Lupus anticoagulant in the acquired immunodeficiency syndrome

Prolongation of partial thromboplastin time was noted in patients with acquired immunodeficiency syndrome (AIDS) who were admitted to the hospital for diagnosis of opportunistic infection. As biopsy procedures were often indicated, detailed investigation of the abnormal coagulation study was performed in four patients. Results confirmed the presence of a lupus anticoagulant. Partial thromboplastin times of 34 consecutive subsequent patients hospitalized with the diagnosis of AIDS-associated opportunistic infection were recorded; prolongation was noted in 24 of these. None of these 38 patients exhibited clinical evidence of bleeding. One patient had a confirmed thrombotic episode. Prolonged partial thromboplastin time is a common finding in hospitalized patients with AIDS and opportunistic infection. If no clinical history of unusual bleeding is noted, the lupus anticoagulant should be suspected. Many patients with AIDS require invasive procedures for disease management; the lupus anticoagulant, an in vitro phenomenon, should not prevent these studies.     

肺型与进展播散型组织胞浆菌病的临床对比分析

目的：比较肺型与进展播散型组织胞浆菌病的临床特点、诊断及预后差异。 方法：回顾性分析中南大学 湘雅医院2009年2月至2015年10月期间收治的组织胞浆菌病住院患者12例,其中肺型4例,进展播散型8例。从临床表 现、影像学、确诊途径及预后等方面分析两者之间的差异性。 结果：肺型组织胞浆菌病临床表现轻微,干咳多见。 进展播散型患者全身症状明显,极易出现反复高热、全身浅表淋巴结肿大、肝脾肿大,可合并咳嗽、腹痛、关节 痛、皮肤改变等。实验室检查示全血细胞减少、肝功能异常、凝血功能异常等。1例肺型患者给予了左下肺切除术, 其余3例肺型及6例进展播散型患者分别给予两性霉素B脱氧胆酸盐、伊曲康唑、伏立康唑或氟康唑抗真菌感染治疗, 好转出院,1例播散型确诊后暂未治疗即出院,1例播散型因合并重症肺炎及活动性肺结核治疗无效死亡。结论：组 织胞浆菌病临床少见,极易漏诊或误诊,依靠骨髓涂片、病理组织切片特殊染色明确病原学是目前确诊的主要依 据,推荐两性霉素B脂质体、两性霉素B脱氧胆酸盐及伊曲康唑抗感染治疗。     

案例教学法结合PDCA循环在1例长期不明原因发热病例诊断和治疗中的应用

目的 应用案例分析法结合PDCA(plan-do-check-action)循环模式分析1例不明原因发热(fever of unknown origin,FUO)患者诊断和治疗经过,演示PDCA循环在诊治长期不明原因发热的线路图。 方法 案例分析法结合PDCA循环分析1例FUO患者病史特点、体征变化、辅助检查变化、并发症的防治;第一个案例分析法结合PDCA循环,通过病史、体检、辅助检查将FUO原因确定为感染性发热;第二个案例分析法结合PDCA循环,通过体征、辅助检查的变化,在感染性发热中剔除病毒和细菌感染,怀疑组织胞浆菌病、寄生虫病等;第三个案例分析法结合PDCA循环,通过骨髓病理检验和血液rK39检测结果,确定患者病因为罕见、输入性黑热病;第四个案例分析法结合PDCA循环,应用案例分析法和既往文献,分析诊断标准,分析治疗方法,预测治疗效果,科学防治并发症。 结果 通过分析1例FUO患者应用案例分析法结合PDCA循环诊断和治疗过程,发现其可以提高FUO的病因诊断的质量和治疗效果,规范临床诊治FUO的水平。 结论 案例分析法结合PDCA循环对提高不明原因发热诊断和治疗水平有益。      

A cryptic cause of cryptococcal meningitis

Cryptococcus neoformans commonly causes opportunistic infection in immunocompromised patients, especially in patients with AIDS. The CD4+ T-lymphocyte count is measured in patients with HIV infection, because it signals an increased risk of opportunistic infection and a decline in immunological function. We report a case of cryptococcal meningitis in a patient with persistently low CD4+ cell counts without evidence of HIV infection. The patient's underlying immunocompromised state was attributed to idiopathic CD4+ T-lymphocytopenia (ICL), a recently described syndrome characterized by depletions in the CD4+ T-cell subsets without evidence of HIV infection. Immunodeficiency can exist in the absence of laboratory evidence of HIV infection, highlighting the importance of evaluating T-cell subsets in patients who present with unusual infections.     

