病原生物学病例讨论第二部分(20220216022223)

1、病原生物学病例讨论第二局部八年制临床医学专业使用上海交通大学医学院病原生物学教研室病例张某，男， 47岁，山西清徐县人，农民。因经常咳嗽以及咳血痰近4 个月，大便有时呈黑便，消瘦一个月余入院治疗。经当地卫生院检查先后拟诊为“支气管炎 “缺铁性贫血， 胃癌？治疗 2 个月余终不见好转。平素身体健康，无生食史，但有吸烟史。胃镜检查：食管 正常，胃部至胃窦部可见散在出血点，新旧交替；粘膜外表发现有大量约 0.51.0 cm 淡红色的寄生虫吸附，活检取出活虫 10 条，在出血点周围的炎症处取出活 组织 2 块送病理检查。体检及化验：贫血外貌，血色素 105g/L，红细胞计数 2.6 x 1012 /L

2、 260万/mm3，白细 胞计数x 1010 /L(10400/mm 3 )，出凝血时间正常，大便黑褐色，隐血" + ，红细胞"+, 涂片发现少许某寄生虫虫卵。腹软有明显压痛，肝胆未及。1 解释本病例中所有的病症和体征。2 胃镜检查的结果中可提供哪些重要线索？病理检查可能会出现哪些结果？3 诊断为肠道寄生虫病的主要依据是什么？应该确诊为哪种肠道寄生虫病？4 卫生院拟诊为“缺铁性贫血、胃癌有何依据？病例二吴XX,男，28岁，因腹痛，腹泻5天就诊。病史：患者于一个月前外出旅游，曾在当地饮食摊就餐屡次。5 天前，患者突感右下腹疼痛,腹泻,大便每日 10余次,为脓血粘液便,量大,腥

3、臭,伴明显里急后重感,曾自 行口服黄连素止泻,腹泻无好转。患者自觉乏力,无发热。小便正常,睡眠尚可。既往身体 健康,无慢性腹泻史,无药物过敏史。C, P 86次份，R 20次/分，Bp 120/80mmHg，无皮疹和出血点，浅表淋巴结未触及， 巩膜不黄,咽 (-),心肺 (-) ,腹平软,右下腹轻压痛,无肌紧张和反跳痛,未触及肿块,肝脾 未触及,腹水征 (-) ,肠鸣音稍活泼,下肢不肿。化验： 大便常规为粘液脓血便, 镜下红细胞数增高,有时可见堆积成团,明显高于白细 胞。粪便涂片检查,发现具有活动性的滋养体,尿常规(-)。问题：1 根据上述病史,写出诊断及诊断依据。2写出该病与常见的菌痢的主要

4、鉴别诊断列出两者的主要鉴别点。3写出该病的治疗原那么。病例三周XX女性，70岁，农民，安徽霍邱人。因纳差、乏力、上腹不适、反复黑便2月于2007-08-02 入院。上腹不适多于进食后缓解，黑便多为成形黑便，每日一到二次。外院病历显示：大便隐血阳性，HB：51g/L ，胃镜示浅表 -萎缩性胃炎，经抑酸、止血处理后上腹部不适好转，但血红蛋白下降至 36g/L 。年轻时喜食生米。既往曾因“贫血在当地医院就诊，予驱虫治疗，具体不详。否认 其他病史。体格检查：T： 36.4o C P: 80 次/分，R 20次/分，BP： 110/60mmhg，贫血貌，其他 无明显阳性体征。2007-08-03血常规：

5、HB:38g/L , X 1012/L, MCV平均红细胞体积正常值：93.28fl。 粪常规：黄色，隐血阳性。肝功能：总蛋白： 57g/L ，白蛋白： 32g/L ，余正常。乙肝两对半、甲肝抗体、戊肝抗体 均为阴性，CEA AFP Ca199均阴性。初步诊断：下消化道出血诊断依据 :外院胃镜未见出血病灶出血原因：下消化道肿瘤 下消化道血管病变 炎症性肠病2007-08-06 肠镜回肠末端见多条长约 5-10m m白色线状虫体，活动，回盲瓣局部粘膜红肿。病理：回盲瓣肠粘膜慢性炎，间质内见嗜酸性粒细胞浸润。2007-08-07 胃镜食管未见异常， 胃粘膜贫血相， 十二指肠球部未见溃疡， 降部见数

