病原生物学病例讨论第二部分_病原生物学病例分析
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病原生物学病例讨论第二部分
（八年制临床医学专业使用）
上海交通大学医学院病原生物学教研室病例一
张某，男，47岁，山西清徐县人，农民。因经常咳嗽以及咳血痰近4个月，大便有时呈黑便，消瘦一个月余入院治疗。经当地卫生院检查先后拟诊为“支气管炎”“缺铁性贫血，胃癌？”治疗2个月余终不见好转。平素身体健康，无生食史，但有吸烟史。
胃镜检查：食管
正常，胃部至胃窦部可见散在出血点，新旧交替；粘膜表面发现有大量约0.5~1.0 cm 淡红色的寄生虫吸附，活检取出活虫10条，在出血点周围的炎症处取出活组织2块送病理检查。
体检及化验：贫血外貌，血色素105g/L，红细胞计数2.6×10 /L（260万/mm），白细胞计数1.04×10 /L(10400/mm)，出凝血时间正常，大便黑褐色，隐血“+++ ”，红细胞“+”，涂片发现少许某寄生虫虫卵。腹软有明显压痛，肝胆未及。
1． 解释本病例中所有的症状和体征。
2． 胃镜检查的结果中可提供哪些重要线索？病理检查可能会出现哪些结果？ 3． 诊断为肠道寄生虫病的主要依据是什么？应该确诊为哪种肠道寄生虫病？ 4． 卫生院拟诊为“缺铁性贫血、胃癌”有何依据？
病例二
吴××，男，28岁，因腹痛，腹泻5天就诊。
病史：患者于一个月前外出旅游，曾在当地饮食摊就餐多次。5天前，患者突感右下腹疼痛，腹泻，大便每日10余次，为脓血粘液便，量大，腥臭，伴明显里急后重感，曾自行口服黄连素止泻，腹泻无好转。患者自觉乏力，无发热。小便正常，睡眠尚可。既往身体健康，无慢性腹泻史，无药物过敏史。
体检：T36.9℃, P 86次/分，R 20次/分，Bp 120/80mmHg，无皮疹和出血点，浅表淋巴结未触及，巩膜不黄，咽(-)，心肺(-)，腹平软，右下腹轻压痛，无肌紧张和反跳痛，未触及肿块，肝脾未触及，腹水征(-)，肠鸣音稍活跃，下肢不肿。
化验：大便常规为粘液脓血便，镜下红细胞数增高，有时可见堆积成团，明显高于白细胞。粪便涂片检查，发现具有活动性的滋养体，尿常规(-)。
问题：
1．根据上述病史，写出诊断及诊断依据。
2．写出该病与常见的菌痢的主要鉴别诊断（列出两者的主要鉴别点）。3．写出该病的治疗原则。10
23病例三
周XX，女性，70岁，农民，安徽霍邱人。因纳差、乏力、上腹不适、反复黑便2月于2007-08-02入院。上腹不适多于进食后缓解，黑便多为成形黑便，每日一到二次。
外院病历显示：大便隐血阳性，HB：51g/L，胃镜示浅表-萎缩性胃炎，经抑酸、止血处理后上腹部不适好转，但血红蛋白下降至36g/L。
年轻时喜食生米。既往曾因“贫血”在当地医院就诊，予驱虫治疗，具体不详。否认其他病史。
体格检查：T：36.4o C P: 80次/分，R：20次/分，BP：110/60mmhg，贫血貌，其他无明显阳性体征。
2007-08-03
12血常规：HB:38g/L，RBC:2.05 ×10/L, MCV（平均红细胞体积）:66.8fl(正常值：93.28fl)。
粪常规：黄色，隐血阳性。
肝功能：总蛋白：57g/L，白蛋白：32g/L，余正常。乙肝两对半、甲肝抗体、戊肝抗体均为阴性，CEA、AFP、Ca199均阴性。
初步诊断：下消化道出血
诊断依据: 外院胃镜未见出血病灶 出血原因：① 下消化道肿瘤
② 下消化道血管病变
③ 炎症性肠病 2007-08-06 肠镜
回肠末端见多条长约5-10mm白色线状虫体，活动，回盲瓣局部粘膜红肿。病理：（回盲瓣）肠粘膜慢性炎，间质内见嗜酸性粒细胞浸润。2007-08-07 胃镜
食管未见异常，胃粘膜贫血相，十二指肠球部未见溃疡，降部见数条白色线状虫体，性状同肠镜下所见。
2007-08-09粪便找到钩虫卵，未查见其他虫卵及阿米巴原虫。入院后予抑酸、止血、输血治疗。2007-08-07开始驱虫治疗
甲苯咪唑：0.2 一日两次，口服。同时予铁剂、维生素C治疗贫血。治疗结果：患者纳差、乏力明显改善 2007-08-13复查血常规：
HB:66g/L，RBC:2.95*1012/L，MCV:75.6fl，网织红细胞：1.90%。2007-08-14 胃镜复查：十二指肠降部未见寄生虫。
问题：
1．该病例在外院治疗有什么教训可吸取？ 2．为什么该病例初步诊断是“下消化道出血”？ 3．为什么肠镜检查时会在回肠未端显示有钩虫寄生？病例四
A 3-year-old girl was brought to the emergency department.of a general hospital following a 3-week history of nausea, poor appetite, and abdominal pain.She had not had any bowel movements for the last 2 days.The patient was of Mexican origin and had recently moved from Mexico with her mother to South Texas.PHYSICAL EXAMINATION VS: T 37℃, P 110/min, R20/min, BP 102/54mmHg PE :Young child in moderate distre due to abdominal pain.Abdomen was distended and mildly tender.LABORATORY STUDIES Blood Hematocrit: 38% WBC: 4500/μL Differential: 62% PMNs, 23% lymphs, 12% eosinophils(eosinophilia)Serum chemistries: Normal
Imaging X-rays of her abdomen were consistent with intestinal obstruction.Diagnostic Work-Up Table 49-1 lists the likely causes of illne(differential diagnosis).Intestinal worm infection was considered based on clinical features and x-ray evidence.Diagnosis is confirmed by identification of ova and parasites by microscopy of trichrome-or iodine-stained concentrated fecal specimens.TABLE49－1 Differential Diagnosis and Rationale for Inclusion(consideration)Appendicitis Intestinal helminth infection Ascaris lumbricoides