艾滋病神经系统原发性感染6例临床分析

目的：分析艾滋病神经系统原发性感染的临床特征,提高对其认识。方法：回顾性分析艾滋病神经系统原发性感染6例临床资料。结果：诊断为慢性HIV脑膜炎1例,艾滋病痴呆综合征4例,空泡性脊髓病1例。经抗病毒及综合治疗死亡4例,病情恶化自动出院1例,病情好转1例。结论：艾滋病神经系统并发症较常见,包括神经系统原发感染,神经系统机会性感染,神经系统肿瘤及抗艾滋病药物诱导疾病,神经系统原发性感染常在艾滋病晚期发生,表现形式复杂,易和神经系统机会性感染相混淆,死亡率高,疗效差,以艾滋病痴呆综合征常见。     

老年人不明原因发热45例

目的 分析老年人不明原因发热（FUO）的病因。方法 选择1999年1月。2004年12月符合FUO诊断标准的老年患者45例进行分析。结果 40例（88.9％）老年FUO患者通过血清学和（或）细菌学、体液或骨髓、组织活检、手术探查以及观察临床过程和（或）治疗反应明确诊断。感染性疾病占42.5％（17／40），其中结核病8例，占感染性疾病的47％（8／17），肿瘤性疾病占35％（14／40），结缔组织病占12.5％（5／40），其他疾病占10％（4／40），病因不明占11，1％（5／40）。结论 感染是我院老年FUO患者的主要病因，其次为肿瘤性疾病和结缔组织病。正确的诊断策略可提高确诊率，减少或避免误诊或漏诊。     

不明原因发热患者骨髓细胞形态学检查结果评价

目的探讨骨髓细胞形态学检查在不明原因发热(FUO)患者诊断中的临床应用价值。方法收集2009~2013年潮州市潮州医院200例不明原因发热的患者,以骨髓细胞学检查前后结果作为对照并分析评价。结果不明原因发热患者200例中通过骨髓细胞学检查明确诊断的有181例,确诊率为90.5%。结论骨髓细胞形态学检查方法在实验室常规检查方法无法确诊的不明原因发热病例中具有较高的确诊率,是不明原因发热患者诊断和鉴别诊断不可或缺的辅助检查手段。     

Pulmonary coinfection by Pneumocystis jiroveci and Cryptococcus neoformans

We communicate the diagnosis by microscopy of a pulmonary coinfection produced by Cryptococcus neoformans and Pneumocystis jiroveci, from a respiratory secretion obtained by bronchoalveolar lavage of an AIDS patient. Our review of literature identified this coinfection as unusual presentation. Opportunistic infections associated with HIV infection are increasingly recognized. It may occur at an early stage of HIV-infection. Whereas concurrent opportunistic infections may occur, coexisting Pneumocystis jiroveci pneumonia (PCP) and disseminated cryptococcosis with cryptococcal pneumonia is uncommon. The lungs of individuals infected with HIV are often affected by opportunistic infections and tumours and over two-thirds of patients have at least one respiratory episode during the course of their disease. Pneumonia is the leading HIV-associated infection. We present the case of a man who presented dual Pneumocystis jiroveci and cryptococcal pneumonia in a patient with HIV. Definitive diagnosis of PCP and Cryptococcus requires demonstration of these organisms in pulmonary tissues or fluid. In patients with < 200/microliter CD4-lymphocytes, a bronchoalveolar lavage should be performed. This patient was successfully treated with amphotericin B and trimethoprim sulfamethoxazole. After 1 week the patient showed clinical and radiologic improvement and was discharged 3 weeks later.     

不明原因发热190例分析

目的分析不明原因发热(FUO)病因,探寻其诊断方法和诊断策略。方法分析符合FUO诊断标准的患者190例。结果167例(87.9%)FUO患者通过血清学和(或)细菌学、体液或骨髓、组织活检、手术探查以及观察临床过程和(或)治疗反应,明确诊断。其中感染性疾病占55.8%(106/190),其中结核病26例,占感染性疾病的24.5%(26/106);结缔组织病占20.5%(39/190);肿瘤性疾病占7.8%(15/190);其他疾病占3.8%(7/190);病因不明占12.1%(23/190)。结论感染性疾病是我院FUO患者的主要病因,其次为结缔组织病和肿瘤性疾病,正确的诊断策略可提高确诊率,减少或避免误诊或漏诊。     

