Kung Chia-Te, Li Chao-Jui, Ko Sheung-Fat, Lee Chen-Hsiang
Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
J Emerg Med. 2013 Jan;44(1):e9-12. doi: 10.1016/j.jemermed.2011.05.097. Epub 2012 Apr 9.
Neurological abnormalities in melioidosis are rare but may manifest as an acute stroke, and in the emergency department (ED), an inappropriate stroke treatment may threaten a patient's life.
A case of cerebral melioidosis is reported in a patient presenting with brainstem signs to increase awareness of the uncommon presentations of melioidosis that may cause a delayed diagnosis in the ED.
A 45-year-old man who worked as a construction worker, with diabetes mellitus and alcoholic liver cirrhosis, presented to the ED after a 10-day period of fever and cough. He was initially diagnosed and treated as a case of community-acquired pneumonia. However, a sudden change in consciousness with 6th and 7th cranial nerve palsy and flaccid paralysis were noted while he was in the ED, and acute brainstem stroke was suspected. Brain magnetic resonance imaging disclosed brainstem lesions, slightly hypointense on T1-weighted images and hyperintense on T2-weighted images. Blood and urine cultures subsequently yielded Burkholderia pseudomallei. Abdominal computed tomography revealed multiple small consolidated patches, ground-glass opacities, small nodules in the lower lungs bilaterally, and a pancreatic tail abscess. Systemic melioidosis with lung, pancreas, urogenic tract, and brainstem involvement was diagnosed. Three weeks after admission, the patient died from a sudden onset of apnea and asystole.
In light of this case, patients with identifiable risk factors, especially underlying diabetes, a history of positive soil contact, and those who lived in an endemic area or ever traveled to an endemic area, and who present themselves with fever and neurologic deficit or multi-organ involvement, should have melioidosis considered in the differential diagnosis.
类鼻疽病中的神经功能异常较为罕见，但可能表现为急性中风，在急诊科，不恰当的中风治疗可能会危及患者生命。
报告1例出现脑干体征的脑类鼻疽病患者，以提高对类鼻疽病不常见表现的认识，这些表现可能导致急诊科的诊断延迟。
一名45岁的建筑工人，患有糖尿病和酒精性肝硬化，在发热咳嗽10天后就诊于急诊科。他最初被诊断并当作社区获得性肺炎进行治疗。然而，在急诊科时，他突然意识改变，伴有第6和第7颅神经麻痹及弛缓性瘫痪，怀疑为急性脑干中风。脑部磁共振成像显示脑干病变，在T1加权图像上略呈低信号，在T2加权图像上呈高信号。随后血培养和尿培养均检出伯克霍尔德菌。腹部计算机断层扫描显示双侧下肺有多个小的实变斑、磨玻璃影、小结节，以及胰尾脓肿。诊断为系统性类鼻疽病，累及肺、胰腺、泌尿生殖道和脑干。入院三周后，患者因突然出现呼吸暂停和心脏停搏死亡。
鉴于该病例，具有可识别危险因素的患者，尤其是患有基础糖尿病、有土壤接触阳性史、居住在流行地区或曾前往流行地区，且出现发热和神经功能缺损或多器官受累的患者，在鉴别诊断时应考虑类鼻疽病。