Schistosoma spp
Taenia spp
Trichuris trichiura Small bowel obstruction from volvulus
Rationale: Abdominal symptoms with eosinophilia have a relatively limited differential, mainly parasitic infection.The various causes can be reliably determined only through stool examination for ova and parasites.Noninfectious causes may also cause similar symptoms but will not demonstrate eosinophilia.COURSE The patient was admitted to the hospital and put on intravenous hydration.Stool examination revealed characteristic nematode eggs.病例五
A 36-year-old man presented to the emergency department of a general hospital with a 10-day history of intermittent diarrhea and tenesmus, with blood and mucus visible in the stool.He had just returned from a working trip to India, where he had visited a rural town in the last week of his trip.PYSICAL EXAMINATION VS: T 38.8℃, P 96/min, R 16/min, BP 130/80 mmHg PE: Ill-appearing male in mild distre;abdominal exam revealed mild diffuse tenderne, and rectal exam was positive for blood.LABORATORY STUDIES Blood Hematocrit: 44% WBC: 11,600/μL Differential: 72% PMNs, 20% lymphs Serum chemistries: Normal Imaging Sigmoidoscopic examination revealed multiple small hemorrhagic areas with ulcers.Diagnostic Work-up Table 46-1 lists the likely causes of illne(differential diagnosis).A clinical diagnosis of dysentery was considered.Investigational approach may include Enteric(bacterial)cultures Stool antigen test for amebic agent Microscopic(ova and parasite)examination Table 46-1 Differential Diagnosis and Rationale for Inclusion(consideration)Dysentery syndrome:
Entamoeba histolytica Enterioinvasive Escherichia coli
Salmonella spp
Shigella dysenteriae
Yersinia enterocolitica Inflammatory bowel disease(IBD)
Rationale: The dysentery syndrome can be caused by multiple pathogens, and stool studies are required to definitively diagnose them.However, epidemiology(history of exposure)can be helpful.E.coli(amebic dysentery)and S.dysenteriae(bacillary dysentery), two of the most common colonic ulcerative diseases, are much more common in developing countries than in the Western hemisphere, and recent travel history should be obtained to rule out these diseases.IBD should always be considered, although after infectious etiologies have been ruled out.COURSE The patient was admitted to the hospital for observation.Microscopic examination of his stool showed many WBCs and RBCs.Microscopic examination of fixed and stained stool specimens subsequently revealed a significant pathogen.食源性感染寄生虫 病例六
张××，男，40岁，吉林人，湖北省襄樊市某汽车制造厂工人。二周前感觉胃肠不适，近几天发现眼脸部肿胀，并逐发展为脸部肌肉有肿胀感，全身肌肉酸痛，发烧。三天前在厂医院就治，服用黄连素和克感敏3天，不见症状缓解。近日因全身肌肉酸痛加剧，吞咽困难，体温明显升高而入院治疗。
询问病史中发现，在感觉胃肠不适前几天与同事在一饭店吃过火锅，食入猪、牛、羊等，在吃火锅的同事中也有人出现类似症状。
体检：体温在38oC~39.5oC之间，咽喉部无炎症，心率90次/分左右，无杂音，肺部（—）。腹软，肝不肿大、无明显压痛。四肢肌肉和脸部肌肉有明显压痛，但未见有包块。