艾滋病合并播散性马尔尼菲青霉菌感染一例

目的：探讨艾滋病合并播散性马尔尼菲青霉菌感染患者临床及实验室特征。方法：（1）用酶免疫法和免疫印迹法检测患者血清的HIV抗体;（2）骨髓涂片及活检观察真菌形态;（3）取皮损做真菌培养,鉴定及动物实验,在25℃和37℃培养中从大体,显微镜及扫描电镜观察真菌特征。结果：播散性马尔尼菲青霉菌病常见临床表现为发热,体重减轻、贫血、丘疹性皮肤损害及肝、脾、淋巴结肿大。在37℃培养或组织中马尔尼菲青霉菌呈酵母型,在组织细胞外真菌较长,常弯曲,有横隔,似腊肠状,在25℃培养中呈菌丝型,并产生红色色素扩散入培养基中,结论：播散性马尔尼菲青霉菌是东南亚地区及中国南部艾滋病患者最重要的机会性感染之一,由于临床表现无特征性,常易误诊,确诊需作真菌培养,此真菌特征为温度双相性;可产生红色色素,可见有横隔的腊肠状细胞,两性霉素B及伊曲康唑治疗有效。     

Histoplasmosis of the larynx

Primary histoplasmosis of the larynx is not a common disease. Most cases of laryngeal histoplasmosis results from hematogenous spread of disseminated histoplasmosis usually originating from pulmonary infection by Histoplasma capsulatum. We report a 52-year-old male chronic smoker who had prolonged hoarseness and was initially diagnosed with laryngeal carcinoma. However, biopsy of the laryngeal mucosa confirmed the diagnosis of histoplasmosis. There were no signs of pulmonary or systemic involvement. Treatment with intravenous amphotericin B was given for a week and oral ketaconazole was given for a month with complete resolution of symptoms.     

播散型组织胞浆菌病21例临床研究

目的：探讨播散型组织胞浆菌病（PDH）的临床特点、诊断及治疗。方法：回顾性分析21例PDH患者的临床资料。结果：PDH的临床表现主要有发热,肝、脾肿大,各类血细胞减少等。18例经骨髓涂片确诊,3例经病理活检确诊。给予抗真菌药物治疗,19例治愈,2例放弃治疗后死亡。结论：通过骨髓涂片、病理组织切片进行病原学检查是确诊的依据。两性霉素B、伊曲康唑和氟康唑治疗有效。     

Bone marrow culture for diagnosis of mycobacterial and fungal infections in febrile patients

The perception and evaluation of patients with fever are constantly evolving. Due to sophisticated technology and financial constraints, increasing numbers of tests are performed earlier in patient evaluation. One is bone marrow culture for mycobacteria and fungi. To assess the yield of this procedure, we reviewed the results of cultures performed from 1982-1986 at Shands Hospital at the University of Florida. There were 124 patients so evaluated. No fungal cultures were positive. Four mycobacterial cultures were positive: three Mycobacterium avium-intracellulare, all in patients with AIDS (Acquired Immune Deficiency Syndrome), and one Mycobacterium tuberculosis in a patient with disseminated disease. Three patients ultimately found by other means to have disseminated mycobacterial infection were culture negative. We conclude that this procedure is of very low yield and only warranted in the patient with severe immunocompromise or the patient with strong clinical evidence of disseminated tuberculosis.     

荧光染色技术在艾滋病患者活检标本病原学诊断中的应用

目的探讨快速真菌与抗酸分枝杆菌荧光技术在艾滋病患者活检标本病原体诊断中的应用价值及意义。方法选取艾滋病患者500例活检标本,采用快速真菌荧光染色及六胺银、PAS染色对300例可疑真菌感染的活检标本进行检测,采用抗酸分枝杆菌荧光染色及萋尼抗酸染色对200例可疑结核的活检标本进行检测,并对检测结果进行对比。结果（1）快速真菌荧光镜检法检出阳性205例（阳性率68.3%）,六胺银染色法检出阳性209例（阳性率69.7%）,PAS染色法检出阳性97例（阳性率39.5%）,快速真菌荧光染色与六胺银染色检出阳性率差异无统计学意义（P>0.05),但高于PAS染色法;（2）抗酸分枝杆菌荧光染色检出阳性179例（阳性率89.5%）,萋尼抗酸染色法检出阳性117例（阳性率58.5%）,抗酸分枝杆菌荧光染色阳性率高于萋尼抗酸染色法,两者差异有统计学意义（P<0.01）;（3）荧光染色比常规特殊染色操作更快速、简便、显示更清晰。结论艾滋病患者并发机会性感染病原体种类多样,普通的特殊染色阳性率不高并且费时费力,而快速真菌及抗酸荧光染色特别是抗酸荧光染色的阳性率明显增高,为活检组织诊断真菌及结核分枝杆菌感染提供一种快速、准确、经济、对比更清晰的染色方法,能够为真菌感染及结核病患者诊断提供可靠的指导依据,值得在病原体诊断工作中广泛使用。     

Histoplasmosis of the small bowel in patients with AIDS

Two cases of jejunal strictures caused by Histoplasma capsulatum in AIDS patients are presented. Both patients were intravenous drug abusers. One patient, who was being treated for Pneumocystis carnii pneumonia, presented with jejunal perforation and the other presented with lower gastrointestinal bleeding and intestinal obstruction. On exploration, both patients were found to have jejunal strictures; one had intestinal perforation, and the other had intestinal obstruction with ulcers and strictures resulting in gastrointestinal bleeding. In areas where it is endemic, histoplasmosis is rarely disseminated. Dissemination is most commonly seen in immunosuppressed patients. Dissemination and extrapulmonary histoplasmosis is now included in the case definition of AIDS.     

