Ribeiro Rita, Patrício Catarina, Pais da Silva Filipa, Silva Pedro Eduardo
Department of Internal Medicine, Hospital de Santo António dos Capuchos, Lisboa, Portugal.
Department of Internal Medicine 2.3-Autoimmune Diseases Unit, Central Lisbon Hospital Centre-Santo António dos Capuchos Hospital, Lisboa, Lisboa, Portugal Chronic Diseases Research Center-CEDOC, NOVA Medical School/Faculdade de Ciências Médicas-Universidade Nova de Lisboa, Lisboa, Lisboa, Portugal.
BMJ Case Rep. 2016 Mar 4;2016:bcr2015213585. doi: 10.1136/bcr-2015-213585.
A 42-year-old black woman presented with fever, polyarthritis, livedo reticularis, subcutaneous calf nodules and hepatomegaly. She had been diagnosed with depression 6 weeks prior. Blood analysis showed anaemia, elevated erythrocyte sedimentation rate and C reactive protein, elevated liver enzymes, and positive antinuclear and antiribonucleoprotein antibodies. Abdominal ultrasound revealed heterogeneous hepatomegaly with necrotic lymphadenopathy around the caeliac trunk and splenic hilum. We considered the following diagnoses: lymphoma, connective tissue disease, tuberculosis and sarcoidosis. Subcutaneous nodule histology was compatible with erythema induratum of Bazin, and liver biopsy evidenced granulomatous hepatitis. Although microbiological examinations were negative in tissue samples, a presumptive diagnosis of hepatic tuberculosis was admitted. Having excluded other causes, erythema of Bazin, livedo reticularis and polyarticular involvement (Ponçet's arthropathy) were accepted as immunological epiphenomena associated with tuberculosis. Empirical antituberculous treatment was started and after 3 weeks the patient improved substantially. This clinical response was a further confirmation of the diagnosis.
一名42岁的黑人女性出现发热、多关节炎、网状青斑、小腿皮下结节和肝肿大。她在6周前被诊断为抑郁症。血液分析显示贫血、红细胞沉降率和C反应蛋白升高、肝酶升高，以及抗核抗体和抗核糖核蛋白抗体呈阳性。腹部超声显示肝脏肿大不均匀，腹腔干和脾门周围有坏死性淋巴结病。我们考虑了以下诊断：淋巴瘤、结缔组织病、结核病和结节病。皮下结节组织学与巴赞硬红斑相符，肝脏活检证实为肉芽肿性肝炎。尽管组织样本的微生物检查结果为阴性，但仍假定诊断为肝结核。排除其他病因后，巴赞红斑、网状青斑和多关节受累（蓬塞关节炎）被认为是与结核病相关的免疫附带现象。开始进行经验性抗结核治疗，3周后患者病情明显改善。这种临床反应进一步证实了诊断。
