Ramsay Hunt综合征31例误诊分析

Ramsay Hunt综合征是由水痘一带状疱疹病毒侵犯膝状神经节引起的耳部带状疱疹,由于其发病部位特殊及特征性皮疹出现延迟,临床易误诊误治.1991～2005年,我们共收治误诊Ramsay Hunt综合征患者31例,现结合临床资料分析如下.     

慢性重症肝炎多尿性高钾血症5例

晚期肝病合并电解质紊乱比较常见,但慢性重症肝炎并发多尿性高钾血症易被临床忽视而致误诊/漏诊.我们采用回顾性分析方法对我院两年来所遇5例,报告如下.     

20篇结核病临床病理讨论系统回顾分析

目的 探讨结核病误诊的原因.方法 手工检索近20年发表在中华结核和呼吸杂志等五种中华级杂志上的20篇有关结核病误诊的临床病理讨论（clinical pathological conference, CPC）文章,并逐一登记患者的临床特征、最后病理诊断、应吸取的教训等.结果 20例结核病中急性粟粒性结核13例,占65.0%;大量使用糖皮质激素引起结核活动、播散共8例,占40.0%.结论 临床医生必须高度重视结核病的诊断,以期减少结核病漏诊.     

成人重症原发性水痘肺炎二例报道并文献复习

水痘感染以儿童多见,但原发性水痘肺炎较少见,成人原发性水痘肺炎则更为少见。成人重症原发性水痘肺炎患者病情进展迅速、皮疹分布广泛、症状严重并易并发心、肝功能损伤。本文报道2例成人重症原发性水痘肺炎患者,并结合通过检索中国知网发现的8例成人原发性水痘肺炎患者进行文献复习,以期提高临床对成人原发性水痘肺炎尤其是成人重症原发性水痘肺炎的认识。     

急性重症病毒性心肌炎临床分析

目的分析急性重症病毒性心肌炎(SAVM)临床特点,总结诊治经验。方法搜集我院2000年1月至2006年8月收治的19例SAVM,分析其临床表现、相关检查结果、诊治经过、预后情况。结果19例中发热14例,晕厥12例,累及房室结传导和束支传导10例,心脏扩大9例,心肌酶学持续升高,心肌钙蛋白均升高;糖皮质激素治疗16例,心脏临时起搏4例。结论临床症状和体征无特异性,临床诊断主要依赖于病毒感染史、临床症状、心肌损伤指标;休息、糖皮质激素、心率支持和血流动力学支持是主要治疗手段。     

糖皮质激素致重症水痘15例

1992～1995年,我们收治重症水痘患者17例,其中15例系因病初在基层医院应用糖皮质激素所致。患者年龄5～18岁,发病3～6天入院。12例肌注或静滴地塞米松(10～35mg),3例静滴氢化可的松(100～300mg)。其中出血性水痘6例,大疱性水痘1例,皮疹化脓感染脓毒血症3例,水痘性脑炎、原发性水痘肺炎各2例,心肌炎1例。本组经皮肤局部处理及全身综合性治疗,均治愈,平均住院14.5天。 体会:本组患者均因发热应用激素降温而致病情加重。由于部分基层医务人员对激素引起的不良后果缺乏足够的认识(尤其对水痘患者),故造成盲目滥用。在对本组患者的治疗过程中,我们体会:①加强皮肤护理,促进疱疹结痂,对防止继发感染颇为重要。②对病程长、体弱、消化道痘疹明显者,给予鼻饲、支持疗法,有利于改善病情。③干扰素不失为理想的抗病毒药物。④输新鲜全血可加速病情好转,改善预后;早用、小量、多次输新鲜血可缩短病     

青年人肺癌16例误诊分析

1996年3月～2007年8月,我们共收治35岁以下青年人肺癌26例,其中16例误诊.现将其临床资料分析如下.     

54例希恩综合征患者临床特征分析及文献复习

回顾性分析本院内分泌科2008年8月至2011年8月期间收治的54例住院希恩综合征患者病史及临床资料.47例患者诊断为垂体危象,19例患者(35.19％)在本次住院前曾长期被误诊,从发生产科事件至确诊的平均年限为( 12.36±1.28)年.静滴氢化可的松抢救垂体危象患者时,入院后第一个24 h平均剂量为( 83.93±7.73)mg,第2个24 h平均剂量为(42.19±5.13)mg.12例患者常规剂量糖皮质激素 口服替代治疗后发生一过性精神障碍.     

重症急性嗜酸粒细胞性肺炎的诊治经验

重症急性嗜酸粒细胞性肺炎(AEP)临床少见,并发嗜酸粒细胞性张力性血性液气胸休克更少见.浙江省宁波市宗瑞医院1991年1月至2008年1月确诊外周血嗜酸粒细胞消失的重症急性嗜酸粒细胞性肺炎6例,入院前均误诊,其中误诊为重症急性细菌性肺炎5例,癌性张力性血性液气胸1例,现将诊治情况报道如下.     

