右心室心肌应变在静脉-动脉体外膜氧合辅助支持治疗暴发性心肌炎急性期中的价值

目的初步探讨二维斑点追踪超声心动图（2D-STE）技术评估右心室心肌应变在静脉-动脉体外膜氧合（V-A ECMO）辅助支持治疗暴发性心肌炎（FM）急性期中的应用价值。 方法选取2018年5月至2021年6月西安交通大学第一附属医院收治的11例FM并且心脏功能恢复良好的患者,所有患者均进行V-A ECMO辅助支持治疗且每日行常规经胸超声心动图检查。采用2D-STE技术获得右心室游离壁纵向应变（RVFWSL）、右心室整体纵向应变（RV4CSL）。 结果V-A ECMO辅助支持治疗FM患者平均时间为（6.0 ± 2.9）d。V-A ECMO辅助支持治疗后,FM急性期患者三尖瓣瓣环收缩期位移（TAPSE）、右心室面积变化分数（RVFAC）、组织多普勒-三尖瓣瓣环收缩期峰值速度（s’）、左心室射血分数（LVEF）日渐改善;RVFWSL、RV4CSL变化趋势为先降低、后逐渐升高;B型氨基端利钠肽原、中性粒细胞计数、白细胞介素6、C反应蛋白、乳酸脱氢酶、肌酸激酶、肌酸激酶同工酶、乳酸水平先升高、后缓慢降低。 结论V-A ECMO辅助支持治疗FM急性期患者期间,右心室心肌应变值与心肌酶指标、炎症指标变化趋势相同。右心室心肌应变值或许可以为V-A ECMO辅助支持治疗FM急性期患者右心室功能变化提供更多的信息。     

Thigh emphysema as the initial presentation of colon ischemia

The incidence of colon ischemia has increased in recent years, and is associated with high morbidity and mortality. The typical presentations of colon ischemia include abdominal pain, bloody diarrhea, and in severe case, ileus, fever and peritonitis. Here, we document a rare case of colon ischemia presenting with subcutaneous and intramuscular emphysema of the thigh. A 76-year-old woman presented to the emergency department for left thigh pain for three days. Physical examination revealed tenderness without obvious crepitus, erythema or swelling over the left groin area and a soft abdomen without tenderness. Plain abdominal film showed abnormal gas formation at the left thigh and chest film demonstrated subphrenic free air. Abdominal computer tomography found sigmoid perforation causing left retroperitoneal abscess, and subcutaneous and intramuscular emphysema over the left pelvic and thigh region. During operation, irreversible ischemia from the terminal ileum through the cecum to the sigmoid colon with gangrene and retroperitoneal abscess were found. Total colectomy with end ileostomy and peritoneal toilet were performed. However, massive bloody ascites from abdominal drainage developed on the 13th day of admission. She later passed away due to hemorrhagic shock. In conclusion, emphysema of the thigh may rarely be caused by an intestinal lesion, such as colon ischemia. Clinicians should be alert of these unusual presentations to find the hidden underlying etiologies.     

Postural guarding and hypertension as initial manifestations of Guillain-Barré syndrome

A child without any prodromal events presented with incapacitating, symmetrical limb pain intensified by any movement. He lacked objective motor weakness or reflex changes. A provisional diagnosis of Guillain-Barré syndrome was not entertained despite sequential examinations that further documented dysesthesia, postural guarding, and hypertension. The clinician must consider Guillain-Barré syndrome as a cause for self-imposed immobilization associated with autonomic dysfunction.     

