A 55 year-old man suffered from fever and consciousness
disturbance for two days.
Brief History
The 55 year-old man was rather well before except abnormal
blood glucose level was noted occasionally. Fever was noted on
July 29,2000 without cough, sneeze, abdominal pain, diarrhea
and dysuria. Headache and nausea developed one day later and
these symptoms can be relieved transiently after taking
medication. The condition deteriorated with vomiting and
persistent fever. He was noticed to become disoriented on the
morning of the first of August and could not respond
adequately to her wife. He was sent to a community hospital
where seizure attacked on arrival. General convulsion and
consciousness loss ensured and endotracheal intubation was
done. Lumbar puncture was performed and pus-like material was
aspirated. Ceftriaxone 1gm was given immediately under the
impression of bacterial meningitis. He was transferred to NTUH
for further management.
Physically, his consciousness was
E1M1VT . Blood pressure
was 121/74 mmHg and temperature was 37.8 °C. The pulse rate
was 142 beats per minute and no spontaneous respiration was
noted. Head was grossly normal. Conjunctiva was not pale and
sclera was not icteric. Neck was stiff to the degree of two
finger-width. Breath sound was clear and chest expansion was
symmetric. Regular heart beat without murmur was disclosed.
Abdomen was soft and flat and bowel sound was normoactive.
Liver and spleen were not palpable. Extremities showed no
petechiae and edema.
Laboratory Data
1. CBC
|
WBC (K/μL) |
RBC (M/μL) |
HB (g/dL) |
MCV (fL) |
PLT (K/μL) |
Band (%) |
Seg (%) |
8/1 |
9.42 |
4.74 |
14.3 |
87.1 |
74.0 |
23 |
68 |
8/5 |
18.22 |
3.49 |
10.4 |
90.3 |
34.0 |
|
|
2. ABG
|
pH |
PCO2(mmHg) |
PO2(mmHg) |
HCO3-(mEq/L) |
B.E(mEq/L) |
FiO2(PEEP) |
Ventilator Mode |
8/1 |
7.41 |
18 |
82.9 |
11.3 |
-11.0 |
0.4 (5) |
CMV |
8/4 |
7.02 |
41.3 |
62.7 |
10.2 |
-19.7 |
1.0 (10) |
CMV |
3. BCS
|
Glu(mg/dL) |
T-Bil(mg/dL) |
D-Bil(mg/dL) |
AST(U/L) |
ALT(U/L) |
BUN mg/dL |
Cre mg/dL |
8/2 |
434 |
2.1 |
1.4 |
44 |
58 |
34 |
2.0 |
8/7 |
257 |
9.8 |
7.3 |
350 |
472 |
70 |
7.8 |
4. Coagulation profile
|
PT |
PTT |
Fibrinogen (mg/dL) |
3P |
FDP (μg/mL) |
D-Dimer |
8/1 |
15.2/11.9 |
54.5/38.1 |
858 |
4+ |
160-320 |
12.25 |
8/7 |
20.5/12.1 |
69.0/38.7 |
|
4+ |
80-160 |
17.35 |
5. CSF study
|
WBC (/μL) |
L:N |
Gram's stain |
Acid fast stain |
Total protein |
LDH |
8/1 |
20736 |
576:20160 |
G(-) bacilli |
negative |
4.2 |
69900 |
Clinical Course &
Treatment
After admission, ceftriaxone 2gm q12h and
penicillin G 3MU q4h were given under the impression of
bacterial meningitis. Cerebrospinal fluid examination showed
marked pleocytosis with neutrophil in majority and
cerebrospinal fluid smear revealed gram negative bacilli.
Penicillin G was discontinued. Head computed tomography showed
diffuse brain swelling and mannitol 150 mL q8h was given under
the impression of increased intracranil pressure. Septic shock
was impressed since August 1. Cerebrospinal fluid culture
yielded Klebsiella pneumoniae
which was sensitive to
ceftriaxone. He was found to have red eyes with chemosis during
hospitalization. Ophthalmologist was consulted under the
impression of endophthalmolitis. Intravitreal injection with
imipenem was given. Abdominal echo was performed on August 3
with negative findings. Repeat lumbar puncture showed elevated
intrathecal pressure (open pressure 250 mmHg) and improvement
of cerebrospinal fluid status. Refractory hypoxemia with
increased oxygen demand to the level of FiO2 of 1.0 developed
on August 5. CXR disclosed bilateral diffuse haziness. Acute
renal failure and deteriorated liver function ensured later.
His blood pressure deceased to 50/30 mmHg at the night of
August 6 and refractory to norepinephrine infusion. The
patient passed away at 4:37 pm August 7.
案例分析
當病人有發燒不退且伴隨有意識變化的情形,其鑑別診斷必須將中樞神經系統的感染排在第一位,至於是病毒性、細菌性或其他血行散佈而來,只有靠進一步的檢查來縮小範圍,因為儘早的治療對病人的預後是重要的決定因素。因此在時間許可下應先作頭部電腦斷層,確定無uncal
hernation的危險再施行腰椎穿刺。取得腦脊髓液作抹片檢查,可提供我們作初步的診斷。如本案例執行腰椎穿刺後,腦脊髓液呈現膿狀且抹片有看到G(-)bacilli,即可斷定是細菌性腦膜炎,然而有些病毒性腦膜炎在發病時,腦脊髓液之血球計數可以是中性白血球為主,若當時無法確定是病毒性或細菌性,則必須同時治療兩種病因。對於治療細菌性腦膜炎,一般建議給予第三代Cephalosporin及Penicillin
G,但因抗藥性之pneumococcus盛行,臨床上漸有以Vancomycin取代Penicillin
G之趨勢;至於治療病毒性腦膜炎,目前可使用的藥物是Acyclovir。
本案例為55歲男性,為糖尿病病人,平時血糖控制不良,台灣地區糖尿病病人特別好發Klebsiella
pneumoniae感染,肺部、肝臟、泌尿道及腦部為常見感染部位,特別當有Klebsiella
pneumoniae
感染時,必須先檢查肝臟是否有肝膿瘍及眼睛是否有因血行性散佈而導致的endophthalmolitis。
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