恙虫病致急性上消化道大出血、多器官功能衰竭经动脉栓塞止血抢救成功一例及文献复习

目的提升对恙虫病(TD)所致上消化道大出血(UGB)、多器官功能衰竭综合征(MOFS)和多器官功能损伤(MOD)的认知。方法分析1例58岁TD男性患者并发UGB、MOFS和MOD的救治经过。结果患者以“发热4 d,皮疹2 d”入院,发病前有野外游玩史,左侧小腿可见1个1.5 cm×1.5 cm焦痂,周围火山口样脱屑,左侧腹股沟淋巴结肿大。实验室检查提示丙氨酸氨基转移酶(ALT)、天门冬氨酸氨基转移酶(AST)、尿素氮(BUN)、肌酐(Scr)、降钙素原(PCT)、羟丁酸脱氢酶(HBDH)、肌酸激酶同工酶(CKim)、乳酸脱氢酶(LDH)升高,超敏C-反应蛋白(hCRP)升高,嗜酸性粒细胞(EOS)降为“0”,根据“恙虫病积分诊断量表”、恙虫病东方体抗体阳性、焦痂恙虫病东方体阳性结果,临床和病原学诊断为“TD伴MOD”。入院第3天反复发生UGB,实验室检查显示ALT、AST、BUN、Scr、PCT、HBDH、CKim、LDH、hCRP进一步升高,血小板(PLT)迅速下降,凝血功能异常,并发生MOFS(循环衰竭、呼吸衰竭),临床诊断为“TD合并MOF(循环衰竭、呼吸衰竭)、MOD(肝脏、肾脏、血液系统)和脓毒血症”,在气管插管辅助呼吸、抗休克、器官保护下,经上腹部多层螺旋CT和数字减影血管造影术检查确定为胃左动脉分支出血致胃出血,对出血血管栓塞止血。恢复期胃镜检查提示出血性溃疡,组织病理学显示炎症反应。本文在国内外首次报道TD致UGB、MOF、MOD、脓毒血症的临床治愈病例。结论TD可引起出血性溃疡,导致UGB、MOF,准确病原学治疗,及时介入止血治疗是抢救成功的关键。

A case with acute upper gastrointestinal hemorrhage and multiple organ failure syndrome caused by tsutsugamushi disease and successfully rescued by arterial embolization and literature review

ObjectiveTo improve the understanding of upper gastrointestinal bleeding (UGB), multiple organ function injury (MOD) and multiple organ failure syndrome (MOFS) caused by tsutsugamushi disease (TD). MethodsThe treatment process of UGB, MOD and MOFS of a 58-year-old male patient with TD was analyzed. ResultsThe patient was hospitalized with fever for four days and rash for two days. He had a history of field trip. There was 1.5 cm × 1.5 cm eschar on left leg for physical examination, crater like scaling around, left inguinal lymph node enlargement. Laboratory examination showed that alanine aminotransferase (ALT), aspartate amino transferase (AST), gomerular filtration rate (GFR), blood urea nitrogen (BUN), serum creatinine (Scr), hydroxybutyrate dehydrogenase (HBDH), creatine kinase isoenzyme (CKim), lactate dehydrogenase (LDH), high-sensitivity CRP (hsCRP) and procalcitonin (PCT) increased significantly, and eosinophils (EOS) decreased to 0. TD with MOD was diagnosed according to the tsutsugamushi integral diagnosis scale, the positive results of Rickettsia tsutsutsugamushi antibody and antigen. On the third day of admission, this patient had repeated UGB, MOFS (shock, respiratory failure), platelet (PLT) decreased rapidly, and ALT, AST, BUN, Scr, HBDH, CKim, LDH, hCRP and PCT furtherly increased. Laboratory examination showed dysfunction of blood coagulation. The clinical diagnosis was TD with MOF (circulatory failure, respiratory failure), mod (liver, kidney and blood system), sepsis. Under the assistance of endotracheal intubation, respiration, anti-shock and organ protection, the upper abdominal multi-slice spiral computed tomography and digital subtraction angiography examination determined that the left gastric artery branch was bleeding, and the bleeding vessels were embolized to stop bleeding. Gastroscopy in convalescence revealed hemorrhagic ulcer and histopathology showed inflammatory reaction. This is the first report of UGB, MOFS, mod and sepsis caused by TD at domestic and overseas. ConclusionsTD could cause hemorrhagic ulcer and lead to UGB and MOFS. On the basis of etiological treatment, interventional treatment for bleeding is the key to successful rescue.