A 67-year-old woman was transferred to our hospital on May
2, 2001 because of abdominal pain and dyspnea and hypotension
for several days. She initially complained of an intermittent
cramping pain over the right upper quadrant (RUQ) abdomen 4
days prior to admission. Sudden onset of dyspnea and altered
mental status were noticed 2 days later. She was sent to the
emergency room of a local hospital where a body temperature of
37.5oC and blood pressure 80/30 mm Hg were found. The
abdominal sonography showed multiple gallstones and swelling
of the gallbladder wall with the “triple-layer” sign. Her
hemodynamics were stabilized by fluid challenge and empirical
antibiotic therapy. She was then transferred to our hospital
for further management.
The patient had had hypertension for several years with
regular medical control. She also had received hormone
replacement therapy with one tablet of unknown drug per day
due to osteoporosis for 2 years. The past history was
otherwise non-contributory.
On examination, her consciousness was drowsy. The body
temperature was 37.5oC, blood pressure 160/92 mm Hg, pulse
rate 120 beats/min, and respiratory rate 24 breaths/min. The
sclerae were not icteric. The pupils were isocoric with prompt
light reflex. The neck was supple, without jugular vein
distension or lymphadenopathy. The chest expanded
symmetrically and the breathing sounds were clear. No heart
murmurs were detected. There were tenderness and muscle
guarding at the RUQ abdomen and the Murphy’s sign was
positive. The liver and spleen were not palpable. The bowel
sounds were hypoactive. No lower leg edema was noticed.
Neither skin rash nor petechiae were found. The initial
laboratory studies revealed white blood cell count of 16.61x
109 cells/L, with 86.2% neutrophil, 5.6% monocytes, and 8.1%
lymphocytes; red blood cell count of 4.19 x 1012 cells/L;
hemoglobin 12.7 g /dL; and 104 x 109 platelets/L. The
prothrombin time and activated partial thromboplastin time
(PTT) were within normal limits. The asparate aminotransferase
was 57 U/L; total bilirubin 1.26 mg/dL; the amylase 253 U/L;
the amylase 123 U/L;blood urea nitrogen 2.0 mmol/dL; and
creatinine 67.2 μmol/dL. The arterial blood gas analysis when
breathing through a mask at an inspired O2 fraction of 35%
showed pH 7.448;PCO2 35.9 mm Hg; PO2 127.9 mm Hg and
HCO3-
25.0 mmol/L . The electrocardiography revealed sinus
tachycardia only.
She underwent a laparoscopic cholecystectomy on May
3, 2001. The operation findings and pathologic report were
both compatible with the diagnosis of chronic cholecystitis.
Unfortunately, she developed haemoptysis, persistent RUQ
abdominal pain and fever immediately after cholecystectomy.
Chest examination showed decreased breathing sounds over right
lower lung field with some basal crackles.
Imaging studies, including the
initial chest radiograph at the local hospital (Fig.
1), the chest radiographs while the patient was being
prepared for cholecystectomy (Fig.2)
and 14 days after the cholecystectomy (Fig.
3), and the computer tomography (CT) scans of the chest 7
days after the cholecystectomy (Fig.
4a and 4b),
are shown. The initial chest radiograph (Fig.
1) is clear, but the image taken while preparing for the
cholecystectomy (Fig.
2) shows alveolar consolidation over the right lower lung
and blunting of the right cardiophrenic angle. The CT scans of
the chest (Fig.
4a and
Fig. 4b) reveal a large filling defect in the right main
pulmonary artery and consolidation of the lower right lung
with cavitation. The follow-up chest radiograph (Fig.
3)
revealed prominent cavitation of the previous lung
consolidation.
The pulmonary angiography showed a large filling
defect in right pulmonary artery, without visualization of the
branches of right pulmonary artery to the right lower lobe.