6、条白色线状虫体，性 状同肠镜下所见。2007-08-09 粪便找到钩虫卵，未查见其他虫卵及阿米巴原虫。入院后予抑酸、止血、输血治疗。2007-08-07 开始驱虫治疗甲苯咪唑：0.2 一日两次，口服。同时予铁剂、维生素C治疗贫血。治疗结果：患者纳差、乏力明显改善2007-08-13 复查血常规：HB:66g/L， RBC:2.95*1012/L ，网织红细胞： 1.90%。2007-08-14胃镜复查：十二指肠降部未见寄生虫。问题：1 该病例在外院治疗有什么教训可吸取？2为什么该病例初步诊断是“下消化道出血？3为什么肠镜检查时会在回肠未端显示有钩虫寄生？病例四 A 3-year-old gir

7、l was brought to the emergency department.of a general hospital following a 3-week history of nausea, poor appetite, and abdominal pain. She had not had any bowel movements for the last 2 days.The patient was of Mexican origin and had recently moved from Mexico with her mother to South Texas.PHYSICA

8、L EXAMINATIONVS: T 37 C , P 110/min, R20/min, BP 102/54mmHgPE :Young child in moderate distress due to abdominal pain. Abdomen was distended and mildly tender.LABORATORY STUDIESBloodHematocrit: 38%WBC: 4500/ 止Differential: 62% PMNs, 23% lymphs, 12% eosinophils(eosinophilia)Serum chemistries: NormalI

9、magingX-rays of her abdomen were consistent with intestinal obstruction.Diagnostic Work-UpTable 49-1 lists the likely causes of illness (differential diagnosis). Intestinal worm infection was considered based on clinical features and x-ray evidence. Diagnosis is confirmed by identification of ova an

10、d parasites by microscopy of trichrome- or iodine-stained concentrated fecal specimens.TABLE49 1 Differential Diagnosis and Rationale for Inclusion (consideration)AppendicitisIntestinal helminth infectionAscaris lumbricoidesSchistosoma sppTaenia sppTrichuris trichiuraSmall bowel obstruction from vol

11、vulusRationale: Abdominal symptoms with eosinophilia have a relatively limited differential, mainly parasitic infection. The various causes can be reliably determined only through stool examination for ova and parasites. Noninfectious causes may also cause similar symptoms but will not demonstrate e

12、osinophilia.COURSEThe patient was admitted to the hospital and put on intravenous hydration. Stool examination revealed characteristic nematode eggs.病例五A 36-year-old man presented to the emergency department of a general hospital with a 10-day history of intermittent diarrhea and tenesmus , with blo

13、od and mucus visible in the stool .He had just returned from a working trip to India , where he had visited a rural town in the last week of his trip.PYSICAL EXAMINATIONVS: T 38.8 C , P 96/min, R 16/min, BP 130/80 mmHgPE: Ill-appearing male in mild distress; abdominal exam revealed mild diffuse tend

14、erness, and rectal exam was positive for blood .LABORATORY STUDIESBloodHematocrit: 44%WBC: 11,600/ 止Differential: 72% PMNs, 20% lymphsSerum chemistries: NormalImagingSigmoidoscopic examination revealed multiple small hemorrhagic areas with ulcers.Diagnostic Work-upTable 46-1 lists the likely causes

15、of illness (differential diagnosis). A clinical diagnosis of dysentery was considered. Investigational approach may includeEnteric (bacterial) culturesStool antigen test for amebic agentMicroscopic ( ova and parasite ) examinationTable 46-1 Differential Diagnosis and Rationale for Inclusion (conside

16、ration)Dysentery syndrome:Entamoeba histolyticaEnterioinvasive Escherichia coliSalmonella sppShigella dysenteriaeYersinia enterocoliticaInflammatory bowel disease (IBD)Rationale: The dysentery syndrome can be caused by multiple pathogens, and stool studies are required to definitively diagnose them.