24例肺炎性假瘤临床误诊分析

我们自1989年6月～2003年8月发现肺炎性假瘤24例，术前确诊4例，误诊20例，为避免误诊，提高本病的诊断水平，现将其诊断情况及误诊原因分析如下。     

Treatment of adult chickenpox with oral acyclovir

Thirty-one late adolescents and adults with varicella were studied. Patients identified within 72 hours of varicella exanthem were offered open treatment with acyclovir (4 g/d), and those patients identified after 72 hours of exanthem were followed up but not treated. Twenty-two patients were treated with acyclovir. Nine patients were not treated. No severe complications occurred in any of the 31 patients. Minor complications, including prolonged fever, localized secondary infections, persistent cough, and prolonged fatigue were more frequent in the untreated group. If the acyclovir therapy was begun within the first 24 hours of varicella exanthem, then the rash and clinical illness were dramatically lessened. Treatment with oral acyclovir should be considered for varicella in adults who are identified within the first 24 hours of exanthem.     

Varicella pneumonia in patients with HIV/AIDS.

OBJECTIVE: To determine the potential role of steroid therapy combined with early antiviral and supportive care in patients infected with human immunodeficiency virus (HIV) with varicella pneumonia. MATERIALS AND METHODS: A retrospective review was conducted of the incidence, clinical course, and outcome of varicella pneumonia in patients with HIV or acquired immunodeficiency syndrome (AIDS). RESULTS: Seven of 12 patients (58%) who were hospitalized with chickenpox developed clinically severe varicella pneumonia. All patients had advanced immunosuppression and all developed diffuse reticulonodular radiographic abnormalities, although two patients had normal chest radiographs on admission. All patients received antiviral therapy within 12 hours of hospital admission. The overall mortality rate was 43%. Six patients were treated with systemic corticosteroids in addition to antiviral agents, including all four of the survivors. CONCLUSIONS: Hospitalized patients with HIV or AIDS with chickenpox are at high risk for developing varicella pneumonia. There is a potentially high rate of death despite prompt initiation of appropriate antiviral therapy. Intensive care management and adjunctive use of systemic corticosteroids may improve outcome.     

Unusual onset of severe varicella in adult immunocompromised patients

Summary Abdominal and back pain has until now been reported as a first sign of severe varicella in immunocompromised children only. We report two adult leukemia patients in whom these symptoms preceded visceral dissemination of varicella infection. Recognizing that this syndrome may occur in adult patients is of clinical importance, since it allows early diagnosis and treatment of the infection.     

Varicella and varicella immunity in patients with lysinuric protein intolerance

Two patients with lysinuric protein intolerance (LPI) had near-fatal generalized varicella infection with severe interstitial pneumonitis, hepatitis, decreased platelet count, bleeding and hypoalbuminaemia. Active haemolysis resulted in anaemia and massive haemoglobinuria. Serum lactate dehydrogenase activity and ferritin concentration, which in patients with LPI in normal circumstances exceed the upper reference values 3-fold to 10-fold, increased to >10 000U/L and >10 000 µg/L, respectively. The patients were treated with fresh frozen plasma, red-cell transfusions and intravenous acyclovir for 14 days, and recovered clinically in a month. Retrospectively, 3 of the 32 other known Finnish patients with LPI had had varicella infection that had been more severe than that in the other children in the family or in subjects in the neighbourhood and had led to hospital admission. Varicella antibodies were measured in 24 patients; 5 had no antibodies and 5 had very low antibody titres. Primary vaccination of three patients with living varicella vaccine increased antibody titres measurably in one patient. We suggest that patients with LPI who have no varicella zoster antibodies should be treated with acyclovir if exposed to varicella and should be (re)vaccinated against chickenpox.     

Varicella among adults: data from an active surveillance project, 1995-2005

We report detailed population-based data on varicella among adults. In 2 US varicella active surveillance sites with high vaccine coverage among young children, the incidence of varicella among adults declined 74% during 1995-2005. A low proportion (3%) of adults with varicella had been vaccinated, with no improvement over the decade of program implementation, suggesting that the decline was likely secondary to herd-immunity effects. Compared with children, adults had more severe varicella in terms of both clinical presentation and frequency of complications. However, <30% of adults with varicella were treated with acyclovir. Among adolescents, illness severity was intermediate between that in children and adults. Varicella cases are preventable through vaccination. As we enter the second decade of the varicella vaccination program in the United States, we need to ensure that susceptible adolescents and adults are adequately protected from varicella by vaccination and that those who acquire varicella are appropriately treated with effective antiviral treatment.     

