<Brief
History>
A 75-year-old man was admitted to the hospital because of
progressive abdominal fullness for 1 month.
Four years before admission, the patient had been
hospitalized because of tarry stool. A diagnosis of gastric
varices with bleeding in addition to alcoholic liver cirrhosis
was made at that time. Two years before admission, imaging
studies revealed two hypervascular tumors in the right liver
lobe, and he received transcatheter arterial embolization
(TAE). Diabetes mellitus was noted during the same admission
course. Six months before admission, elevated
alpha-fetoprotein level and multiple hepatic tumors were
noted. The patient hesitated and refused further TAE
treatment. One month before admission, he became aware of
progressive abdominal fullness. Abdominal sonography showed
ascites. He was prescribed with furosemide and spironolactone,
but the abdominal fullness didn't improve. There was no
history of chills, sweats, headache, a recent stiff neck,
cough, dysuria, diarrhea, myalgia, arthralgia or weight
loss.
On admission, the temperature was 38.4°C, the pulse
was 96, and the respirations were 20. The blood pressure was
140/ 80 mmHg. Physical examination revealed shifting dullness.
Mild tenderness with mild rebound tenderness was noted in the
whole abdomen. Bowel sounds were hypoactive, and no masses
were palpated. The urine was normal. The white cell count was
6440 per cubic millimeter, and neutrophils were 90.7%.
Abdominal fullness improved with peritoneocentesis. The white
cell count of ascites was 1900 per cubic millimeter, but
lymphocyte predominated to 72%. The serum-ascites albumin
gradient was 1.4 gram per deciliter. Cefoxitin was given
intravenously under the suspicion of spontaneous bacterial
peritonitis since the first hospital day. The fever fluctuated
in spite of the use of antibiotics, so flomoxef was prescribed
in place of cefoxitin since the 4th hospital day. A CT scan of
the abdomen revealed thickening of the peritoneum (Fig-3.JPG) and edematous change of
the omentum and mesentery. No obvious lymphadenopathy was
present. Several tumors of 1.5cm in size were also noted over
both lobes of liver with global enhancement in the arterial
phase (Fig-1.JPG,
Fig-2.JPG
). In
spite of the antibiotic treatment, there was still mild fever.
Metronidazole was added 10th hospital day, but the fever
persisted. Blood and ascites culture for bacteria didn't yield
any microorganism. There was also no response to
discontinuation of all antibiotics. Because of lymphocyte
predominance on repeated ascites examinations, diagnostic
laparoscopy was performed on the 26th hospital day. Multiple
miliary lesions were noted with little adhesion (Fig-4.JPG).
Pathology of the biopsy specimen revealed granulomatous
inflammation with patches of caseating necrosis and multiple
atypical Langhans giant cells (Fig-5.JPG).
Acid-fast stain showed a few acid-fast positive bacilli (Fig-6.JPG
).
Mycobacterium tuberculosis was also reported on the 28th
hospital day. So the patient was given anti-TB treatment with
combination of INH, RIF, EMB and PZA.
However, conjugate hyperbilirubinemia developed on the 32nd
hospital day. Anti-TB treatment was shifted to EMB and
streptomycin. Levofloxacin was added on the 36th hospital day
according to the suggestion of the infection specialist. Fever
subsided gradually later. Hyperbilirubinemia also improved
after the change of anti-TB regimen.
<Laboratory
Results>
1. CBC and Differential Count:
|
WBC |
RBC |
Hb |
Hct |
MCV |
Plt |
Band |
Seg |
Eos |
Baso |
Mono |
Lym |
|
K/μl |
M/μl |
g/dl |
% |
fl |
K/μl |
% |
% |
% |
% |
% |
% |
4/14 |
6.44 |
3.81 |
12.4 |
35.3 |
92.7 |
169 |
0.0 |
90.7 |
0.6 |
0.3 |
5.4 |
3.0 |
5/10 |
6.22 |
3.48 |
11.2 |
33.3 |
95.7 |
148 |
0.0 |
86.5 |
1.0 |
0.5 |
7.7 |
4.3 |
5/15 |
5.89 |
3.63 |
11.6 |
33.8 |
93.1 |
183 |
0.0 |
76.0 |
2.0 |
0.0 |
7.0 |
12.0 |
5/24 |
5.09 |
3.34 |
11.1 |
32.9 |
98.5 |
140 |
0.0 |
69.0 |
0.0 |
0.0 |
13.0 |
17.0 |
2.
Biochemistry:
|
Alb |
Glo |
Bil T/D |
AST |
ALT |
ALP |
gGT |
BUN |
Cre |
Na |
K |
|
g/dl |
g/dl |
mg/dl |
U/l |
U/l |
U/l |
U/l |
mg/dl |
mg/dl |
mmol/l |
mmol/l |
4/14 |
2.8 |
3.1 |
0.81/ |
23 |
|
|
|
14.0 |
0.7 |
132 |
3.58 |
5/10 |
|
|
1.2/ |
44 |
18 |
301 |
160 |
23.8 |
0.9 |
137 |
4.4 |
5/15 |
2.9 |
3.9 |
3.2/2.5 |
69 |
19 |
320 |
185 |
17.6 |
0.7 |
133 |
4.6 |
5/27 |
|
|
1.47/0.5 |
52 |
29 |
293 |
151 |
13.2 |
0.9 |
129 |
3.3 | 3. Coagulation:
|
PT |
PTT |
4/14 |
13.6/12.0 |
52.3/38.6 | 4. Ascites
Studies:
|
Appear. |
Rivalta |
RBC |
WBC |
L:N:M&H |
A/G |
LDH |
Glu |
Cytology |
|
|
|
|
|
|
g/dl |
U/l |
mg/dl |
|
4/17 |
Y;T |
+ |
5000 |
1900 |
72:21:7 |
1.4/1.2 |
209 |
201 |
Negative |
4/23 |
Y;T |
+ |
0 |
1500 |
95:3:2 |
1.8/1.5 |
218 |
217 |
Negative |
5/01 |
Y;TT |
+ |
0 |
800 |
96:4:0 |
1.19/ |
|
170 |
Negative | 5.Hepatology Profiles:
|
aFP |
HbsAg |
Anti-HBs |
Anti-HCV |
|
ng/ml |
|
|
|
4/16 |
194.47 |
Negative |
Weakly Positive |
Negative |
案例分析 此為一個酒精性肝炎併肝硬化及肝腫瘤的病人, 同時患有糖尿病.
腹水在一個月的利尿劑使用後仍持續存在, 接著發生腹痛以及發熱. 在自發性腹膜炎的懷疑之下住院進行抗生素治療.
期間雖然曾經更換過抗生素的處方, 發熱情況仍然持續. 而細菌培養均無結果. 反覆的腹水檢查, 白血球數依然升高,
但係淋巴球為主. 經腹部電腦斷層攝影檢查, 並無明顯的淋巴節病變. 在懷疑結核性腹膜炎的前提下, 病人接受腹腔鏡檢查.
腹腔鏡可見粟粒狀病灶散佈在腹膜上, 切片下亦顯示有肉芽腫性發炎及蘭格罕士氏巨細胞. 油鏡下可以看到少量的抗酸桿菌.
腹水結核菌培養在送檢四週後證實結核桿菌的存在. 病人發熱的情況在抗結核藥物使用後一週回復到正常體溫. 此外,
病人的膽紅素值在四種抗結核藥物使用下竄升三倍,
經更換藥物後逐漸改善.
|