帕博利珠单抗相关爆发性心肌炎一例

免疫检查点抑制剂(ICIs)是近年来肿瘤治疗领域的最重要进展之一。随着ICIs适应证的不断拓展及国内原研药相继进入临床,ICIs将用于越来越多的肿瘤患者,然而ICIs的严重不良反应尚未引起临床医师的广泛关注。该文报道1例肝癌术后复发接受帕博利珠单抗治疗引起爆发性心肌炎的病例,患者主要表现为心肌酶升高,难治性心律失常,伴有肝损伤,呼吸衰竭等,虽经积极抢救最终死亡。该例提示ICIs相关免疫性心肌炎早期症状不典型,但疾病呈爆发性进展,需要临床医师早期识别,及早干预。     

Neurological manifestations as the initial presentation of acute myelogenous leukemia

This case report illustrates neurological deficits as an unusual presentation of acute myelogenous leukemia. Neurological deficits are rare early in this disease. Our patient presented with anorexia, malaise, headache, and multiple cranial nerve palsies. A high WBC count and abnormal peripheral smear led to the diagnosis of leukemia. This report demonstrates that, although rare, CNS symptoms may be the initial manifestation of leukemia. Blood dyscrasias should not be overlooked in patients with the acute onset of neurological symptoms. A complete blood count and differential should be obtained under those circumstances.     

CNS toxoplasmosis as the initial presentation of the acquired immunodeficiency syndrome

Neurological manifestations are present in 30% to 60% of patients with acquired immunodeficiency syndrome (AIDS) and may be the initial presentation in 10% to 20% of cases. Central nervous system toxoplasmosis now represents the most common focal brain lesion in patients with AIDS and possibly the most common opportunistic infection. A case of fulminant central nervous system toxoplasmosis as the initial presentation of AIDS is presented. Emergency physicians will be confronted with neurological complications of AIDS with increasing frequency in the future and should maintain a high index of suspicion for human immunodeficiency virus infection in young patients with neurological dysfunction.     

MR心肌应变在暴发性心肌炎初步应用及与心肌水肿相关性分析

目的评估心脏磁共振(CMR)心肌应变对暴发性心肌炎诊断价值及与心肌水肿相关性。方法回顾性分析29例暴发性心肌炎患者及19例正常志愿者临床及影像学资料,均在3.0 T行CMR成像,扫描序列包括心脏电影、T2WI、T1mapping、T2mapping、延迟强化。在常规电影图像上进行心肌应变分析,得出长轴(LS)、圆周(CS)及径向(RS)应变值。两组之间采用独立样本t检验或Mann-Whitney U检验进行统计分析,心肌应变与心肌水肿进行Spearman相关性分析,并采用ROC分析各参数鉴别两者的效能。结果与对照组相比,暴发性心肌炎RS、CS、LS均明显减低,而T1、T2及细胞外容积(ECV)值明显升高。CS与T1、ECV及T2呈明显正相关性(T1:r=0.415,P<0.05;ECV:r=0.724,P<0.001;T2:r=0.469,P<0.05),RS与ECV之间存在明显负相关(r=-0.497,P<0.05)。心肌应变诊断暴发性心肌炎AUC值均较高。结论CMR心肌应变在暴发性心肌炎具有较高的诊断价值,CS及RS与心肌水肿有明显相关性。     

Polyarticular symmetric tophaceous joint inflammation as the initial presentation of gout

A 76-year-old woman suffered from bilateral distal index finger pain and swelling. The patient had been initially treated with antibiotics for herpetic whitlow complicated by a secondary bacterial infection. Gout was diagnosed through clinical history, physical examination and identification of monosodium urate crystals in the joint aspirate. Gout appearing as polyarticular, symmetric tophi involving the periungual region and distal interphalangeal joint has not been previously described.     

Atypical chest pain as an initial presentation of primary fibromyalgia

Four patients with atypical chest pain initially believed to be cardiac in origin were subsequently found to have primary fibromyalgia. All patients had characteristic findings of this condition, and the diagnosis was confirmed by demonstrating muscle tender and trigger points which reproduced the chest symptoms. None were found to have significant cardiac conditions, and all improved after a specific treatment program. Primary fibromyalgia should be suspected in patients with atypical chest pain. Appropriate treatment can result in optimal medical management and avoidance of costly medical tests.     

Obstructive sleep apnoea/hypopnoea as the initial presentation of relapsing polychondritis

Relapsing polychondritis (RP) is a relatively rare rheumatological condition, which can affect the upper airway and prove potentially life threatening. We report the first case of RP presenting initially as the obstructive sleep apnoea/hypopnoea syndrome, discuss management and review the extant literature.