17、 However, epidemiology (history of exposure) can be helpful. E. coli (amebic dysentery) and S. dysenteriae (bacillary dysentery), two of the most common colonic ulcerative diseases, are much more common in developing countries than in the Western hemisphere, and recent travel history should be obtai

18、ned to rule out these diseases. IBD should always be considered, although after infectious etiologies have been ruled out.COURSEThe patient was admitted to the hospital for observation. Microscopic examination of his stool showed many WBCs and RBCs. Microscopic examination of fixed and stained stool

19、 specimens subsequently revealed a significant pathogen.食源性感染寄生虫病例六张XX,男，40岁，吉林人，湖北省襄樊市某汽车制造厂工人。二周前感觉胃肠不适， 近几天发现眼脸部肿胀， 并逐开展为脸部肌肉有肿胀感， 全身肌肉酸痛，发烧。三天前在厂 医院就治, 服用黄连素和克感敏 3 天,不见病症缓解。 近日因全身肌肉酸痛加剧, 吞咽困难, 体温明显升高而入院治疗。询问病史中发现,在感觉胃肠不适前几天与同事在一饭店吃过火锅,食入猪、牛、羊 等,在吃火锅的同事中也有人出现类似病症。体检：体温在 38ooC 之间,咽喉部无炎症,心率 90 次 /分

20、左右,无杂音,肺部 。 腹软,肝不肿大、无明显压痛。四肢肌肉和脸部肌肉有明显压痛,但未见有包块。化验：血常规 WBC 19200 ,中性粒细胞 50%,淋巴细胞 32%,嗜酸性粒细胞 18%。尿 常规正常,粪检未查见虫卵。问题：1根据上述病史、体检及化验结果,你疑心患者是什么病？2要确诊此病,你认为还应当作哪些检查？3可采取什么治疗方法缓解病情,以进一步确诊疾病？病例七1 个月余患者刘某，男， 50 岁，浙江义乌县防疫站医师。病人主诉是：因间歇性咳嗽伴右侧胸痛1周，加重3d为，于1996年5月2日急诊入院。住院后发热 1天、咳嗽气促胸 痛，嗜酸性粒细胞增多。初诊为右胸膜炎，经抗感染、海群生治疗

21、病情好转。6 月初突然痰中带血丝、伴有盗汗，发现胸腔有胸水，施胸腔穿刺术，抽出淡黄色液体300ml ，胸水涂片检出抗酸分枝杆菌，结核菌PCR佥测阳性。既往史从事血吸虫病、肺吸虫病流行病学调查及 病原体别离工作 20 年；有食腌蟹、腌虾等习惯。给予吡喹酮4800mg辅以口服异烟肼、乙胺丁醇并肌注链霉素半个月，病情缓解，体 症消失而出院。1. 根据本病人的病症，考虑产生病症的主要疾病是什么？诊断依据是什么？ 2本病例突然发现胸腔有积水，提示哪些疾病的可能性较大？ 3本病患者从事的工作可以高度疑心可能的是那种寄生虫病？ 4该病人住院半月出院，在疾病治疗上应还须注意什么问题？病例八患者黄某，男性， 2

22、9 岁，湖南韶山人。以畏寒，发热伴乏力 1 周为主诉入院。患者于 1 周前因饮少量啤酒后感到上腹部不适，饱胀感；当晚出现畏寒、发热，体温达38C，无咳嗽、胸痛及咯血等病症。 住院后以上呼吸道感染进行对症治疗而无效。 血象常规检查， 嗜酸 性粒细胞 0.33，患者于 1 0年前患甲肝已治愈， 入院后给予抗炎抗过敏治疗， 初步诊断为“嗜 酸性粒细胞增多症，过敏性肺炎，急性肝炎而转入解放军某医院肝炎科。患者转入肝炎科后行静脉点滴促进肝细胞生长因子，口服保肝类药物等， 二周后复查功能仍为异常，疑为某寄生虫病。追问病史，患者喜爱钓鱼和下河捕鱼，但从未曾生食过鱼。 作华支睾吸虫皮实检查为 ，粪检直接涂片法