Isolated cryptococcal osteomyelitis in immunocompetent patient

Cryptococcosis is a common opportunistic infection in AIDS patients. Almost all cases present with meningitis with or without fungaemia. Cryptococcal osteomyelitis occurs as part of a disseminated infection. Isolated cryptococcal osteomyelitis is rare and more so in immunocompetent patients. A case of isolated osteomyelitis caused by Cryptococcus neoformans in an immunocompetent patient is reported here. A female patient of 60 years old presented with pain and swelling of left clavicle. The histopathological examination of the biopsied material (bony fragment) showed histiocytes, lymphocytes with many foam cells showing organisms, the morphology was consistent with cryptococcus. Fluconazole was advised and she responded favourably.     

艾滋病机会性感染的中医药防治研究

艾滋病病毒感染人体后,破坏人体的细胞免疫功能,使患者的抵抗力降低,导致多种病原体侵袭而发生诸多机会性感染.抵抗力降低加上机会性感染,成为艾滋病患者死亡的主要原因.根据近年来相关文献时艾滋病机会性感染的研究报道,总结中医药防治艾滋病常见机会性感染的经验,为艾滋病的预防和治疗提供依据.     

艾滋病合并马尔尼菲青霉菌感染中枢神经系统1例

报道1例晚期艾滋病合并马尔尼菲青霉菌感染中枢神经系统的临床表现及治疗。患者为41岁男性,持续高效抗逆转录病毒治疗（HAART）1年余,1个月前因出现头痛症状而住院治疗。脑脊液检查提示脑压及蛋白均明显升高,并高于正常值。头颅CT提示两侧额叶低密度灶,轻度脑积水。初始考虑结核性脑膜炎,给予抗结核及甘露醇脱水降颅压治疗,疗效欠佳而自动出院。出院后脑脊液培养出马尔尼菲青霉菌。马尔尼菲青霉菌是目前发现的唯一温度依赖性双相真菌,可引起致命的系统性真菌病,以前在人类感染性疾病谱中是一个较为罕见的的病原体,但现在是东南亚地区艾滋病患者最为常见的机会性感染之一。马尔尼菲青霉菌感染最常见部位是皮肤、肺脏和内皮网状系统,包括骨髓、淋巴结、肝脏和脾脏,但中枢神经系统罕见。     

以足底感染为首发表现的血行播散性结核1例报道

 报道1例以左足底局部感染起病的血行播散性结核病例的临床、影像及诊治过程。血行播散性结核发病率低,仅占结核病的1%~2%,临床表现多样且非特异性,诊断非常困难。本例通过宏基因二代测序技术,在外周血检测到结核分枝杆菌复合群,为早期诊断结核病提供了非常重要的病原依据。后续骨髓活检、淋巴结活检病理提示肉芽肿,痰、左足脓液、淋巴结组织均培养到结核分枝杆菌,最终明确诊断为血行播散性结核。     

Histoplasmosis and Thrombocytopenic Purpura: Transmission by Renal Homotransplantation

Two patients with disseminated histoplasmosis are reported. One patient presented with severe thrombocytopenic purpura and splenomegaly. Histoplasmin skin test, blood and bone marrow cultures and smears, sputum cultures, and chest radiographs were negative for Histoplasma capsulatum. She died on the sixth hospital day from a massive intracerebral hemorrhage. Cardiorespiratory function was maintained until one kidney was removed for homotransplantation. The second patient, with chronic glomerulonephritis and uremia, received the renal homograft from the first patient. Initial signs of homograft rejection developed five days postoperatively. Diffuse thrombocytopenic purpura occurred shortly thereafter. Spores of Histoplasma capsulatum were observed in blood smears, in leukocyte concentrates, and in five-day leukocyte cultures from the blood obtained prior to death. Disseminated histoplasmosis was found in both patients at autopsy. The severe platelet deficit in both cases suggests that systemic histoplasmosis should be considered as a cause of thrombocytopenic purpura.

To our knowledge, this is the first reported instance of direct transmission of Histoplasma capsulatum, and must be considered a hazard in homotransplantation.

In vitro leukocyte cultures as a method for early diagnosis of certain disseminated fungous infections needs further investigation.