化验：血常规WBC 19200，中性粒细胞50%，淋巴细胞32%，嗜酸性粒细胞18%。尿常规正常，粪检未查见虫卵。
问题：
1．根据上述病史、体检及化验结果，你怀疑患者是什么病？ 2．要确诊此病，你认为还应当作哪些检查？
3．可采取什么治疗方法缓解病情，以进一步确诊疾病？ 病例七
患者刘某，男，50岁，浙江义乌县防疫站医师。病人主诉是：因间歇性咳嗽1个月余伴右侧胸痛1周，加重3d为，于1996年5月2日急诊入院。住院后发热1天、咳嗽气促胸痛，嗜酸性粒细胞增多。初诊为右胸膜炎，经抗感染、海群生治疗病情好转。6月初突然痰中带血丝、伴有盗汗，发现胸腔有胸水，施胸腔穿刺术，抽出淡黄色液体300ml，胸水涂片检出抗酸分枝杆菌，结核菌PCR检测阳性。既往史从事血吸虫病、肺吸虫病流行病学调查及病原体分离工作20年；有食腌蟹、腌虾等习惯。
给予吡喹酮4800mg，辅以口服异烟肼、乙胺丁醇并肌注链霉素半个月，病情缓解，体症消失而出院。
1.根据本病人的症状，考虑产生病症的主要疾病是什么？诊断依据是什么？ 2．本病例突然发现胸腔有积水，提示哪些疾病的可能性较大？ 3．本病患者从事的工作可以高度怀疑可能的是那种寄生虫病？ 4．该病人住院半月出院，在疾病治疗上应还须注意什么问题？
病例八
患者黄某，男性，29岁，湖南韶山人。以畏寒，发热伴乏力1周为主诉入院。患者于1周前因饮少量啤酒后感到上腹部不适，饱胀感；当晚出现畏寒、发热，体温达38℃，无咳嗽、胸痛及咯血等症状。住院后以上呼吸道感染进行对症治疗而无效。血象常规检查，嗜酸性粒细胞0.33，患者于10年前患甲肝已治愈，入院后给予抗炎抗过敏治疗，初步诊断为“嗜酸性粒细胞增多症，过敏性肺炎，急性肝炎”而转入解放军某医院肝炎科。
患者转入肝炎科后行静脉点滴促进肝细胞生长因子，口服保肝类药物等，二周后复查功能仍为异常，疑为某寄生虫病。追问病史，患者喜爱钓鱼和下河捕鱼，但从未曾生食过鱼。作华支睾吸虫皮实检查为（＋），粪检（直接涂片法）中未查见华支睾吸虫虫卵。口服吡喹酮2周后食酸性粒细胞数和肝功能均恢复正常。
1.此病例最终证实属于哪种寄生虫病？是怎样感染本病的？ 2.为什么在粪便中查不到华支睾虫虫卵？有几种可能性？
3.华支睾吸虫病和肝炎的症状上有哪些相似之处？在诊断上如何鉴别？ 病例九
李某，大学在读学生，在某年十一月发现大便中带有白色物，大小呈指节样，见有多节相连或单节样，有时白色节片样物是破裂的，也有完整的单节片有微蠕动。该患者从粪便中取出白色节片后去医院就诊。
询问病史：患者在当年七月曾随父母去西双版纳旅游，自述在旅游中没有食过生猪肉。但吃过“云南过桥米线”，在傣族旅游区吃过猪肉的菜肴。猪肉菜肴为肉糜样，发白，由当地的麻椒类的作料和盐、味精等搅拌而成，口感麻、辣、香、鲜。
体格检查：颈软，未触及肿大淋巴结；心、肺、血压均正常；腹软，无压痛和包块。粪便检查：见有带绦虫卵，对粪便中白色节片检查后，发现节片两侧呈分枝状。诊断：猪带绦虫感染
治疗：经吡喹酮20mg/kg•d，Tid×3d 治疗，驱出大量大小不等白色节片。问题：
1．该患者可能从哪些途径感染猪带绦虫的？ 2．该患者经吡喹酮治疗后，如何确定驱虫疗效? 3．用什么药物驱虫可较好的确定驱虫效果？ 4．该患者驱出成虫后还应注意什么问题？
病例十
陈××，女，28岁，江西人，南昌市郊务农。婚后二年，近来停经一个多月，身感不适，估计有身孕，在江西某市妇幼保健院产科就诊。经产科医生检查确诊其已怀孕约二个月，然后，用在清学方法检测了风疹病毒、巨细胞病毒和弓形虫抗体，结果：风疹病毒和巨细胞病毒抗体均阴性，弓形虫IgG阳性。
时隔半月，该孕妇第二次去该妇幼保健院就医。
体格检查：颈软，未触及肿大淋巴结；耳根部位也未见肿大的淋巴结；心、肺、血压均正常。
X线检查：未见胎儿有钙化样病灶。
医生告知：孕妇有弓形虫感染，弓形虫可通过胎盘感染胎儿，并影响胎儿的发育，造成畸胎或脑组织发育异常等。建议作人流终止妊娠。
问题：
请你进一步从诊断、治疗和监测方面提出你的意见。组织内寄生虫 病例十一
徐××，男，50岁，上海人，上海市某公司经理，因高烧入某市级医院治疗。患者入院前三天才从南非返沪，自述在南非工作了三个月，在刚到南非时服用过疟疾预防药。在离开南非前患者已有不规则发热，自服退热片无效。在入院当天曾在某区中心医院按普通感冒就治过，使用过头孢类抗菌素。入院后每天都有不规则发热，头痛症状明显并逐渐加重，入院前四天体温在37oC~39.8oC，检测颅内压有些增高。入院后血检结果也未检测到疟原虫，但考虑其才从南非回来，有疟原虫感染的可能，除使用抗菌素和对症治疗外，也使用了氯喹和伯氨喹啉等抗疟药，但未见症状有所缓解。入院第6天上午，病人症状明显加重，出现昏迷。同时再次进行血检，结果在血中检获有疟原虫，经防疫部门鉴定，血片中疟原虫满视野为恶性疟原虫。入院第7天晚上，患者被诊断为脑型疟抢救无效而死亡。
问题：
1．此患者在进入疟区工作时在疟疾预防存在什么错误？
2．医院在对此患者的疾病诊断方面存在什么问题？
3．根据此患者在南非工作期间感染疟疾，在治疗方面应使用哪种抗疟更合理？ 病例十二
陈××，女，62岁，内蒙古二连市的居民。8个月前无明显诱因突发双下肢无力，不能行走。当地诊断为“脑积水”，于7个月前，行侧脑室腔分流术,术后病情好转，但一个月后症状复发。
体检：双下肢肌张力增高, 双侧眼底可见视乳头水肿, 考虑脑室端已堵塞。
ＭＲI（核磁共振检测）表现：双侧侧脑室明显扩张,侧脑室周围可见异常阴影信号,三、四脑室无明显改变。仔细读片后发现,双侧侧脑室体部清晰可见囊壁，囊壁光滑，且部分与脑室壁重叠的囊性病变,脑室内壁可见阴影信号, 提示有颗粒状物体。右侧囊性病变占位大小约7ｃｍ×3ｃｍ×2.5ｃｍ,左侧约6ｃｍ×2.5ｃｍ×2.5ｃｍ。
手术及病理：术中可见双侧侧脑室内巨大囊肿,通过扩大的室间孔相连,呈哑铃形,囊壁乳白色半透明,与脑室壁无粘连,囊液淡黄色透明、约40ｍｌ,分流管脑室端位于囊外,引流孔已全部堵塞,与脑室壁粘连。
问题：
1．该患者被诊断为脑棘球蚴病，请写出诊断依据。2．进一步如何治疗？
3．请写出该患者感染此病的感染方式可能有哪些？ 病例十三
患者王××，男，37岁，武汉市郊县农民。因持续高热18天，伴有咳嗽和腹泻，外院诊治无效。发病30天后，于9月15日入院治疗。
体检：体温39.7℃，血压15.0/10.5 kPa。精神萎靡，反应迟钝，右肋下触及肝边缘，左肋下缘2 cm触及脾脏、质中等、无压痛。血白细胞3.2×109/L，中性粒细胞和嗜酸性细胞增高；肥达氏反应：O凝集素1∶80，H凝集素1∶160；三次粪便直接涂片检查均阴性。入院后给予抗菌素治疗，环丙沙星0.4 g/d，静脉滴注1周，高热持续不退。改为吡喹酮治疗，用药后第4天发热缓解，出院。随访2周，病人无发热。
问题：
1．此病人可能患的什么寄生虫病？写出诊断依据。2．进一步确诊该寄生虫病可用什么实验诊断? 3．分析该患者临床症状产生的病理学依据。
病例十四
