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肺放线菌病一例报告

目的 通过分析1例肺放线菌病患者的临床特征及诊治过程，结合文献复习，加强临床医生对本病的认识，以期早期诊断、规范治疗，改善患者预后。方法 回顾性分析1例肺放线菌病患者的临床资料，以“肺放线菌病”、“放线菌肺炎”为关键词在万方数据库、中国知网数据库、中国期刊全文数据库，以“pulmonary”和“actinomycosis”为关键词在PubMed数据库检索相关文献进行文献复习，总结肺放线菌病的临床特征、影像学特点、诊断手段、治疗及预后不良相关因素。结果 患者男，53岁，因“反复咳嗽、咳痰4－个月，伴咯血15 d”入院。患者无明显肺外临床表现，内科查体未见明显异常，外院胸部CT提示左下肺团片影，两次痰液送检二代测序，均检出放线菌菌属（检出最多序列数4393），革兰阳性格雷文尼放线菌多（检出最多序列数4258）。入院后予头孢哌酮舒巴坦针静脉滴注抗感染19 d，出院后继续复方磺胺口服，随访至2021年3月患者胸部影像学提示病变已明显吸收好转。结合本例及国内外文献报道的肺放线菌病相关资料，结果显示该病中老年男性多见，口腔卫生条件不良是该病的主要危险因素，临床症状无特异性，主要表现为咳嗽、咳痰、咯血，胸部CT典型表现为团块影并空洞形成，增强后不均匀强化，病灶内见稍低密度或气体密度，经支气管活检、经皮肺穿刺或手术标本病理为主要确诊手段，近年二代测序技术已成为诊断该病的重要工具。放线菌对多种抗菌药物敏感，但抗菌药物治疗疗程长，推荐6～12个月。内科及介入无法控制的大咯血以及抗菌药物治疗长疗程前提下临床症状无缓解、胸部影像学肺部病灶无明显吸收的患者，手术可能是一种治疗选择。结论 肺放线菌病的临床特征及影像学表现均不典型，影像学上常表现为巨大团块，临床上常被误诊为肿瘤。痰液、纤维支气管镜灌洗液标本及经皮肺穿刺组织标本病原微生物二代基因测序有助于确诊。经抗菌药物治疗预后良好，对于止血药物及介入无法控制的大咯血、使用长疗程抗菌药物后临床症状仍缓解不明显或胸部影像学病变未见明显吸收的患者，手术可能是一种治疗选择。

急性肺栓塞危险分层及预后评估研究进展

宏基因组二代测序辅助诊断军团菌病伴横纹肌溶解和急性肾损伤一例

目的 加强临床医生对军团菌病多器官损害临床特点的认识，针对目前军团菌诊断的难点，重视宏基因组二代测序（metagenomic next-generation sequencing，mNGS）在本病诊断中的应用价值，以早期诊断与精准治疗，改善军团菌病患者的预后。方法 分析 1 例经 mNGS 确诊的嗜肺军团菌病患者的临床特点、治疗过程及预后。结果 患者男，61 岁，因“发热、咳嗽伴乏力 3 d”就诊。发病初期除呼吸道症状外，合并多系统症状。住院期间，在肺泡灌洗液及肺组织中，mNGS 检出嗜肺军团菌，结合临床特点诊断军团菌病。患者经有创呼吸、抗感染、血液透析、保肝等综合治疗后，最终顺利出院。结论 对于病程短，以肺炎表现为主伴多器官受累的疾病，尤其伴肌酸激酶显著升高者应警惕军团菌感染可能。对于病情危重且少痰或无痰的患者，在缺少其他检测方法（如军团菌尿抗原）的情况下，可行纤维支气管镜取肺泡灌洗液或经皮肺穿刺取肺组织进行mNGS检查，以早期明确病原体。军团菌肺炎伴发横纹肌溶解和急性肾损伤时，及早予以针对病因及并发症的综合治疗有助于改善患者预后。

A Case of Renal Contusion with Acute Pulmonary Embolism: Treatment Experience and Literature Review

ObjectiveTo investigate the anticoagulant drug treatment decision for patients with renal contusion and acute pulmonary embolism, and to enhance the level of treatment for this disease. MethodsA retrospective analysis of the clinical data of a patient with renal contusion and acute pulmonary embolism treated at the West China Hospital of Sichuan University, along with a relevant literature review. Databases including PubMed, Ovid Medline, Embase, VIP, Wanfang and Chinese National Knowledge infrastructure were searched using the keywords as “Pulmonary embolism” AND “Hemorrhage”from January 1983 to December 2023. ResultThe patient was a 21-year-old male who presented with right kidney contusion for 5 days and dyspnea for 1 day. The abdominal CT scan revealed a ruptured right kidney accompanied by hemorrhage and hematoma in the surrounding tissue. Abdomen ultrasound: a low echogenic area measuring approximately 10.6 cm×2.8 cm is noted around the right kidney. The CT pulmonary angiography (CTPA) demonstrated filling defects at the bifurcation of the pulmonary trunk, as well as within the upper and lower lobes of both lungs and their respective branches. The blood gas analysis of patient indicated (face mask oxygen therapy at 10 L/min, oxygenation index of 120): pH 7.456, PCO2 24.9 mm Hg, PO2 73.2 mm Hg. His myocardial markers were Myoglobin: 79.21 ng/ml, Troponin T: 58.7 ng/L, BNP: 2062 ng/L. The patient was diagnosed with renal contusion and pulmonary embolism, and was treated with subcutaneous heparin（initial dose is given as an 80 IU/kg intravenous bolus, followed by a continuous infusion of 12-18 IU/kg/h） and low-molecular-weight heparin at a dose of 0.8 ml every 12 hours one after another for anticoagulation, along with symptomatic treatment. Following the intervention, the patient's respiratory distress showed significant improvement, and subsequent arterial blood gas analysis indicated enhanced oxygenation. Then, the anticoagulant medication was adjusted to oral rivaroxaban anticoagulation for 6 months, follow-up CTPA scan revealed complete resolution of the pulmonary embolism and the abdominal CT scan indicated a reduction in the extent of patchy low-density shadows surrounding the right kidney, leading to the discontinuation of anticoagulation therapy. After searching the above-mentioned databases, total of 26 articles were identified that reported on 30 patients diagnosed with high-risk bleeding and acute pulmonary embolism; among these, 3 patients succumbed while 27 exhibited clinical improvement. ConclusionsPatients with renal contusion and acute pulmonary embolism can be safely and effectively treated with low-dose heparin anticoagulation under close monitoring. High-risk bleeding patients with acute pulmonary embolism present a significant challenge in clinical practice. After weighing the risks of bleeding disorders and the adverse outcomes of pulmonary embolism, it is necessary to find the optimal balance between anticoagulation and bleeding. Consequently, the formulation of personalized treatment strategies in accordance with established guidelines can enhance patient outcomes.