博文

目前显示的是 五月, 2015的博文

新英格兰:口内黑素瘤

一60岁女性口腔钝挫伤后上牙龈出现黑色变2月。患者既往体健,无吸烟史和饮酒史。体检示上颌前牙唇侧(图A)和腭侧(图B)可及弥漫性的黑素色素沉着,无牙齿松动,未及淋巴结肿大。X线未见骨质破坏,PET-CT示上颌前牙区可及高代谢信号,未见淋巴结转移。切除活检组织病理学检查示恶性黑素瘤。口腔内的原发性恶黑不常见。不幸的是口腔恶黑早期无明显症状,因此很可能延误诊断。该患者病变切除后进行化疗。诊断后随访26月病情复发且有远处转移。 Intraoral Malignant Melanoma A 60-year-old woman presented with a 2-month history of black discoloration on her upper gums after blunt trauma to the mouth. She had previously been well and was a lifelong nonsmoker and nondrinker. On examination, diffuse black pigmentation was seen on both the labial and palatal sides of the anterior maxilla (Panels A and B, respectively), without tooth mobility or palpable lymphadenopathy. No bone destruction was detected on a standard dental radiograph. A hypermetabolic signal was seen in the anterior maxillary area on positron-emission tomography–computed tomography, with no metastatic spread to the lymph nodes. Incisional biopsy and histologic analysis revealed malignant melanoma. Primary malignant melanoma is uncommon in the oral cavity.

新英格兰:肺萎陷

一位终末期肝病的46岁女性因复发性肝性胸水需多次胸腔穿刺,现出现呼吸困难而就诊。胸部检查右肺未及呼吸音,X线检查示右肺液气胸(图A中箭头所示气胸,星号示胸水)。猪尾导管排尽积水后仍持续性气胸(图B箭头所示)。胸部CT检查示肺萎陷(阻塞性肺不张后气胸),胸膜增厚,未见支气管阻塞(图C)。肺萎陷因慢性炎症引起的胸膜增厚阻止了肺复张引起。胸膜壁层不分离,其间充盈液体,从而引起液气胸。排净胸水后引起阻塞性肺不张后气胸的原因是肺不能再扩张到充满胸腔。阻塞性肺不张后气胸的其它原因排除了支气管阻塞。肺萎陷的治疗为手术治疗,切除纤维化的胸膜脏层以利于肺部扩张。该患者行胸腔镜手术切除了胸膜和胸膜固定术后右肺完全复张。 Trapped Lung A 46-year-old woman with end-stage liver disease that was complicated by recurrent hepatic hydrothorax requiring multiple thoracenteses presented with breathlessness. Chest examination found no breath sounds on the right side. Radiography of the chest revealed a hydropneumothorax (Panel A; the arrows indicate pneumothorax, and the asterisk hydrothorax). The hydrothorax was drained with the use of a pigtail catheter, with persistent pneumothorax (Panel B, arrows). A computed tomographic scan of the chest showed trapped lung (pneumothorax ex vacuo) with thickened visceral pleura and no evidence of endobronchial obstruction (Panel C). Trapped lung is due to fibrous visceral ple

新英格兰:眼结膜黑素瘤

一位78岁女性既往有青光眼史和糖尿病史。患者常规进行白内障检查,发现其右眼出现一红色斑和褐色斑丘疹病变。患者自诉该病变出现已1年,期间病变大小出现变化,偶有出血,但无疼痛、瘙痒或视力改变。行巩膜角膜切除术,并辅以冷冻治疗和外酒精外用。组织病理学检查示恶性结膜黑素瘤,伴原发性获得性不典型黑变病,厚1mm宽4mm。结膜黑素瘤可源于原发性获得性黑变病,常有局部转移,治疗后易复发。该患者辅助治疗有化疗和局部外用丝裂霉素。淋巴检查、骨扫描和头颈、胸腹CT检查未凶转移,治疗8月后未见复发。 Conjunctival Melanoma A 78-year-old woman with a medical history of glaucoma, diabetes, and cataracts presented for a routine ophthalmologic visit, during which she was found to have an erythematous and brown maculopapular lesion in her right eye. She reported that the lesion had been present for approximately 1 year, during which time it had fluctuated in size and bled occasionally, but that it had not been associated with pain, pruritus, or visual changes. An excisional scleral keratectomy was performed, followed by cryotherapy and alcohol application. Histopathological analysis revealed malignant conjunctival melanoma associated with primary acquired melanosis with atypia, measuring 1.0 mm thick and 4.0 mm in diameter. Conjunctival melanoma can

