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2018CSE:三个病例,详解糖尿病酮症酸中毒的诊断“陷阱”!

2018-08-26 渝小苏 医学界内分泌频道

糖尿病+酮症+酸中毒=DKA?这3个病例让你大开眼界。

糖尿病酮症酸中毒(DKA)是临床中常见的糖尿病急性并发症之一,它由于胰岛素不足或作用明显减弱和升糖激素不适当升高引起的糖、脂肪和蛋白质代谢严重紊乱综合征,临床上常表现为:高血糖、高血酮和代谢性酸中毒。
 反过来而言,在临床上遇到血糖升高,高血酮或尿酮阳性,同时合并代谢性酸中毒的患者,能够100%确定DKA的诊断吗?
 
在昨天的中华医学会第十七届内分泌学分会年会上,来自吉林大学白求恩第一医院的王桂侠教授从3个病例出发,讲解如何避免DKA诊断中的“习惯性思维”。
  

图:王桂侠教授现场演讲
 
病例1

53岁男性,突发视力模糊、乏力、恶心、呕吐2天,失明及呼吸困难1天。既往:2型糖尿病史6年,吸烟饮酒史。

血糖 17.9mmol/L,HbA1C 9%,尿酮体1+,pH 7.14,pO2 92mmHg,pCO2 10mmHg,HCO3- 3.4mmol/L,BE -22.6mmol/L。
 
初看病例,以为DKA确诊无疑。可是,该患者同时合并突发视力障碍,尿酮体仅1+,但代酸严重。你认为可能的诊断是?
 
追问病史发现,患者在发病前有饮酒史,而且朋友也出现了与其类似的症状。加上合并失明这一特殊情况,最终查明其病因是甲醇中毒。

甲醇中毒有主要3大表现:

① 神经系统损害:甲醇对神经系统有直接的麻醉作用,轻者表现为头痛、头晕、乏力、嗜睡等症状,严重出现昏迷、癫痫样抽搐;

② 眼部症状:由于甲醇及其代谢物甲醛、甲酸在房水和眼组织内含量较高,致使视网膜代谢障碍,易引起视网膜细胞、视神经损害及视神经脱髓鞘。因此常见视力模糊甚至失明。

③ 代谢性酸中毒:甲醇及代谢物抑制某些氧化酶系统,致需氧代谢障碍,体内乳酸及其他有机酸积聚。血气分析为AG(阴离子间隙)升高性代谢性酸中毒表现。

病例2

56岁女性,发现血糖升高15年,乏力、恶心、呕吐4天,加重伴周身酸痛,尿量少,尿色深2天。既往有高血压史15年。

血糖 4.9mmol/L,尿酮体 2+,pH 7.2,pO2 79mmHg,pCO2 23mmHg,HCO3- 9mmol/L,BE -17.3mmol/L,肌酐 182mmol/L,AST 292U/L。

患者有糖尿病史,尿酮阳性合并代谢性酸中毒,但是血糖不高,同时合并周身疼痛、尿量少、尿色深,实验室检查发现肝肾功能异常。可能的诊断是?
 
追问病史发现,患者4天前服用某诊所“中药”后发病,查肌酸激酶:15725U/L,肌红蛋白:7897ng/mL,考虑诊断为:横纹肌溶解综合征。

横纹肌溶解综合征是由各种原因引起的横纹肌细胞受损溶解,从而肌细胞内容物释放入细胞外液及血液循环引起的综合征。它的病因除了剧烈体力活动、肌肉直接损伤缺血外,部分药物也会有横纹肌溶解的风险,如他汀类药物、环孢素A、伊曲康唑等,其他病因还包括酗酒、感染、结缔组织病等。
 
该病最典型的表现是肌肉疼痛、无力以及酱油色尿液,部分患者可以没有明显的肌肉疼痛,而仅以乏力为临床表现,也可出现不典型的症状如恶心、呕吐等。实验室检查可发现血清肌酸激酶、肌红蛋白明显升高,同时肌酐、尿素氮、尿酸水平升高,代谢性酸中毒及电解质紊乱,尿液为肌红蛋白尿,镜检无或少量红细胞。