23、中未查见华支睾吸虫虫卵。口服吡喹 酮 2 周后食酸性粒细胞数和肝功能均恢复正常。1. 此病例最终证实属于哪种寄生虫病？是怎样感染本病的？2. 为什么在粪便中查不到华支睾虫虫卵？有几种可能性？3. 华支睾吸虫病和肝炎的病症上有哪些相似之处？在诊断上如何鉴别？病例九李某，大学在读学生，在某年十一月发现大便中带有白色物，大小呈指节样，见有多 节相连或单节样， 有时白色节片样物是破裂的， 也有完整的单节片有微蠕动。 该患者从粪便 中取出白色节片后去医院就诊。询问病史：患者在当年七月曾随父母去西双版纳旅游，自述在旅游中没有食过生猪肉。 但吃过“云南过桥米线 ，在傣族旅游区吃过猪肉的菜肴。猪肉菜肴为肉糜样

24、，发白，由当 地的麻椒类的作料和盐、味精等搅拌而成，口感麻、辣、香、鲜。体格检查：颈软，未触及肿大淋巴结；心、肺、血压均正常；腹软，无压痛和包块。粪便检查：见有带绦虫卵，对粪便中白色节片检查后，发现节片两侧呈分枝状。诊断：猪带绦虫感染治疗：经吡喹酮20mg/kg?d, Tid X3d治疗，驱出大量大小不等白色节片。问题：1该患者可能从哪些途径感染猪带绦虫的？2该患者经吡喹酮治疗后，如何确定驱虫疗效?3用什么药物驱虫可较好确实定驱虫效果？4该患者驱出成虫后还应注意什么问题？病例十陈XX,女，28岁，江西人，南昌市郊务农。婚后二年，近来停经一个多月，身感不适，估计有身孕， 在江西某市妇幼保健院产科

25、就诊。 经产科医生检查确诊其已怀孕约二个月，然后, 用在清学方法检测了风疹病毒、巨细胞病毒和弓形虫抗体,结果：风疹病毒和巨细胞病毒抗体均阴性,弓形虫 IgG 阳性。时隔半月,该孕妇第二次去该妇幼保健院就医。体格检查：颈软,未触及肿大淋巴结；耳根部位也未见肿大的淋巴结；心、肺、血压均正常。X 线检查：未见胎儿有钙化样病灶。医生告知： 孕妇有弓形虫感染, 弓形虫可通过胎盘感染胎儿, 并影响胎儿的发育, 造成 畸胎或脑组织发育异常等。建议作人流终止妊娠。问题：请你进一步从诊断、治疗和监测方面提出你的意见。组织内寄生虫病例十徐XX,男，50岁，上海人，上海市某公司经理，因高烧入某市级医院治疗。患者入

26、院前三天才从南非返沪， 自述在南非工作了三个月， 在刚到南非时服用过疟疾预防药。 在离 开南非前患者已有不规那么发热, 自服退热片无效。 在入院当天曾在某区中心医院按普通感冒 就治过,使用过头孢类抗菌素。 入院后每天都有不规那么发热, 头痛病症明显并逐渐加重,入 院前四天体温在 37ooc，检测颅内压有些增高。入院后血检结果也未检测到疟原虫，但考虑 其才从南非回来, 有疟原虫感染的可能, 除使用抗菌素和对症治疗外, 也使用了氯喹和伯氨 喹啉等抗疟药,但未见病症有所缓解。入院第 6 天上午,病人病症明显加重,出现昏迷。同 时再次进行血检, 结果在血中检获有疟原虫, 经防疫部门鉴定, 血片中疟原虫