新英格兰NEJM:副肿瘤性神经性肌强直

一位70岁男性患有冠心病,慢性阻塞性肺疾病,40年吸烟史,2月来出现肌肉震颤和痉挛,汗多,并且体重减轻了10kg。体检发现肌纤维震颤(非自觉性肌肉颤搐,肌肉痉挛)和肌束震颤(可在此 观看视频 )。肌纤维震颤在睡觉时加重并持续存在。压缩肌肉后未见无力,强直,萎缩或者弛等现象。肌电力示特异性的神经性肌强直和肌纤维震颤放电特征。血清学检查示电压门控钾通道复杂抗体阳性(396pmol/l,正常值<85pmol/l)。根据临床表现,肌电力和血清学检查,诊断为神经性肌强直。这种强直是由于外周神经过度兴奋导致了肌纤维的激活。开始使用卡马西平治疗,但是症状控制不理想。可能是因为神经性肌强直可能是副肿瘤性的,患者有吸烟史和明显的体重减轻史,因此应该排除癌症的可能。锁骨上淋巴结活检显示小细胞肺癌。患者于3月后因化疗并发症而死亡。 Paraneoplastic Neuromyotonia A 70-year-old man with coronary artery disease, chronic obstructive pulmonary disease, and a 40-pack-year smoking history presented to a neurologist with a 2-month history of muscle twitching and spasms, excessive sweating, and a 10-kg weight loss. The physical examination revealed myokymia (involuntary, undulating muscle twitching) and fasciculations (see video ). Myokymia worsened with exercise and persisted during sleep. There was no muscle weakness, rigidity, atrophy, or delayed muscle relaxation after contraction. Needle electromyography showed characteristic neuromyotonic and myokymic discharges

新英格兰NEJM:慢性肾病引的甲改变

一位59岁女性16年前左肾因多囊肾而进行了肾移植,3年来指甲出现了改变。该患者一直接受强的松,霉酚酸酯和他克莫司的免疫抑制治疗。该患者处于慢性肾闰4期,一年来出现血肌酐水平升高(1.7-2.2mg/dl「150-194umol/l」),血尿毒瘾氮升高(26-28mg/dl 「9.3-13.6mmol/l」)。查体发现患者的所有指甲远端50%的部分甲床呈粉红色,近端出现白色带。Lindsay甲,也叫对半甲,最早见于1967年报道,指慢性肾病患者20-60%的甲床出现红色,粉红色或者褐色。氮质血症水平和甲床之间并无相关性。近端出现白色带可能与慢性贫血有关,褐色带可能与β-黑素细胞刺激激素增多而引起的黑色素沉积增多有关。本病无特殊治疗方法,以治疗原有疾病为主,控制慢性肾病是第一位的。 Lindsay’s Nails in Chronic Kidney Disease A 59-year-old woman who had undergone transplantation of the left kidney 16 years earlier for the treatment of polycystic kidney disease presented with an incidental finding of nail changes that had been present for at least 3 years. She was undergoing treatment with prednisone, mycophenolate mofetil, and tacrolimus for immunosuppression. She had stage 4 chronic kidney disease, with elevated levels of creatinine (1.7 to 2.2 mg per deciliter [150 to 194 μmol per liter]) and blood urea nitrogen (26 to 38 mg per deciliter [9.3 to 13.6 mmol per liter]) during the past year. On examination, all the patient’s fin