博文

目前显示的是 四月, 2015的博文

新英格兰NEJM:二尖瓣环状钙化

一位81岁女性因口腔癌术后出现心衰。诊断表明患者围手术期体内水分过多并出现肺栓塞,这导致了患者术后出现心衰。胸片显示心脏部分出现一个大的密集钙化区,与二尖瓣钙化一致。二尖瓣钙化呈半圆形(术前正后位如图A和图B箭头所示,侧位如图C箭头所示)。胸部CT横切面示二尖瓣后外侧出现环形钙化(轴切面如图D箭头所示,短轴切面如图E箭头所示)。胸部超声检查示二尖瓣狭窄和中度返流,左心室舒张功能障碍,左室射心数为69%。老年人的二尖瓣钙化通常通过胸部X线检测到,一般认为是退行性改变,一般无明显临床症状。当二尖瓣钙化较重时,可以引起心脏瓣膜功能障碍(如本例患者),常导致完全性房室传导阻滞,二尖瓣返流,有时也会引起二尖瓣狭窄。二尖瓣钙化可能与糖尿病,高血压,高血脂血症,以及继发于肾衰甲状旁腺功能亢进有关。该患者住院期间通过口服药物进行保守治疗,未进行手术治疗,现已失访。 Mitral Annular Calcification An 81-year-old woman was transferred to the medical service with cardiac failure after surgery for oral cancer. A diagnostic workup indicated perioperative overhydration and pulmonary embolism as causative factors for her symptoms. Chest radiography revealed a large, dense area of calcification overlying the heart, consistent with mitral annular calcification. Calcification was semicircular in the location of the mitral valve, as seen on the preoperative posterior–anterior view (Panel A, arrowhead; Panel B, arrow, shows an enlarged view) and a lateral view (Panel C, arrowhead). Comput

新英格兰NEJM:胺碘酮诱发的轮生状角膜病变

一位50岁的的女性自述双眼可看到光晕数周。患者既往无眼外伤史和角膜屈光手术史。2年前患者口服胺磺酮治疗房颤。体格检查发现双眼矫正视力为20/20,并有轻度散光。眼裂隙灯检查示角膜上皮呈轮生状,即胺碘酮诱发轮生状角膜病的典型表现。眼的其它部分正常。轮生状角膜病是胺碘酮常见的副作用。角膜的改变极少引起视力障碍,但是有些患者可能会看到光晕和色环。胺碘酮其他眼部副作用还有白内障和视神经病变。建议患者不用担心,可以配载太阳镜以减轻光晕症状,另外坚持每年门诊随访。最后一次随访是就诊的12个月后,眼科仅有角膜沉积物,其他一切正常。 Amiodarone-Induced Vortex Keratopathy A 50-year-old woman was referred by her general practitioner after she reported seeing halos around lights through both eyes for a few weeks. She had no history of ocular trauma or previous refractive corneal surgery. She had begun taking amiodarone for atrial fibrillation 2 years previously. On physical examination, her best corrected visual acuity was 20/20 bilaterally. Refraction showed minimal astigmatism. Slit-lamp examination of the anterior segment showed a whorl-like pattern of corneal epithelial deposits bilaterally, characterizing amiodarone-induced vortex keratopathy (also called cornea verticillata). Other ocular structures were normal. Vortex keratopathy is a common side effect

新英格兰NEJM:成人会厌炎

一位65岁既往体健女性因咽喉痛,声音低沉和自我感觉发热7天而就诊于急诊科。体格检查示:患者体温正常,血压140/86mmHg,血氧饱和度正常(98%)。患者前颈部轻度肿胀并伴有压痛,颈部淋巴结未触及肿大,患者无流涎。X线示颈外侧软组织「拇指片」影(图A箭头所示),表明患者有会厌肿胀,提示会厌炎。CT示实体肿胀以及会厌部(图B箭头所示),舌根和舌扁桃体水肿。间接喉镜检查示会厌和舌根出现红斑和炎症,从而出现舌扁桃体的肥大,喉部再现痰。因可能出现气道阻塞的可能,给予患者头孢曲松钠和地塞米松治疗,并留观了48小时。患者血培养一直为阴性。第3天患者症状消失,患者可以进食。患者出院后给予头孢呋辛治疗1周。 Epiglottitis in an Adult A previously healthy 65-year-old woman presented to the emergency department with a 7-day history of throat pain, difficulty swallowing, muffled voice, and subjective fevers. On presentation, she was afebrile and hemodynamically stable with normal oxygen saturation (blood pressure, 140/86 mm Hg; oxygen saturation, 98% while the patient was breathing ambient air). Physical examination revealed mild tenderness and swelling in the anterior neck, without cervical lymphadenopathy or drooling. Lateral soft-tissue radiography of the neck showed the “thumb sign” (Panel A, arrow), indicating a swollen epiglottis, suggestive of epiglottitis. Computed tomography of the neck re

新英格兰NEJM:指纹消失

一65岁女性乳腺癌Ⅳ期患者在银行交易时不能授权,因为系统无法辨认的指纹(图A)。3月来该患者因三阴性乳腺癌(即雌激素受体,孕激素受体和人表皮生长因子受体2缺失的一种乳腺癌)接受卡培他滨和贝伐单抗治疗。在第一个化疗期间,出现1级手-足综合症(掌跖红肿),但是通过局部治疗症状后消失。手-足综合症是某些化疗药物的副作用,以手掌和足部的红肿疼痛为特征。经过第三个化疗疗程,手-足综合症症状加重,并且出现自我护理活动受限。PET-CT示乳腺癌的肺转移减少了50%,患者终止了卡培他滨的治疗,之后又维持在小剂量的治疗水平。患者没有出现更严重的毒副作用,但拇指指纹(图B)和手指指纹(图C)消失了。我们给他提供了一封关于指纹消失的说明信,指出乳腺癌的化疗是造成指纹消失的原因。 Loss of Fingerprints A 65-year-old woman with stage IV breast cancer presented after being denied authorization to perform a banking transaction because her fingerprints were unrecognizable (Panel A). For 3 months, she had undergone treatment for triple-negative breast cancer (a tumor characterized by the lack of expression of estrogen receptor, progesterone receptor, and human epidermal growth factor receptor type 2 [HER2]) with capecitabine and bevacizumab. During the first cycle, grade 1 of the hand–foot syndrome (palmar–plantar erythrodysesthesia) developed and was successfully treated with topical agents. The hand–foot syndrome is a side effect of certai