A 28-year-old Hispanic man was brought to the emergency department of a general hospital for severe headaches and two generalized seizures.He had first noticed headaches, which had been getting more frequent, several weeks before.He denied fever or chills.The patient was a recent immigrant from Mexico.There was no previous history of seizures.PHYSICAL EXAMINATION VS: T 37℃ , P 83/min, R 14/min,BP 136/80 mm Hg PE: Young male in moderate distre due to headache;neurologic exam was normal.LABORATORY STUDIES Blood Hematocrit: 45% WBC: 7200/μL
Differential: 52% PMNs, 23% lymphs, 12% eosinophils Blood gases: Normal Serum chemistries: Normal
Imaging A CT scan of his brain revealed an intracranial calcified cyst, and further imaging with MRI confirmed the presence of similar lesions, some with a scolex visible(Fig.64-1).Diagnostic Work-Up Table 64-1 lists the likely causes of illne(differential diagnosis).The presumptive diagnosis should be on the basis of clinical picture and epidemiologic information.The likelihood of exposure during foreign travel, and characteristic findings on CT or MRI scans, are adjuncts to clinical diagnosis.Lumbar puncture and peripheral blood collection are an eential beginning of investigation.Microbiologic investigation may include.Gram stain and acid-fast stain of CFS Cultures of CSF and blood for bacteria, fungi, mycobacteria Antibody detection(e.g., immunoblot aay of IgG in serum or CSF specific for the invasive stage of a parasite)In failed tests above
Cryptococcal antigen in CSF and serum
CSF VDRL
Serologic tests for others included in differential diagnosis
Table 64-1 Differential Diagnosis and Rationale for Inclusion(consideration)Brain absce Craniopharyngioma Cryptococcal meningoencephalitis Medulloblastoma Neurocysticercosis Toxoplasmosis Tuberculoma
Rationale: Intracerebral ma lesions have many poible causes(common ones are listed above).Homogeneous maes may be malignancies, and ring enhancement is claically aociated with brain absce.Cystic maes may be malignant, but they are also claically aociated with neurocysticercosis.Other infectious causes of intracerebral maes include toxoplasmosis, tuberculoma, and cryptococcoses.COURSE The patient was admitted to the hospital for observation and diagnostic investigation.A lumbar puncture was performed.The CSF analysis revealed a WBC count of 35/ , with lymphocytic and eosinophilic pleocytosis, slightly elevated protein(62 mg/dL), and a normal glucose level.A positive serologic investigation specific for a parasite yielded the diagnosis.病例十五
患者李某，男，36岁，上海市浦东人，汽车司机，家中饲养以只从青海来的狼犬。因持续咳嗽半年余，间断咳血痰3个月。于1998年4月以“双飞阴影待查，先天性肺囊肿带排除”入院治疗。体检：心律齐，腹平软，肝肾正常。左肺叩诊浊音，呼吸音减低，双肺未闻及干啰音和湿啰音。胸部X线片：友肺下野外带可见6.5×4.5cm的阴影，左下肺内内带可见7cm×7.5cm及9cm×7.5cm大小阴影，双侧阴影均边缘光滑，密度均匀一致，阴影周围清晰，未见钙化及浸润性病灶。病人入院后痰量增加，办左侧胸痛和低热。经抗炎药治疗，肺部病灶无改变。后经B超定位下行左侧经费内包块穿刺抽去少许液体。穿刺液内查到棘球蚴的原头节，经包虫皮试和ELISA试验均为强阳性，诊断为肺棘球蚴病；即行左下肺切除术。术后给予阿苯达唑600mg/d治疗，口服一年，随访至今健康。1.上述症状中哪些与包虫病有关？
2.包虫病是如何感染人体的？应该怎样预防？
