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横纹肌溶解伴骨筋膜室综合征1例

2019-01-28 薛栋 中国骨与关节损伤杂志

患者,女,40岁。于入院前7h双下肢胀痛,逐渐加重,尤以左小腿严重。当天爬30层楼梯,睡眠中被双下肢疼痛惊醒。患者发病前常有过量活动,2年前因抑郁症住院治疗,出院后未服药,无明显相关症状。入院时精神可,痛苦面容,尿量少且呈茶色。查体可见双下肢明显肿胀、触痛,左小腿张力高,触痛明显,左侧足背动脉未触及,左小腿及左足皮温低,感觉减弱。常规检查:白细胞12.5×109/L,红细胞5.06×1012/L,

病例报道

患者,女,40岁。于入院前7h双下肢胀痛,逐渐加重,尤以左小腿严重。当天爬30层楼梯,睡眠中被双下肢疼痛惊醒。患者发病前常有过量活动,2年前因抑郁症住院治疗,出院后未服药,无明显相关症状。入院时精神可,痛苦面容,尿量少且呈茶色。查体可见双下肢明显肿胀、触痛,左小腿张力高,触痛明显,左侧足背动脉未触及,左小腿及左足皮温低,感觉减弱。常规检查:白细胞12.5×109/L,红细胞5.06×1012/L,血红蛋白151g/L,血小板371×109/L,肌酸激酶33877U/L,乳酸脱氢酶1998U/L,肌红蛋白>1000μg/L,血清钾3.8mmol/L,尿红细胞2+。电解质、心电图无异常。双小腿MRI显示双侧比目鱼肌、胫骨后肌高信号,左侧明显,左小腿后浅间室边缘可见高亮信号。确诊为横纹肌溶解综合征、左小腿骨筋膜室综合征,给予患者大量补液等基础治疗,监测电解质、肾功能。入院后10h行左小腿筋膜间室切开减压术,术中见浅层肌肉色白,深层肌肉色鲜红,充分减压小腿4个间室。术后查看肢体远端血运恢复,住院期间各关键检验指标恢复正常。术后30d行左小腿切口清创缝合,切口愈合后出院。

讨论

横纹肌溶解综合征是由于骨骼肌损伤导致细胞内物质释放到循环系统,以肌红蛋白尿、电解质异常和急性肾损伤为特征的临床综合征。临床上关于横纹肌溶解综合征的报道并不少见,但合并骨筋膜室综合征者并不多。横纹肌溶解综合征发生的原因可分为骨骼肌缺血低氧、物理因素、化学因素及生物因素。骨骼肌缺血缺氧常见于过量运动后,而肥胖及长时间手术都可能增加横纹肌溶解综合征发生的风险。物理因素包括创伤、电击和中暑等,化学因素包括药物、毒物等。生物因素相对少见,如可引起肌炎的任何细菌及病毒感染,以及被动物咬伤后进入体内的有机毒物。对于反复发生横纹肌溶解综合征的患者应考虑是否存在遗传性代谢或肌营养不良疾病。

骨骼肌损伤的主要表现为患肢明显疼痛、肿胀及功能障碍,出现红色或棕色尿液提示循环系统中可能出现大量的肌红蛋白,而肌红蛋白水平升高会严重损伤肾脏功能。本例出现尿量减少,肾排泄率降低,肾功能存在损伤。肌酸激酶和肌红蛋白可能升高10~100倍,其升高水平与肌肉损伤程度成正比,也与急性肾损伤的发生率成正比,横纹肌溶解综合征的诊断及预后与此相关。另外需监测血小板计数及D-二聚体,警惕出现弥散性血管内凝血。横纹肌溶解综合征的治疗主要以阻止进一步骨骼肌损伤,预防急性肾功能衰竭,预防并处理可能危及生命的高钾血症。早期补充大量液体以恢复肾灌注和增加尿液流量,并促进代谢物的排出,另外血液透析可以迅速改善症状,防止出现急性肾损伤,极大地降低患者病死率。监测血钾并持续心电监测防止发生心律失常。由于骨骼肌损伤引起的肌肉炎症及水肿可能二次增加局部压力并阻断血液循环,如果出现患肢疼痛加重,远端肢体无动脉搏动及皮温下降,应及时切开减压,防止发生远端肢体缺血坏死。

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    2019-01-29 ylzr123

    感谢小编为我们准备了如此丰盛的精神大餐,同时也向作者致谢!认真学习了,点赞!

    0

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