27、满视野为恶性 疟原虫。入院第 7 天晚上,患者被诊断为脑型疟抢救无效而死亡。问题：1此患者在进入疟区工作时在疟疾预防存在什么错误？ 2医院在对此患者的疾病诊断方面存在什么问题？ 3根据此患者在南非工作期间感染疟疾,在治疗方面应使用哪种抗疟更合理？ 病例十二陈XX,女，62岁，内蒙古二连市的居民。8个月前无明显诱因突发双下肢无力，不能 行走。当地诊断为“脑积水,于 7 个月前,行侧脑室腔分流术 , 术后病情好转,但一个月 后病症复发。体检：双下肢肌张力增高 , 双侧眼底可见视乳头水肿 , 考虑脑室端已堵塞。MR I核磁共振检测表现：双侧侧脑室明显扩张，侧脑室周围可见异常阴影信号，三、 四脑室无明

28、显改变。仔细读片后发现 ,双侧侧脑室体部清晰可见囊壁,囊壁光滑,且局部与 脑室壁重叠的囊性病变 ， 脑室内壁可见阴影信号 ， 提示有颗粒状物体。右侧囊性病变占位大 小约 7 cmX 3 cmX 2.5 cm ,左侧约 6 cmX 2.5 cmX 2.5 emo手术及病理：术中可见双侧侧脑室内巨大囊肿 ，通过扩大的室间孔相连 ，呈哑铃形 ，囊壁 乳白色半透明，与脑室壁无粘连，囊液淡黄色透明、约 40ml ,分流管脑室端位于囊外，引流 孔已全部堵塞，与脑室壁粘连。问题：1该患者被诊断为脑棘球蚴病,请写出诊断依据。2进一步如何治疗？3请写出该患者感染此病的感染方式可能有哪些？病例十三患者王XX,男，

29、37岁，武汉市郊县农民。因持续高热18天，伴有咳嗽和腹泻，外院诊治无效。发病 30天后，于 9月 15 日入院治疗。体检C,血压15.0/10.5 kPa。精神萎靡，反响迟钝，右肋下触及肝边缘，左肋下缘2 cm触及脾脏、质中等、无压痛。血白细胞3.2 X09/l，中性粒细胞和嗜酸性细胞增高；肥达氏反响：O凝集素1 : 80, H凝集素1 : 160;三次粪便直接涂片检查均阴性。入院后给予抗菌 素治疗，环丙沙星0.4 g/d，静脉滴注1周，高热持续不退。改为吡喹酮治疗，用药后第4天发热缓解,出院。随访 2 周,病 人无发热。问题：1 此病人可能患的什么寄生虫病？写出诊断依据。2进一步确诊该寄生虫

30、病可用什么实验诊断?3分析该患者临床病症产生的病理学依据。病例十四A 28-year-old Hispanic man was brought to the emergency department of a general hospital for severe headaches and two generalized seizures.He had first noticed headaches, which had been getting more frequent, several weeks before. He denied fever or chills. The patie

31、nt was a recent immigrant from Mexico. There was no previous history of seizures.PHYSICAL EXAMINATIONVS: T 37 C , P 83/min, R 14/min,BP 136/80 mm HgPE: Young male in moderate distress due to headache; neurologic exam was normal.LABORATORY STUDIESBloodHematocrit: 45%WBC: 7200/ 止Differential: 52% PMNs

32、, 23% lymphs, 12% eosinophilsBlood gases: NormalSerum chemistries: NormalImagingA CT scan of his brain revealed an intracranial calcified cyst, and further imaging with MRI confirmed the presence of similar lesions, some with a scolex visible (Fig. 64-1).Diagnostic Work-UpTable 64-1 lists the likely

33、 causes of illness (differential diagnosis). The presumptive diagnosis should be on the basis of clinical picture and epidemiologic information. The likelihood of exposure during foreign travel, and characteristic findings on CT or MRI scans, are adjuncts to clinical diagnosis. Lumbar puncture and p

34、eripheral blood collection are an essential beginning of investigation. Microbiologic investigation may include.Gram stain and acid-fast stain of CFSCultures of CSF and blood for bacteria, fungi, mycobacteriaAntibody detection (e.g., immunoblot assay of IgG in serum or CSF specific for the invasive