3.包虫病多流行于西北地区，上海出生和生长且从未去过牧区的居民是真阳怎样感染包虫病的？
病例十六
A 49-year-old woman presented with high fever and chills, jaundice, and upper abdominal pain for 3 days.The patient was a recent immigrant from Argentina.One year before, she first noticed a sensation of fullne in the right upper quadrant of her abdomen.Her part medical history was unremarkable.In her country of origin, she had been, healthy and active, working in the field and breeding and raising sheepdogs.PHYSICAL EXAMINATION VS: T 39.5℃, P 112/min, R 18/min, BP 102/60 mmHg PE: The patient appeared acutely ill and was obviously jaundiced.Right upper quadrant abdominal tenderne was noted.LABORATORY STUDIED Blood Hematocrit: 34% WBC: 22, 400/μl Differential: 55% PMNs, 20% bands, 12% lymphs, 8% eosinophils Serum chemistries: alkaline phosphatase 340 U/L;bilirubin 4.3 Imaging A CT scan of the liver demonstrated a large multiloculated cyst with bile duct dilation(Fig.51-1).Diagnostic Work-Up Table 51-1 lists the likely causes of the woman’s illne(differential diagnosis).A clinical diagnosis of hepatic hydatid cyst(tapeworm)disease was considered based on the imaging studies(CT scans of liver).Serologic tests specific for a tapeworm mat include.ELISA to detect IgG in patient’s serum(screening)Immunoblot aay to confirm the diagnosis
TABLE 51-1 Differential Diagnosis and Rationale for Inclusion(consideration)Cholanditis Hydatid cyst(tapeworm)disease Liver absce Viral hepatitis
Rationale: Clinical diagnosis is difficult;the history of exposure is helpful.The symptoms are suggestive of biliary tract infection, which may have many causes.Vital hepatitis would not produce lesions seen in the CT scan.The more common causes are listed above.Hydatid cyst is a poibility when appropriate epidemiology is present.COURSE Given the patient’s clinical status, she was taken to the operating room.The liver lesion was completely removed surgically, and the biliary obstruction was relieved.The patient received an antihelminthic drug postsurgery.An ELISA and subsequent immunoblot test for antibodies against a tapeworm confirmed the specific etiology.病例十七
A 9-year-old boy was brought to the hospital by his parents with complaints of repeating intense chills and daily high fever for 4 days.The parents said that when his fevers would abate,he would become drenched in sweat and feel exhausted and drained.The parents also reported diarrhea, nausea, and abdominal pain.On the days of admiion the patient was noted to be lethargic and difficult to arouse.A generalized seizure was witneed in the emergency department The family had immigrated to the United States from West Africa 3 weeks before the onset of the current illne.PHYSICAL EXAMINATION VS: T 40℃ , P 140/min, R 28/min,BP 82/40 mm Hg PE: Thin male minimally responsive to verbal commands.Pupils were reactive and neck was supple.Conjunctiva was pale, and abdominal exam showed hepatosplenomegaly.LABORATORY STUDIES Blood Hematocrit: 18% WBC: 16300/μL