Adenine arabinoside in severe thrombocytopenia due to hemorrhagic varicella

An 18-year-old man, admitted because of severe bleeding manifestations due to varicella thrombocytopenia was administered 800 mg/day adenine arabinoside (Ara-A) intravenously for 5 days. 2 days after the start of this treatment the bleeding phenomena became markedly reduced and a progressive increase in the platelet count was noted thereafter. Although a spontaneous improvement is known to occur in patients with varicella thrombocytopenia, the rapid clinical improvement after the Ara-A administration is suggestive for its beneficial effect in the presented patient.     

Varicella zoster meningitis complicating combined anti-tumor necrosis factor and corticosteroid therapy in Crohn’s disease

Opportunistic viral infections are a well-recognized complication of anti-tumor necrosis factor (TNF) therapy for inflammatory bowel disease (IBD). Cases of severe or atypical varicella zoster virus infection, both primary and latent reactivation, have been described in association with immunosuppression of Crohn’s disease (CD) patients. However, central nervous system varicella zoster virus infections have been rarely described, and there are no previous reports of varicella zoster virus meningitis associated with anti-TNF therapy among the CD population. Here, we present the case of a 40-year-old male with severe ileocecal-CD who developed a reactivation of dermatomal herpes zoster after treatment with prednisone and adalimumab. The reactivation presented as debilitating varicella zoster virus meningitis, which was not completely resolved despite aggressive antiviral therapy with prolonged intravenous acyclovir and subsequent oral valacyclovir. This is the first reported case of opportunistic central nervous system varicella zoster infection complicating anti-TNF therapy in the CD population. This paper also reviews the literature on varicella zoster virus infections of immunosuppressed IBD patients and the importance of vaccination prior to initiation of anti-TNF therapy.     

Epidemiology of primary varicella and herpes zoster hospitalizations: the pre-varicella vaccine era

To determine the epidemiology and costs of hospitalization with primary varicella and herpes zoster in the prevaccine era and the usefulness of hospital discharge data to determine the population impact of vaccination on these conditions, statewide hospital discharge data in Connecticut from 1986 to 1995 were analyzed. Annual hospitalizations for herpes zoster were 4-fold higher than for primary varicella (16.1 vs. 4.1/100,000). Overall, 69% and 83%, respectively, had no underlying immunosuppressive conditions. Regarding primary varicella, 53% of patients were aged <15 years, there was a marked winter-spring seasonality, and Hispanics and blacks were 4.1 and 2.6 times more likely than whites to be hospitalized. Regarding herpes zoster, 66.9% of patients were aged >64 years, and there was no seasonality. The mean patient charges in 1995 were $12,819 for primary varicella and $15,583 for herpes zoster. Analysis of population-based hospital discharge data is a feasible means of monitoring the impact of varicella immunization on severe morbidity due to primary varicella and herpes zoster.     

Clinical varicella-zoster virus reinfection observed in two advanced-age persons]

We observed two mild varicella cases of an advanced-age man and woman, although varicella in the adult generally presents a more severe course than in the child. The cases had been exposed to his great-grandchild and her grandchild with varicella in their home. They did not experience neuralgia as is typical from herpes zoster. Serological examinations revealed that they had high IgG-antibodies (Ab) against varicella-zoster virus (VZV), but low anti-VZV IgM-Ab. They were also found to have a high level of Ab against VZV soluble antigens (Ag) which are generally low in primary VZV infection. Immunoblotting analysis of anti-VZV IgG-Abs using sera from case 1 or 2 showed that their reaction patterns resembled those of sera children who contracted mild varicella after immunization with varicella vaccine and a herpes zoster-patient rather than those of sera from an immunocompetent adult with varicella. These results of serological examinations and their clinical course indicated that the cases had contracted varicella in the past and were again exposed to VZV resulting in clinically overt but mild varicella.     

Diagnostic skin test reactions with varicella virus antigen and clinical application of the test.

Varicella virus antigen was prepared and used in skin testing of 75 children one to 17 years old. Results of skin tests were analyzed in relation to history of varicella, presence of absence of neutralizing antibody, and susceptibility to clinical varicella. All 22 children with no history of varicella and no neutralizing antibody were negative in the skin test when an erythematous change of greater than or equal to 5 mm in diameter was taken as a positive result. Of the 53 children with neutralizing antibody, only three were negative in the skin test. The skin test was applied clinically in an institution for mentally retarded children immediately after varicella infection occurred in a patient. A total of 65 patients were examined by the skin test, and 24 children with negative results were given live varicella virus vaccine. As a result, no spread of varicella was observed except for three cases, which developed two weeks after onset of illness in the index case. Thus the skin test seems clinically useful in the determination of susceptibility of individuals to clinical varicella.