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罕见!毛霉菌竟然引起自发性胃穿孔

2019-02-19 蒲公英 医博士

自发性胃穿孔是消化道溃疡性疾病的常见并发症之一,而毛霉菌病是一种罕见的机会菌感染,通常见于免疫功能低下的患者,这种罕见的通过血管入侵性的毛霉菌病可引起鼻,肺,皮肤,胃肠,肾脏病变,但原发性胃肠道感染毛霉菌实属罕见,本例病案报道毛霉菌感染引起的自发性胃穿孔的罕见病例。

自发性穿孔是消化道溃疡性疾病的常见并发症之一,而毛霉菌病是一种罕见的机会菌感染,通常见于免疫功能低下的患者,这种罕见的通过血管入侵性的毛霉菌病可引起鼻,肺,皮肤,肠,肾脏病变,但原发性胃肠道感染毛霉菌实属罕见,本例病案报道毛霉菌感染引起的自发性胃穿孔的罕见病例。

病例介绍

一名52岁的女性患者因手臂出现蜂窝组织炎于急诊科就诊,患者既往患有吸食海洛因,糖尿病高血压和慢性肾病(需透析治疗)病史。急诊下行局部切开引流并使用广谱抗生素(IV),哌拉西林,他唑巴坦治疗,但病情未好转并继续恶化,发生了败血症并伴有持续性腹痛,后被转移至重症监护病房(ICU)。

生命体征:血压80/50mmHg,体温38℃,心率120次/分。查体:腹胀,板状腹,肠鸣音弱。实验室检查发现酸中毒,白细胞计数增高。

鉴于患者的症状和临床表现,进行了全腹增强CT检查,结果提示:胃壁水肿增厚,腹腔游离气体,消化道穿孔可能性大(图1)。随即急诊下行剖腹探查术,发现腹腔大量胆汁性液体,逐一检查腹腔脏器,发现胃穿孔,胃透壁性坏死(图2),其余未见明显异常。术中行上消化道内镜检查,发现食管组织活性尚可,但由于血流动力学不稳,患者行全胃切除术,空肠造瘘。术后病理提示:胃粘膜广泛溃疡,胃壁全层致密急性炎症和多上皮样肉芽肿,证实有侵袭性毛霉菌感染(图3,图4)。


图1,全腹增强CT提示:腹腔内大量游离气体,表明腹腔内有空腔脏器穿孔(红色箭头),胃壁积气或胃壁内积气(蓝色箭头)


图2,透壁胃坏死的术后标本,箭头指向穿孔部位


图3,毛霉菌病的组织学表现的照片,通过光学显微镜检查胃壁组织切片。真菌形式的毛霉菌病的组织学显示非隔膜菌丝和血管侵润,导致组织坏死


图4,毛霉菌病形态的显微照片

术后第二天拔管,使用广谱抗生素治疗,包括美洛培南,甲硝唑,卡泊芬净。在术后第四天,辅助使用脂质体两性霉素B治疗。然而,由于败血症和多器官衰竭,患者在术后第21天死亡。

结论

继发于侵袭性毛霉菌的透壁性胃坏死引起的胃穿孔是罕见的,了解这种真菌病原体的侵入特性及其临床表现和毛霉菌感染的患者危险因素有益于疾病的早期诊断管理。对于毛霉菌病的诊断需要高度怀疑,建议采用脂质体两性霉素B进行初始辅助治疗有助于改善患者愈后。

原始出处:

Termos S, Othman F, Alali M, et al. Total Gastric Necrosis Due to Mucormycosis: A Rare Case of Gastric Perforation. American Journal of Case Reports. 2018; 19:527-533. doi:10.12659/AJCR.908952.

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  5. [GetPortalCommentsPageByObjectIdResponse(id=971346, encodeId=9a039e134620, content=<a href='/topic/show?id=694a63e113e' target=_blank style='color:#2F92EE;'>#毛霉菌#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=77, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=63711, encryptionId=694a63e113e, topicName=毛霉菌)], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220519/c2ab253484ee4527a2d4e9589a4821ac/45de9bf494a54becb2ea4369c9d11e85.jpg, createdBy=7a3710, createdName=小小医者, createdTime=Sun Jun 06 18:21:12 CST 2021, time=2021-06-06, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1679320, encodeId=1eb716e932043, content=<a href='/topic/show?id=92008609344' target=_blank style='color:#2F92EE;'>#自发性胃穿孔#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=76, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=86093, encryptionId=92008609344, topicName=自发性胃穿孔)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=987827746195, createdName=syscxl, createdTime=Mon Apr 29 23:45:00 CST 2019, time=2019-04-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1723840, encodeId=49de1e2384099, content=<a href='/topic/show?id=36ea988949a' target=_blank style='color:#2F92EE;'>#霉菌#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=98894, encryptionId=36ea988949a, topicName=霉菌)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=6bd333549766, createdName=qingrejiedu, createdTime=Sun Sep 15 08:45:00 CST 2019, time=2019-09-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1377975, encodeId=c42d13e797549, content=<a href='/topic/show?id=0d1ce5437ef' target=_blank style='color:#2F92EE;'>#穿孔#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=61, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=75437, encryptionId=0d1ce5437ef, topicName=穿孔)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=0ee7414, createdName=lanyan20020086, createdTime=Thu Feb 21 10:45:00 CST 2019, time=2019-02-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1467408, encodeId=0913146e4080f, content=<a href='/topic/show?id=ef32e9539e8' target=_blank style='color:#2F92EE;'>#罕见#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=79539, encryptionId=ef32e9539e8, topicName=罕见)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=29f36868190, createdName=syscxl, createdTime=Thu Feb 21 10:45:00 CST 2019, time=2019-02-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1471856, encodeId=aeed14e185668, content=<a href='/topic/show?id=10db8325169' target=_blank style='color:#2F92EE;'>#胃穿孔#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=56, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=83251, encryptionId=10db8325169, topicName=胃穿孔)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=01a27182605, createdName=wgx308, createdTime=Thu Feb 21 10:45:00 CST 2019, time=2019-02-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1530586, encodeId=967815305866f, content=<a href='/topic/show?id=ed4a860e872' target=_blank style='color:#2F92EE;'>#自发性#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=46, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=86078, encryptionId=ed4a860e872, topicName=自发性)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=584a12117168, createdName=sodoo, createdTime=Thu Feb 21 10:45:00 CST 2019, time=2019-02-21, status=1, ipAttribution=)]
    2019-02-21 syscxl
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    2019-02-21 wgx308
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    2019-02-21 sodoo

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