Differential: 50% PMNs, 15% lymphs, 20%bands.Platelets: 42000/μL Blood gases: pH7.28, Pco230mmHg, Po2mmHg Serum chemistries: Glucose 40mg/dL,BUN45mg/dL, AST240U/L,ALT310U/L, LDH820U/L, creating2.6mg/Dl.l
Imaging Head CT was unremarkable.Diagnostic Work-Up Table 79-1 lists the likely causes of illne(differential diagnosis).Investigational approach for specific microbiologic diagnosis may include Lumbar puncture and CFS examination to rule out bacterial meningitis.Blood cultures to detect blood-borne bacteria
Thick and thin smear for blood-borne parasites
In failed diagnosis, virus-specific serology for the listed infections.Table 79-1 Differential Diagnosis and Rationale for Inclusion(consideration)African trypanosomiasis Aspetic meningitis Babesiosis Bacterial meningitis Dengue fever Leptospirosis Malaria Typhoid fever
Rationale: A diagnosis shouble be aggreively sought in patients who present with sever It is always important to rule out bacterial meningitis initially.Epidemiology is important for a patient to determine the poible history of exposure in an area endemic for a variety of infections.Typhoid fever and parastic infections are geographically limited, so a good history of travel is important as well.Babesiosis is found in the northeastern and upper Midwestern U.S., and leptospirosis is aociated with animal exposure.Dengue, malaria, and trypanosomiasis are all endemic in Africa, with the latter two infections typically causing periodic fever.COURSE The patient was admitted and required mechanical ventilation for impending respiratory failure.Lumbar puncture was performed, which was normal.Blood cultures were drawn and were negative for biood-borne pathogens.Based on the given history of travel,thick and thin blood smears were performed and yielded a diagnosis.病例十八A 30 year-old white women was brought to the emergency department of a local hospital with a 2-week history of progreively severe headache, nausea, and vomiting;several seizures had occurred over the past 2 days.She had been HIV positive for 3 years and had been diagnosed with AIDS a year before the current espisode.She had been on HIV therapy, but was currently failing her regimen.She was also on aerosolized pentamidine because of a bactrim allergy.Her brother, who brought her to the ED, could not recall any history of seizures.PHYSICAL EXAMINATION VS: T 38℃ , P 86/min, R 14/min,BP 104/70 mm Hg PE: She was in moderate distre due to the headache bnt was able to answer questions.Mild right-sided weakne was apparent on exam.LABORATORY STUDIES Blood Hematocrit: 34% WBC: 7400/μL
Differential: normal.CD4+ counts: 62/μL Blood gases: Normal Serum chemistries: Normal