新英格兰NEJM:眼前房出血

一33岁男性猪饲养员因双眼出现突发性双眼视模糊、疼痛、发红和畏光而就诊。患者有10天的持续高热史(39.4℃),全身不适和肌肉疼痛史。眼科检查示双侧虹膜睫状体炎(前葡萄膜炎)。泼尼松龙滴眼液和软膏等局部治疗后疼痛和畏光减轻,但第二天左眼前房出现和血(图A 3点示位置有一光反射区,图B 9点位置示前房部分有一明亮区)。实验室检查示γ-谷氨酰转移酶为129U/L (正常值<55U/L),丙氨酸氨基转移酶为49U/L (正常值<45U/L),白细胞计数为11700/ml (正常值范围为4400/ml-11300/ml)。临床和实验室检查结果提示诊断为钩端螺旋体病。血清学检查钩端螺旋体 interrogans serovar serjoe 的IgM和IgG抗体阳性。眼前房出血常因眼外伤引起,但是在极少数病例可引感染引起。经过持续的局部和系统阿莫西林治疗,患者的症状逐渐消退,2周内实验室检查和视力也恢复正常,前房出血和眼部发红也在1月内消失。 Hyphema A 33-year-old man who was a pig farmer presented with sudden blurred vision, pain, redness, and photophobia in both eyes. He had a 10-day history of persistent fever (temperature, 39.4 C°), malaise, and myalgia. Ophthalmologic examination revealed bilateral iridocyclitis (anterior uveitis). Local treatment (prednisolone eyedrops and ointment and cyclopentolate eyedrops) alleviated the pain and photophobia overnight, but the next morning he had hyphema in his left eye (Panel A shows a view with the light-source reflection at the 3 o’clock position, and Pane

新英格兰NEJM:瘢痕疙瘩

一位24岁男性因肺包虫病而行手术治疗,术后8周在切口部位皮肤出现瘤样无症状病变。患者同时还行阿苯达唑作为辅助疗法。诊断为瘢痕疙瘩。瘢痕疙瘩一般因手术,外伤,烧伤或者皮肤炎症等损伤真皮而引起。瘢痕疙瘩易复发,所以不推荐手术治疗,一般可以采用糖皮质激素局部封闭治疗,激光治疗或者放射治疗方法,但疗效常欠佳。本例患者因皮损较大,采用手术切除治疗,同时进行糖皮质激素局部封闭。术后1月未见复发,现已失访。 Incisional Keloid A 24-year-old man underwent thoracic surgery for pulmonary hydatid disease, and 8 weeks later, asymptomatic, tumorlike, cutaneous lesions developed over the incision site. The patient was receiving albendazole as an adjunct therapy. A clinical diagnosis of keloid was made. Keloids typically occur in response to dermal injuries such as surgical wounds, lacerations, burns, or inflammatory skin conditions. Because recurrence is common, surgical removal is generally not recommended; treatments with glucocorticoid injections, laser therapy, or radiotherapy may be tried but are usually associated with a poor response. Given the large size of the lesion in this patient, surgical excision was performed, with an immediate infiltration of glucocorticoids. There was no recurrence 1

新英格兰NEJM:人体内长鸡蛋

新英格兰杂志发表了一篇报道:患者体内长了一个“鸡蛋”。 一位62岁的老年男性因20多年的尿频来诊。体格检查和实验室检查无特殊发现。腹部和骨盆CT显示8.5cm大小的包块,中央出现钙化(图A红色箭头所示)。该包块对膀胱形成压迫(图A蓝前头所示)。腹腔镜检查发现包块活动良好,表面光滑,质硬,大小约9.5cmX7cm,重约220g(图B和图C)。对包块进行切开发现其可分为数层(为了清楚的显示边缘,对外层进行了绿色染色)(图D)。组织病理学检查发现包块主要是呈分层排列的非细胞成分(纤维组织),还有类蛋白样物质和纤维素样坏死物质,周围是钙化圈。该结果与腹腔游离体一样,一般认为是由肠扭转,肠血管梗塞以及游离的肠脂垂等形成的纤维化团块。这种团块小的时候常常无明显自觉症状,但是随着团块的增大,可以导致压迫周围组织,从而引起躯体症状,如肠梗阻,尿潴留或者尿频(本例患者就是出现的尿频)。经过手术取出包场后,患者的尿频症状痊愈。 Peritoneal Loose Body A 62-year-old man presented for evaluation of a history of urinary frequency of more than 20 years. The physical examination and laboratory findings were unremarkable. Computed tomography of the abdomen and pelvis revealed an 8.5-cm midline mass with central calcification (Panel A, red arrow) superior to and compressing the bladder (Panel A, blue arrow). Laparoscopy revealed a free-floating, smooth, firm, rubbery mass measuring 10 cm by 9.5 cm by 7.5 cm and weighing 220 g (Panels B and C). The sectioned specimen included several layers; green ink was used to del