Many Hollow Lesions in Lungs, Patient Case Study
The patient, male, 67 years old, has a history of high blood pressure, gout, and schistosomiasis cirrhosis. He was admitted to the hospital due to "abdominal distension with swelling of both lower extremities for more than 3 months and fatigue with fever for 4 days."
The patient had bloating without obvious inducement more than 3 months ago, without abdominal pain, diarrhea, and no diagnosis and treatment. The symptoms of posterior bloating gradually increased, and he felt chest tightness and shortness of breath, and gradually appeared swollen orbits and extremities. After a certain degree of relief, with a reduction in urine output, see a local hospital.
Urine examination: urine protein 3+, biochemical: albumin 16.7 g / L, creatinine 171.4 μmol / L, urea nitrogen 11.96 mmol / L, uric acid 757.3 μmol / L.
CT scan of lung: cirrhosis, splenomegaly, ascites. Cardiac ultrasound: left ventricular diastolic dysfunction. The patient was admitted to the Department of Nephrology of our hospital for further diagnosis and treatment. A biopsy of renal puncture was performed on 2015-12-17. The pathology was in accordance with membranous nephropathy (stage I) with moderate-to-severe tubular interstitial lesions. treatment.
The patient developed fever after cold 4 days ago, with cough and sputum, and yellow mucus sputum. He went to the local hospital for treatment.
Measure body temperature at 38.6 ℃, check blood routine + CRP: white blood cell 18.7 * 109 / L, neutrophil classification 90.2%, CRP> 200 mg / L.
CT scan of lung: patch of right upper lobe, both lungs For multiple nodules, the body temperature dropped after anti-infection treatment with cefoperazone sulbactam needle + azithromycin needle, but cough and sputum increased, and he was admitted to our hospital for further diagnosis and treatment.
Physical Examination of Hollow Lesions in Lungs patient
P 85 times / min, R 18 times / min, BP
150/76 mmHg, T 37.1 ℃. Clear mind, good
spirit, no yellow staining of the skin sclera, superficial lymph nodes are not
enlarged.
The breath sounds of both lungs are thick, and a little damp rales can be heard.
The heart
rhythm was uniform and no pathological murmur was heard.
The abdomen was soft,
and there was no obvious tenderness and rebound pain.
The liver and spleen were less than the lower ribs. Murphy (-), mobile dullness (-), and no obvious edema in both lower extremities.
Consider that the patient has a history of repeated hospitalizations, a variety of chronic diseases, long-term use of immunosuppressive agents, there is a higher risk of infection by drug-resistant bacteria, the blood count and inflammation indicators of the outpatient hospital are significantly increased, and the anti-infection effect of enzyme-containing inhibitors is not good. The extensive coverage of meropenem strengthens anti-infection and further improves the relevant inspections.
Blood test + CRP: white blood cell count 18.41 * 10 9 / L, neutrophil classification 90.6%, CRP 82.2 mg / L; procalcitonin 1.12 ng / ml, biochemical: albumin 26.7 g / L, alanine aminotransferase 27U / L, creatinine 96.6 μmol / L, fungal G test negative, tuberculosis antibody positive.
CT scan of the lungs: multiple lesions in both lungs, considering conditional pathogen infection with multiple cavitation, partial bronchiectasis, and multiple mediastinal lymphadenopathy.
The basis of the patient's liver cirrhosis and chronic kidney
disease belongs to the immunocompromised host. Pulmonary imaging suggests
multiple hollow lesions, which need to be considered from two aspects:
infectious and non-infectious (tumor, vasculitis). The patient has an acute
onset, the blood and inflammation indicators are significantly increased, and
the anti-infection part is effective.
First of all, infectious lesions are
considered. They are divided into purulent and non-purulent lesions.
The main pathogens that can cause multiple hollow lesions in the lung are Staphylococcus aureus, Klebsiella pneumoniae, Streptococcus, Actinomycetes, Aspergillus, Cryptococcus, Mycobacterium, Nocardia, Parasites, etc.
No obvious abnormalities were found after complete bronchoscopy.
The smear and culture were negative.
The patient's body temperature is still fluctuating, 03-22 Blood culture return:
Nocardia, sputum smear: found a large number of Gram-positive Streptococcus, consider mixed infection, empirically adjusted to cefoperazone sulbactam needle + compound sulfamethazine With oxazole anti-infection treatment, the patient's cough and sputum were significantly improved, and his body temperature returned to normal (Figure 4). He was discharged from the hospital and ordered to continue anti-infection treatment for at least six months.
Clinically encountered immunocompromised hosts
This case reminds us that in clinically encountered immunocompromised hosts with unexplained fever, the conventional anti-infection effect is not good, especially when accompanied by special imaging manifestations, the possibility of opportunistic pathogen infection needs to be considered, and blood culture The diagnosis of sexual diseases is crucial.
Nocardia
Nocardia is an uncommon gram-positive bacilli, which is not a
normal flora of the human body. It is widely found in soil, decaying vegetables
and aquatic environment.
Since the cell wall of Nocardia contains mycolic acid, it is usually Presents varying degrees of acid resistance.
Nocardiasis
Its intrusion into the body includes inhalation (the most common), ingestion with food, and direct infection through the skin. Nocardiasis is regarded as an opportunistic infection. Most patients with Nocardia infection have impaired immune function. The most common are glucocorticoid therapy, malignant tumors, organ transplantation, hematopoietic stem cell transplantation, and HIV infection, but about 1 / 3 of the infected people have normal immune function.
Nocardiosis has two characteristics, one is the ability to spread to almost any organ (especially the central nervous system), and the other is that despite proper treatment there is still a tendency to relapse or progress. Severe nocardiasis includes some cases of lung infection, all cases of disseminated or CNS infection, and all cases of infection that involve more than one site in patients with compromised immune function.
TMP-SMX is recommended as part of the first-line treatment of nocardiosis. In vitro susceptibility testing and animal models of disease have confirmed that many antibiotics have anti-nocardia activity, including amikacin, imipenem, meropenem, Third-generation cephalosporins (ceftriaxone and cefotaxime), minocycline, fluoroquinolones (such as moxifloxacin), linezolid, tigecycline and dapsone.
For those with severe infections, combined treatment is
required. Due to the recurrent nature of Nocardia infection, for patients with
simple immune infections with normal immune function, doctors usually treat for
3-6 months, but if there is impaired immune function, it is 6-12 months.
Severe lung infection need to treat for 6-12 months or longer. All patients with CNS involvement should be treated for at least 1 year.
Refer:
Author's Bio
Name: Gwynneth May
Educational Qualification: MBBS, MD (Medicine) Gold Medalist
Profession: Doctor
Experience: 16 Years of Work Experience as a Medical Practitioner
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