Miller Mark A
Division of Infectious Diseases, SMBD-Jewish General Hospital and McGill University, Montreal, Quebec.
Can J Infect Dis. 2002 Sep;13(5):333-8. doi: 10.1155/2002/606382.
A 21-year-old man presented to the emergency room complaining of fever, chills, diarrhea and nausea with vomiting of two days' duration. He had a past medical history of remote jejunal dysplasia, which was surgically corrected when he was a child. He was taking no regular medications. He had been well until two days earlier, when he developed a sudden onset of fever to 39.9°C, chills and severe nausea with frequent bouts of vomiting. He remembered feeling more tired than usual for three days before the onset of his fever, but nothing more specific. He saw a physician the day after the onset of fever, and the physician prescribed oral cotrimoxazole double-strength, of which he took one dose. Due to persistence of the above symptoms, he presented to the emergency room. He had travelled to Cuba for a seven-day vacation at a resort, and returned home 14 days before the onset of symptoms. He had experienced one day of mild diarrhea while in Cuba, but two of his friends experienced two to three days of diarrhea without fever at the same time while there. He denied abdominal pain, headache, cough, shortness of breath, rash, urinary symptoms or other problems. He had no risk factors for HIV infection. On examination, he was toxic and experiencing rigors, but was awake and alert. His temperature was 39.8°C, pulse was 107 beats/min and respirations were 30 breaths/min. The examination was normal except for evidence of dehydration and marked splenomegaly without tenderness. A chest radiograph and urinalysis were normal. The patient's hemoglobin level was 167 g/L, his platelet count was 138x10/L and his leukocyte count was 9.5x10/L with a marked shift to the left. The patient's creatinine level was 139 μmol/L, urea level was 6.8 mmol/L, total bilirubin level was 48 μmol/L (44% conjugated), alanine aminotransferase level was 113 U/L and gamma glutamyl transpeptidase level was 83 U/L. Other liver function tests were normal. Blood and urine cultures were obtained. An abdominal ultrasound confirmed the presence of splenomegaly with a tiny splenic cyst and an otherwise normal examination (including a normal liver). Infectious enteritis with sepsis was diagnosed and the patient was started on intravenous ciprofloxacin. The following day, two sets of blood cultures that were taken while the patient was in the emergency room showed the presence of Gram-negative rods, which were identified the next day as species (serogroup C1), susceptible to ampicillin, cotrimoxazole, fluoroquinolones and ceftriaxone. After three days of taking parenteral ciprofloxacin, the patient felt subjectively better but continued to have afternoon and evening fevers of more than 40°C, accompanied by rigors and extreme exhaustion. His platelets decreased daily, to a nadir of 49x10/L, and his leukocytes decreased to 3.8x10/L. HIV serology was negative. He had no other new complaints, and the examination was unchanged. Repeat blood cultures were negative. A diagnostic procedure was performed to explain the persistent sepsis. What is your diagnosis?
一名21岁男性因发热、寒战、腹泻、恶心伴呕吐两天就诊于急诊室。他既往有小肠发育异常病史,小时候接受过手术矫正。他未规律服药。两天前他身体状况良好,之后突然发热至39.9°C,伴有寒战、严重恶心及频繁呕吐。他记得在发热前三天感觉比平时更疲倦,但无其他特殊情况。发热次日他看了医生,医生开了双倍剂量的口服复方新诺明,他服用了一剂。由于上述症状持续存在,他前来急诊室就诊。他曾前往古巴一个度假胜地度了七天假,在症状出现前14天回国。他在古巴时曾有一天轻度腹泻,但他的两个朋友在那里同时也有两到三天无发热的腹泻。他否认腹痛、头痛、咳嗽、气短、皮疹、泌尿系统症状或其他问题。他没有感染HIV的危险因素。体格检查时,他呈中毒面容且有寒战,但神志清醒、警觉。体温39.8°C,脉搏107次/分,呼吸30次/分。除有脱水迹象及明显脾肿大(无压痛)外,检查均正常。胸部X线片和尿液分析正常。患者血红蛋白水平为167g/L,血小板计数为138×10⁹/L,白细胞计数为9.5×10⁹/L,并有明显的核左移。患者肌酐水平为139μmol/L,尿素水平为6.8mmol/L,总胆红素水平为48μmol/L(44%为结合胆红素),丙氨酸转氨酶水平为113U/L,γ-谷氨酰转肽酶水平为83U/L。其他肝功能检查正常。采集了血培养和尿培养标本。腹部超声证实有脾肿大,伴有一个微小的脾囊肿,其他检查(包括肝脏)正常。诊断为感染性肠炎伴败血症,患者开始静脉滴注环丙沙星。次日,患者在急诊室时采集的两组血培养显示有革兰氏阴性杆菌生长,第二天鉴定为某菌种(血清群C1),对氨苄西林、复方新诺明、氟喹诺酮类和头孢曲松敏感。静脉滴注环丙沙星三天后,患者主观感觉好转,但仍有下午和晚上超过40°C的发热,伴有寒战和极度疲惫。他的血小板每日下降,最低降至49×10⁹/L,白细胞降至3.8×10⁹/L。HIV血清学检查为阴性。他没有其他新的不适主诉,体格检查无变化。重复血培养为阴性。进行了一项诊断性检查以解释持续的败血症。你的诊断是什么?