Imaging Head MRI revealed ring-enhancing lesions in the left parietal lobe and right frontal lobe(Fig.63-1).Diagnostic Work-Up Table 63-1 lists the likely causes of illne(differential diagnosis).A clinical diagnosis of encephalitis was considered based on the evidence of brain lesions.Investigational approach may include.Cultures of blood and CSF for bacteria and Cryptococcus neoformans Serology.A significantly high titer of IgG specific for Toxoplasma gondii in a single serum may support the diagnosis of Toxoplasma encephalitis.In failed investigation, the following tests can be undertaken:
Histology of brain biopsy
Detection of genetic material by PCR in CSF and biospy
Table 63-1 Differential Diagnosis and Rationale for Inclusion(consideration)Cryptococcus neoformans Listeria monocytogenes Mycobacterium tuberculosis Nocardia asteroides Primary CNS lymphoma Progreive multifocal leukoencephalopathy(PML):JC virus Toxoplasma gondii
Rationale: Focal brain lesions are due to only a few causes in patients with AIDS.T.gondii and CNS lymphoma-the most common causes-can usually be differentiated basdd on lab and radiologic findings, although clinically, they may manifest similarly.The first three organisms are more likely to cause meningitis, as opposed to ma lsions with neurologic deficits.The other causes are much le common, and they may or may not exhibit ring enhancement.PMLdoes not usually cause ma lesions.COURSE The patient was admitted to the hospital for further evaluation and lab investigation.L umbar puncture revealed normal opening preure, and CSF examination showed WBCs 45/μL, protein 78 mg/μl glucose 64 mg/μl.Bacterial, fungal, and viral cultures of CSF were all negative.Based on results of a positron emiion tomography(PET)scan and serology tests, the the patient was empirically started on therapy.病例十九
A 41-year-old man presented with a 4-month history of worsening abdominal pain, diarrhea, nausea, and vomiting with blood.His abdominal pain was mainly in his right upper quadrant.The man had recently immigrated to the United States from Kenya.PHYSICAL EXAMINATION VS: T 37℃, P 110/min, R16/min, BP 136/80mmHg PE :An ill-appearing male in mild distre due to abdominal pain;enlargement of the liver and spleen, with mild tenderne, was noted.LABORATORY STUDIES Blood Hematocrit: 32% WBC: 9400/μL Differential: 54% PMNs, 20% lymphs, 18% eosinophils Serum chemistries: AST 78 U/L, ALT 92 U/L, bilirubin 3.2 μmol/L, albumin 3.1 g/dL
Imaging Abdominal ultrasound showed enlarged liver and spleen with evidence of portal hypertension.Diagnostic Work-Up Table 52-1 lists the likely causes of the man’s illne(differential diagnosis).Diarrheal stool specimens may be positive for blood.Routine enteric investigation may be a good start to rule out enteric bacterial causes of diarrhea;however, further investigation for specific microbiologic diagnosis may include Blood culture.Can aid in ruling out typhoid fever or other blood-borne agents that cause febrile illne Ova and parasite examination of stool
TABLE 52-1 Differential Diagnosis and Rationale for Inclusion(consideration)Dysentery syndrome
Entamoeba histolytica
