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呼吸科经典病例推荐——支原体肺炎

2017-12-12 MedSci MedSci原创

由肺炎支原体引起的肺炎,曾称原发性非典型性肺炎,常见呼吸系统传染病,本病呈世界分布,以温带为主。全年均有发生,以秋季为主。呈周期性流行,间隔约4~5年,发病数可较常年高3~5倍。本病多在家庭、军队、学校或集体住宅区内流行,或呈地区性流行。本病起病缓慢,有发热、阵发性刺激性咳嗽,少量黏液性或黏液脓性痰(偶有血痰)。肺部体征多不明显,但易引起肺外多系统受累,也可威胁生命或死亡。好发于儿童或青少年,



由肺炎支原体引起的肺炎,曾称原发性非典型性肺炎
,常见呼吸系统传染病,本病呈世界分布,以温带为主。全年均有发生,以秋季为主。呈周期性流行,间隔约4~5年,发病数可较常年高3~5倍。本病多在家庭、军队、学校或集体住宅区内流行,或呈地区性流行。本病起病缓慢,有发热、阵发性刺激性咳嗽,少量黏液性或黏液脓性痰(偶有血痰)。肺部体征多不明显,但易引起肺外多系统受累,也可威胁生命或死亡。好发于儿童或青少年,约占肺炎总数的15%~30%,流行年可高达40%~60%;一般预后良好,为自限性疾病。

病史

患者女,29岁,平素体健,无烟酒等不良嗜好。患者15天前在运动出汗受凉后出现咽痛、咳嗽,伴发热,体温高达39.6℃,并咳少量黄色黏痰,无呼吸困难、胸痛及喘息等症状。 

于当地医院就诊,检测外周血白细胞为4.8×10^9/L,中性粒细胞为0.69,血红蛋白为137g/L,血小板为100×10^9/L。先后给予"克林霉素、阿奇霉素"静脉滴注,1周后体温下降至37.6℃,咳嗽、咳痰症状减轻,但未继续治疗。 

患者停药3天后再次出现发热,咳嗽及咳痰加重,体温达38.5℃,再次就诊,检测外周血白细胞为7.4×10^9/L,中性粒细胞为0.71,血红蛋白为142g/L,血小板为124×10^9/L(发病第10天)。X线胸片示左下肺片状渗出性病变,再次给予"阿奇霉素0.5g/d"静脉滴注,体温未下降,咳嗽及咳痰症状未减轻,未见尿色加深及皮肤黄染等体征。 

治疗4天(发病第14天)后复诊时外周血白细胞为5.4×10^9/L,中性粒细胞为0.60,血红蛋白为99g/L,血小板为248×10^9/L,次日为求进一步治疗来本院就诊,

查体

患者意识清,精神疲软头颅发育正常,精神状态安静,查体合作。周围浅表淋巴结未及肿大,全身无水肿,皮肤温、湿度及颜色无殊,无皮疹、结节等。颈软无抵抗,颈部血管无殊,未触及异常肿块。胸壁无静脉曲张,胸壁无压痛,剑突下见心脏搏动,无三凹征。胸廓正常无畸形,左下肺听诊可闻及湿性啰音,心脏听诊无殊。全腹触诊,腹肌软,无压痛及反跳痛,四肢无殊。

辅助检查:

胸部CT双下肺沿支气管树分布的渗出性病变,部分融合成片

骨髓穿刺红细胞增生活跃

静脉血涂片可见红细胞聚集现象

血常规:血白细胞4.1×10^9/L、、中性粒细胞62%、血红蛋白83g/L红细胞3.0×10^12/L血小板248×10^9/L网织红细胞4%。

大生化:血总胆红素16.3μmol/L直接胆红素3.7μmol/L、、血乳酸脱氢酶653U/L

尿常规:尿胆红素阴性尿胆原阳性

其他:D-二聚体1.3μg/L血清支原体抗体IgM阳性冷凝集素滴度1∶256直接抗人球蛋白试验(Coombs试验)示抗IgG阴性C3d阳性间接Coombs试验示自身细胞阳性2次血培养均未见细菌生长痰细菌培养无致病菌生长军团菌抗体阴性

简要解析:

肺炎支原体,曾名为类胸膜肺炎微生物(PPLO),是介于病毒与细菌之间的一种没有细胞壁的病原体,可通过细菌滤器。在琼脂培养基中生长时,需要含胆固醇的酵母浸出液及20%马血清。其菌落很小,很少超过0.5mm,肉眼不易观察。在显微镜下菌落呈圆形均匀的颗粒状,外围有透明带。MP呈球形、杆状和丝状等多种形态。仅有由三层膜组成的胞浆膜,革兰染色呈阴性。胞质内含核糖体和双股DNA。在有氧或无氧条件下生长较其他支原体为慢,接种后5~10天才能见到。能发酵葡萄糖产生乳酸,能产生过氧化酶类溶血素。


肺炎支原体基因组DNA全序列长835及849Kbp,分子量5.1×108


P1蛋白是肺炎支原体的膜表面蛋白质,分子量为170KD,具有抗原性和免疫原性,对黏附细胞与致病起重要作用。其基因序列已全部阐明,位点特异的13肽亦已合成。


肺炎支原体的核糖体大小约为70s,内含5、16及23s3种rRNA,并有50种左右的蛋白质,其中16srRNA有较保守的重复序列,且有种属特异性,常被用于探针杂交分型及PCR分型。肺炎支原体对呼吸道上皮细胞有特殊的亲和力,对青霉素耐药,对红霉素等大环内酯类抗生素极为敏感。


临床表现上,支原体肺炎存在以下特征:


1.潜伏期 6~35天,平均3周。


2.症状和体征 病情轻重不一,可以从无症状到严重的间质性肺炎。典型病例表现:起病缓慢,病初仅有头痛(69.8%)及乏力,2~3天后症状逐渐加重,出现发热、寒战(56%),随即发生咽痛(52.7%)、肌痛(41.8%)及咳嗽(10%的患者无咳嗽)。初始为干咳,后为顽固痉挛性剧咳,日轻夜重,甚至影响睡眠,剧咳可导致面部水肿、胸闷、胸痛、头晕、头痛,干咳无痰或咳后有白色黏液痰和脓痰,有时带血丝或咯血。少数患者出现胸骨后疼痛。发热见于80%以上的患者,热型不定,体温常在39℃左右,热程约1~2周。


肺部体征多不明显,大龄儿在整个病程中肺部常无任何阳性体征。少数患者仅在一周末时出现肺部体征,主要为肺部可闻哮鸣音及干湿啰音、胸膜摩擦音。晚期部分患者皮肤可出现斑丘疹、多形性红斑、结节性红斑。

 

完整病例请前往【梅斯医生】→病例库→呼吸→“发热伴咳嗽、咳痰15天,血红蛋白下降2天 

更多点评分析,趣味的学习,详情尽在梅斯医生上,您可以在这里体验模拟诊疗


下载链接:http://www.bioon.com/index_forword.asp?id=9429

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  2. [GetPortalCommentsPageByObjectIdResponse(id=1614714, encodeId=4bed1614e14dc, content=<a href='/topic/show?id=1f0a5e0662f' target=_blank style='color:#2F92EE;'>#支原体#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=56, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=57066, encryptionId=1f0a5e0662f, topicName=支原体)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=7fb019527746, createdName=ms5906905816781247, createdTime=Thu Dec 14 01:09:00 CST 2017, time=2017-12-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=269164, encodeId=74a926916499, content=了解了解.继续关注, beContent=null, objectType=article, channel=null, level=null, likeNumber=72, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=93f31631454, createdName=1dd8c52fm63(暂无匿称), createdTime=Wed Dec 13 17:06:59 CST 2017, time=2017-12-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=268987, encodeId=38a626898e31, content=学习学习学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzR8ylhYfiaoAUx2BsaYHVia1IKhG3Cg8CT84rBrn6iaVRkyAibJxBcLEXabOQ5p19vWgDe34ib5ErxNgx/0, createdBy=8a701629084, createdName=jihuaijun1112, createdTime=Wed Dec 13 01:02:39 CST 2017, time=2017-12-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=268878, encodeId=93a72688e8eb, content=后来呢?, beContent=null, objectType=article, channel=null, level=null, likeNumber=83, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=48ce1618316, createdName=stupidox, createdTime=Tue Dec 12 16:22:34 CST 2017, time=2017-12-12, status=1, ipAttribution=)]
    2017-12-13 1dd8c52fm63(暂无匿称)

    了解了解.继续关注

    0

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    2017-12-13 jihuaijun1112

    学习学习学习

    0

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    2017-12-12 stupidox

    后来呢?

    0

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