: a diagnostic approach using non-invasive and bronchoscopic procedures. Thorax. 2001; 56: 379-387.

8. Yale, SH, Limper, AH. Pneumocystis carinii Pneumonia in Patients without Acquired Immunodeficiency Syndrome: Associated Illnesses and Prior Corticosteroid Therapy. Mayo Clin Proc. 1996; 71(1): 5-13.

9. Green, H, Paul, M, Vidal, L, Leibovici, L. Prophylaxis of Pneumocystis Pneumonia in Immunocompromised Non-HIV-Infected Patients: Systematic Review and Meta-analysis of Randomized Controlled Trials. Mayo Clin Proc. 1996; 82(9): 1052-1059.

10. Ewig, S, Bauer, T, Schneider C, Pickenhain, A et al. Clinical characteristic and outcome of Pneumocystis carinii pneumonia in HIV-infected and otherwise immunosuppressed patients. Eur Respir J. 1995;8: 1548-1553.

11. Matsumura, Y, Shindo, Y, Iinuma, Y, Yamamoto, M et al. Clinical characteristics of Pneumocystis pneumonia in non-HIV patients and prognostic factors including microbiological genotypes. BMC Infect Dis. 2011;11:76-84.

12. Chan, ED, Morales, DV, Welsh, CH, et al. Calcium Deposition with or without Bone Formation in the Lung. Am J Respir Crit Care Med. 2002; 165:1654-69.

13. Yousem, SA. The Surgical Pathology of Pulmonary Infarcts: Diagnostic Confusion with Granulomatous Disease, Vasculitis, and Neoplasia. Mod Pathol. 2009;22:679-85.

14. Thomas, CF and Limper, AH. Pneumocystis Pneumonia. NEJM. 2004;350:2487-98.

15. Bartlett, MD and Smith, JW. Pneumocystis carinii, and Opportunist in Immunocompromised Patients. Clin Microbiol Rev. 1991;4(2):137-49.

16. Bein, ME, Lee, DBN, Mink, JH, et al. Unusual Case of Metastatic Pulmonary Calcification. AJR. 1979;132:812-816.

17. Wechsler, RJ, Feld, R, Munoz, SJ, et al. Suprahepatic Circumcaval Ring: CT Finding After Orthotopic Liver Transplantation. AJR. 1992; 183:545-48.

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