Shigella dysenteriae
Infectious gastroenteritis(Salmonella)Inflammatory bowel disease Schistosomiasis Typhoid fever Viral hepatitis
Rationale: In a person from a superendemic area, infectious gastroenteritis must always be considered.Diarrhea is very common and is not very useful by itself for narrowing the differential diagnosis.Other symptoms, such as hepatosplenomegaly, are helpful because most common causes of diarrhea do not lead to this complication.Schitosomiasis is one of the causes that should be considered;it is very common in endemic areas.Typhoid fever is always a consideration in patients with fever and abdominal pain who have recently been in a developing country.Acute viral hepatitis should be considered in patients who have fever and right-upper-quadrant pain, although hematemesis would not be expected.COURSE Stool specimens and blood cultures were obtained.The patient was started on appropriate empirical therepy.Characteristic fluke eggs were identified in the concentrated stool after trichrome-staining.病例二十
A 42-year-old man presented to a clinic with complaints of 3 weeks of worsening diarrhea, abdominal pain, and fevers.He had noticed an itchy rash over his buttocks and groin area for the past 2 weeks.A 15-lb weight lo was also noted.A month before his symptoms started, he had returned from a 3-month trip to El Salvador, where he worked in a rural area.PYSICAL EXAMINATION VS: T 38.8℃, P 84/min, R 16/min, BP 112/62 mmHg PE: An erythematous maculopapular rash was present on his groin and buttock area.LABORATORY STUDIES Blood Hematocrit: 43% WBC: 10,200/μL Differential: 52% PMNs, 15% lymphs, 24% eosinophils Serum chemistries: Normal Imaging No imaging studies were done
Diagnostic Work-up Table 50-1 lists the likely causes of illne(differential diagnosis).Stool should be examined for leukocytes.Investigational approach may include Enteric(bacterial)cultures Microscopic(ova and parasite)examination Toxin testing for Clostridium difficile In failed investigation, colonic biopsy and histopathology to differentiate idiopathic ulcerative colitis and Crohn disease
Table 50-1 Differential Diagnosis and Rationale for Inclusion(consideration)Amebic dysentery Bacillary dysentery Clostridium difficile colitis Crohn disease Helminth infection Hookworms Strongyloides stercoralis Ascaris lumbricoides Trichuris trichiura
Rationale: The unique feature regarding this case is the significant degree of eosinophilia.This limits the differential eentially to parasitic infections.Other etiologies can also be considered if initial work-up is negative, although these would be rare in the presence eosinophilia.Noninfectious causes may be considered if infection has been ruled out.COURSE The patient was admitted to the hospital.A stool sample was sent to the state public health laboratory, where ova and parasite examination revealed nematode larvae.ETIOLOGY Strongyloides stercoralis(strongyloidiasis)