35、stage of a parasite)In failed tests aboveCryptococcal antigen in CSF and serumCSF VDRLSerologic tests for others included in differential diagnosisTable 64-1 Differential Diagnosis and Rationale for Inclusion (consideration)Brain abscessCraniopharyngiomaCryptococcal meningoencephalitisMedulloblastom

36、aNeurocysticercosisToxoplasmosisTuberculomaRationale : Intracerebral mass lesions have many possible causes (common ones are listed above). Homogeneous masses may be malignancies, and ring enhancement is classically associated with brain abscess. Cystic masses may be malignant, but they are also cla

37、ssically associated with neurocysticercosis. Other infectious causes of intracerebral masses include toxoplasmosis, tuberculoma, and cryptococcoses.COURSEThe patient was admitted to the hospital for observation and diagnostic investigation. A lumbar puncture was performed. The CSF analysis revealed

38、a WBC count of 35/ , with lymphocytic and eosinophilic pleocytosis, slightly elevated protein (62 mg/dL), and a normal glucose level. A positive serologic investigation specific for a parasite yielded the diagnosis病例十五患者李某，男， 36 岁，上海市浦东人，汽车司机，家中饲养以只从青海来的狼犬。因 持续咳嗽半年余，间断咳血痰 3个月。于 1998年 4月以“双飞阴影待查，先天性肺

39、囊肿带排除 x 4.5cm的阴影，左下肺内内带可见 7cmxx 7.5cm大小阴影，双侧阴影均边缘光滑， 密度均匀一致， 阴影周围清晰， 未见钙化及浸润性病灶。 病人入院后痰量增加，办左侧胸痛 和低热。经抗炎药治疗，肺部病灶无改变。后经B超定位下行左侧经费内包块穿刺抽去少许 液体。 穿刺液内查到棘球蚴的原头节， 经包虫皮试和 ELISA 试验均为强阳性， 诊断为肺棘球 蚴病；即行左下肺切除术。术后给予阿苯达唑 600mg/d 治疗，口服一年，随访至今健康。1. 上述病症中哪些与包虫病有关？2. 包虫病是如何感染人体的？应该怎样预防？3. 包虫病多流行于西北地区， 上海出生和生长且从未去过牧区的

40、居民是真阳怎样感染包虫病的？病例十六A 49-year-old woman presented with high fever and chills, jaundice, and upper abdominal pain for 3 days.The patient was a recent immigrant from Argentina. One year before, she first noticed a sensation of fullness in the right upper quadrant of her abdomen. Her part medical history

41、 was unremarkable. In her country of origin, she had been, healthy and active, working in the field and breeding and raising sheepdogs.PHYSICAL EXAMINATIONVS: T °C , p 112/min, R 18/min, BP 102/60 mmHgPE: The patient appeared acutely ill and was obviously jaundiced. Right upper quadrant abdomin

42、al tenderness was noted.LABORATORY STUDIEDBloodHematocrit: 34%WBC: 22, 400/ MDifferential: 55% PMNs, 20% bands, 12% lymphs, 8% eosinophilsSerum chemistries: alkaline phosphatase 340 U/L; bilirubin 4.3ImagingA CT scan of the liver demonstrated a large multiloculated cyst with bile duct dilation (Fig.

43、 51-1).Diagnostic Work-UpTable 51-1 lists the likely causes of the woman's illness (differential diagnosis). A clinical diagnosis of hepatic hydatid cyst (tapeworm) disease was considered based on the imaging studies (CT scans of liver). Serologic tests specific for a tapeworm mat include.ELISA

44、to detect IgG in patient 's serum (screening) Immunoblot assay to confirm the diagnosisTABLE 51-1 Differential Diagnosis and Rationale for Inclusion (consideration)CholanditisHydatid cyst (tapeworm) diseaseLiver abscessViral hepatitisRationale : Clinical diagnosis is difficult; the history of ex

