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病例漫谈112:NEJM:弥散性芽生菌病 [复制链接]

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银光图片

患者为一名39岁男子,因急性咯血和寒战而就诊。


该患者胸部计算机断层扫描(CT)显示右上肺叶浸润病灶(如图A所示),他接受了左氧氟沙星治疗。就诊后一个月,他左手无名指出现疼痛和肿胀。在检查时发现手指有红斑、肿胀和压痛(如图B所示);X光片显示为骨髓炎。



进行初次胸部CT八周后,进行了再次胸部CT扫描显示右上肺叶持续浸润病灶。在近节指骨出现脓液并进行引流。用氢氧化钾制剂染色显示具有广泛出芽的酵母(如图C所示)。将脓液标本及痰标本进行培养得到了皮炎芽生菌。


病史记录显示,该病人曾在去年夏天在明尼苏达北部徒步旅行。在患者的病程中这一事件表明患者感染皮炎芽生菌发生在明尼苏达北部,表现为最初的肺疾病和随后的血行播散到创伤部位,导致骨髓炎和脓肿形成。


该患者被诊断为播散性芽生菌病,并接受口服伊曲康唑治疗1年,在治疗的这段时间内,患者手指已经愈合,肺浸润也已得到解决。


原文来自:

Disseminated Blastomycosis

The new EnglandJournal of Medicine


    A 39-year-old man presented with acutehemoptysis and chills. Computed tomography (CT) of his chest showed aninfiltrate in the right upper lobe (Panel A), and he was treated withlevofloxacin. One month after this presentation, his 5-year-old son pulled onhis left ring finger, which caused pain and swelling. On examination, thefinger was erythematous, swollen, and tender (Panel B); a radiograph showedevidence of osteomyelitis. Eight weeks after the initial chest CT, a follow-upchest CT scan showed persistent infiltrate in the right upper lobe. Purulentfluid was found around the proximal phalanx and was drained. Staining with apotassium hydroxide preparation revealed yeast with broad-based budding (PanelC). Cultures of the purulent fluid specimens and sputum samples grewBlastomyces dermatitidis. History taking at this time revealed that the patienthad gone hiking in northern Minnesota during the preceding summer. The events inthe patient’s illness suggest that acquisition of B. dermatitidis occurred innorthern Minnesota and manifested as the initial pulmonary disease andsubsequent hematogenous spread to a traumatized digit, leading to osteomyelitisand abscess. A diagnosis of disseminated blastomycosis was made, and thepatient was treated with oral itraconazole for 1 year, by which time the fingerhad healed and the pulmonary infiltrate had resolved.

最后编辑蛋蛋JY 最后编辑于 2017-03-13 14:53:06
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