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病例30-2017:精神状态改变、菌血症并有急性肝衰竭的65岁女性患者
Case 30-2017 — A 65-Year-Old Woman with Altered Mental Status, Bacteremia, and Acute Liver Failure


Roby P. Bhattacharyya ... 其他 • 2017.09.28

述评一:自身免疫性肝炎患者的脓毒症诊治

 

张文宏*,艾静文

复旦大学附属华山医院感染科

*通讯作者

 

本期NEJM介绍了一例感染相关的病例:65岁女性,糖皮质激素治疗后出现脓毒症及急性肝衰竭,经血培养诊断为空肠弯曲菌感染1

这例患者具有自身免疫性肝炎背景,合并肝硬化,同时为糖皮质激素治疗后,因此合并了众多造成免疫低下的因素。终末期肝病,特别是自身免疫性肝病患者,面临肠道菌群移位和肠道感染导致脓毒症的风险增高2,疾病进展至肝硬化以及糖皮质激素的使用都会显著增加感染的风险3。而合并脓毒症后,患者自身免疫性肝炎及肝硬化的背景使得感染可以迅速诱发肝衰竭,显著增加死亡率4。该病例虽得以在相对短的时间内明确病因,但患者最终死亡,更进一步显示了自身免疫性肝病进展至终末期时伴发感染的危险极高,并且预后极差。

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病历陈述


Alexandra J. Coromilas医师(内科):一例患自身免疫性肝炎和急性肝衰竭的65岁女性患者,为进行肝移植的评估而转入我院。

患者于此次入院6年前在另一家医院行肝功能检查提示异常结果,之前一直处于通常的健康状态。她随后进行了进一步检查,发现抗核抗体滴度升高。铜蓝蛋白、α1-抗胰蛋白酶和抗线粒体抗体水平均正常,组织转谷氨酰胺酶抗体和病毒性肝炎的检测呈阴性。医师做出了自身免疫性肝炎伴肝硬化的推定诊断,并推荐使用糖皮质激素治疗。然而,据称在随后1年中未经治疗情况下,肝功能试验结果恢复正常。





作者信息

Roby P. Bhattacharyya, M.D., Ph.D., Efren J. Flores, M.D., and Marwan M. Azar, M.D.
From the Department of Medicine, Division of Infectious Disease (R.P.B.), and the Departments of Radiology (E.J.F.) and Pathology (M.M.A.), Massachusetts General Hospital, and the Departments of Medicine (R.P.B.), Radiology (E.J.F.), and Pathology (M.M.A.), Harvard Medical School — both in Boston.

 

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