病例3

86岁男性,糖尿病4年,四肢无力2天。既往白癜风病史30余年,发现低钾血症1年,间断补钾。

血糖 14.8mmol/L,HbA1C 8%,尿酮体 1+,pH 7.34,pO2 94mmHg,pCO2 28mmHg,HCO3- 17mmol/L,BE -6.4mmol/L,血钾 2.4mmol/L。

该患者高血糖、尿酮阳性、代谢性酸中毒,同时合并严重低钾血症,其血钾降低程度似乎无法用DKA解释。可能的诊断是?
  
计算阴离子间隙发现:AG=[Na+]+[Cl-]+[HCO3-]=137-(107.5+17)=12.5(正常),同时查患者尿pH 6.5,氯化钙负荷试验阳性,考虑为I型肾小管酸中毒(继发于干燥综合征)。
肾小管酸中毒(RTA)是由于肾小管泌氢障碍或碳酸氢根重吸收障碍导致的肾脏酸化功能障碍而产生的一种临床综合征,主要表现为AG正常的高氯型代谢性酸中毒,低钾,尿pH值增高(>6.0),肾小球滤过率相对正常。
 
肾小管酸中毒可分为4型:I型,远端RTA;II型,近端RTA;III型,兼有I型和II型的特点;IV型,高血钾型RTA。其中I型RTA分为原发性(遗传性)和继发性两种病因。它的诊断试验为氯化钙/氯化铵负荷试验。
 
总结:当遇到糖尿病合并尿酮阳性,同时代谢性酸中毒的患者时,切莫断定为DKA,而应该更多地了解患者的病史、症状和体格检查,以检查有无其他可能的病因。
 
在临床中,可先确定有无代谢性酸中毒,判断呼吸代偿系统反应,随后通过计算阴离子间隙而判断患者是否为AG升高或正常型代谢性酸中毒(见下图),从而分类进行逐一排查,最终找出正确的病因。
  

图:代谢性酸中毒的病因分析流程图

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  4. 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content=超赞的分享!学习了!丰富了自己的临床经验!, beContent=null, objectType=article, channel=null, level=null, likeNumber=77, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d7e71713450, createdName=太阳系小猪, createdTime=Mon Aug 27 07:22:35 CST 2018, time=2018-08-27, status=1, ipAttribution=)]
    2019-06-05 sjzlzc015
  5. 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content=超赞的分享!学习了!丰富了自己的临床经验!, beContent=null, objectType=article, channel=null, level=null, likeNumber=77, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d7e71713450, createdName=太阳系小猪, createdTime=Mon Aug 27 07:22:35 CST 2018, time=2018-08-27, status=1, ipAttribution=)]
    2018-08-28 mashirong
  7. 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  8. 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content=超赞的分享!学习了!丰富了自己的临床经验!, beContent=null, objectType=article, channel=null, level=null, likeNumber=77, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d7e71713450, createdName=太阳系小猪, createdTime=Mon Aug 27 07:22:35 CST 2018, time=2018-08-27, status=1, ipAttribution=)]
    2018-08-27 huangshang9812

    哈哈哈,学习了

    0

  9. 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content=超赞的分享!学习了!丰富了自己的临床经验!, beContent=null, objectType=article, channel=null, level=null, likeNumber=77, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d7e71713450, createdName=太阳系小猪, createdTime=Mon Aug 27 07:22:35 CST 2018, time=2018-08-27, status=1, ipAttribution=)]
    2018-08-27 1e145228m78(暂无匿称)

    学习了,谢谢作者分享!

    0

  10. 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content=超赞的分享!学习了!丰富了自己的临床经验!, beContent=null, objectType=article, channel=null, level=null, likeNumber=77, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d7e71713450, createdName=太阳系小猪, createdTime=Mon Aug 27 07:22:35 CST 2018, time=2018-08-27, status=1, ipAttribution=)]
    2018-08-27 太阳系小猪

    超赞的分享!学习了!丰富了自己的临床经验!

    0

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