45、posure is helpful. The symptoms are suggestive of biliary tract infection, which may have many causes. Vital hepatitis would not produce lesions seen in the CT scan. The more common causes are listed above. Hydatid cyst is a possibility when appropriate epidemiology is present.COURSEGiven the patien

46、t 's clinical status, she was taken to the operating room. The liver lesion was completely removed surgically, and the biliary obstruction was relieved. The patient received an antihelminthic drug postsurgery. An ELISA and subsequent immunoblot test for antibodies against a tapeworm confirmed th

47、e specific etiology.病例十七A 9-year-old boy was brought to the hospital by his parents with complaints of repeating intense chills and daily high fever for 4 days.The parents said that when his fevers would abate,he would become drenched in sweat and feel exhausted and drained. The parents also reporte

48、d diarrhea, nausea, and abdominal pain. On the days of admission the patient was noted to be lethargic and difficult to arouse. A generalized seizure was witnessed in the emergency department The family had immigrated to the United States from West Africa 3 weeks before the onset of the current illn

49、ess.PHYSICAL EXAMINATIONVS: T 40 °C , p 140/min, R 28/min,BP 82/40 mm HgPE: Thin male minimally responsive to verbal commands. Pupils were reactive and neck was supple. Conjunctiva was pale, and abdominal exam showed hepatosplenomegaly.LABORATORY STUDIESBloodHematocrit: 18%WBC: 16300/ 丄Differen

50、tial: 50% PMNs, 15% lymphs, 20%bands.Platelets: 42000/ pLBlood gases: pH7.28, Pco230mmHg, Po2mmHgDl.lImagingHead CT was unremarkable.Diagnostic Work-UpTable 79-1 lists the likely causes of illness (differential diagnosis). Investigational approach for specific microbiologic diagnosis may includeLumb

51、ar puncture and CFS examination to rule out bacterial meningitis.Blood cultures to detect blood-borne bacteriaThick and thin smear for blood-borne parasitesIn failed diagnosis, virus-specific serology for the listed infections.Table 79-1 Differential Diagnosis and Rationale for Inclusion (considerat

52、ion)African trypanosomiasisAspetic meningitisBabesiosisBacterial meningitisDengue feverLeptospirosisMalariaTyphoid feverRationale : A diagnosis shouble be aggressively sought in patients who present with sever It is always important to rule out bacterial meningitis initially.Epidemiology is importan

53、t for a patient to determine the possible history of exposure in an area endemic for a variety of infections.Typhoid fever and parastic infections are geographically limited, so a good history of travel is important as well. Babesiosis is found in the northeastern and upper Midwestern U.S., and lept

54、ospirosis is associated with animal exposure. Dengue, malaria, and trypanosomiasis are all endemic in Africa, with the latter two infections typically causing periodic fever.COURSEThe patient was admitted and required mechanical ventilation for impending respiratory failure.Lumbar puncture was perfo

55、rmed, which was normal. Blood cultures were drawn and were negative for biood-borne pathogens. Based on the given history of travel,thick and thin blood smears were performed and yielded a diagnosis.病例十八A 30 year-old white women was brought to the emergency department of a local hospital with a 2-we

56、ek history of progressively severe headache, nausea, and vomiting; several seizures had occurred over the past 2 days.She had been HIV positive for 3 years and had been diagnosed with AIDS a year before the current espisode. She had been on HIV therapy, but was currently failing her regimen. She was

57、 also on aerosolized pentamidine because of a bactrim allergy. Her brother, who brought her to the ED, could not recall any history of seizures.PHYSICAL EXAMINATIONVS: T 38 C , P 86/min, R 14/min,BP 104/70 mm HgPE: She was in moderate distress due to the headache bnt was able to answer questions.Mild right-sided weakness was apparent on exam.LABORATORY STUDIESBloodHematocrit: 34%WBC: 7400/ 止Differential: normal.CD4+ counts: 62/ 止Blood gases: NormalSerum chemistries: NormalImagingHead MRI revealed ring-enhancing lesions in the left parietal lobe and right fr