The duplex study of deep veins of the lower limbs was
negative, and the echocardiography did not show right
ventricular (RV) thrombi either. The serum levels of protein
C, protein S, and antiphospholipid antibody were within normal
limits. The autoimmune profiles were also normal. The sputum
culture grew Pseudomonas aeruginosa.
A diagnosis of cavitary pulmonary
infarct was made. High dose of intravenous ceftazidine and
heparin were administered immediately after the findings of
the CT scans were obtained on the 7th day after
cholecystectomy, with the activated PTT maintained at 1.5-2.0
folds of the control. The follow-up chest radiograph 8 weeks
later, however, showed only partial resolution of the
consolidation of the right lower lung and the CT scans did not
reveal shrinkage of the thrombi in the right pulmonary artery.
The perfusion scan (Fig.
5)
and the
Doppler sonography failed to show reperfusion of the infracted
lung either. The patient therefore underwent a lobectomy of
the right lower lobe and embolectomy on July 5, 2001. Culture
of the removed lung tissues still yielded Pseudomonas
aeruginosa which was sensitive to the antibiotic used. The
post-operation course was smooth and the patient was
discharged on the 10th hospital day after the operation with
continued maintenance therapy of anticoagulation.
Laboratory
data: 1.
CBC/DC:
|
WBC |
RBC |
Hb |
Hct |
MCV |
PLT |
|
K/uL |
M/uL |
G/dL |
% |
fL |
K/uL |
900502 |
16.6 |
4.19 |
12.7 |
38.7 |
92.4 |
104 |
900504 |
24.57 |
3.93 |
12.0 |
36.4 |
92.6 |
158 |
900704 |
9.01 |
4.71 |
13.3 |
41.1 |
87.3 |
250 | 2.
Biochemistry
|
BUN |
Cre |
Na |
K |
T-Bil |
D-Bil |
GOT |
ALP |
|
mg/dl |
mg/dl |
mmole/l |
mmole/l |
mg/dl |
mg/dl |
U/l |
U/l |
900502 |
5.5 |
0.76 |
137 |
3.8 |
1.26 |
890822 |
57 |
123 | 3.
ABG
|
pH |
PCO2 |
PO2 |
HCO3- |
BE |
condition |
|
* |
mmHg |
mmHg |
mEq/l |
mEq/l |
|
900502 |
7.448 |
35.9 |
127.9 |
25 |
+1.2 |
mask, 8 L, FiO2 = 35% |
900503 |
7.43 |
32.9 |
143.5 |
21.3 |
-1.9 |
Mask 8L
FiO2=40% | 4. Inhibitor protein
study
|
ATIII: Ag |
ATIII:Fun |
PC: Ag |
PC: Fun |
PS Ag:Total |
PS Ag:Free |
900507(%) |
73 |
72 |
83 |
53 |
122 |
80 | 5.
Antiphospholipid antibody
|
APA<5:(-); 5~15:BL;>15:(+) |
ACA<16:(-);16~21:BL;21~60:Mod.(+) |
DRVVT>1.2 |
900507 |
2.262 |
4.273 |
1.24 |
900704 |
1.860 |
8.942 |
NEGATIVE | 6.
900508 |
Sputum culture: (2+)* |
Pseudomonas aeruginosa | 7.
900528 |
Culture of protected sheath
brushing : Pseudomonas aeruginosa |
|
Catheter: Confluent | 8.
900528 |
Culture of bronchioalveolar lavage: Pseudomonas
aeruginosa 89000 /ml | 9.
900705 |
Culture of lung abscess : (3+)Pseudomonas
aeruginosa |
病案分析 本病例為一位接受賀荷蒙補充療法的停經後女性。突然產生右上腹痛、低血壓、及呼吸喘之症狀,經過初步的檢查,診斷為膽囊結石併敗血症。但是開刀後呼吸喘及右上腹痛的症狀持續,併出現血痰,才將診斷的注意力集中至肺部。從臨床上的症狀,再加上病人在接受賀荷蒙療法,肺栓塞應列入診斷考慮。之後雖然迅速診斷並且給予適當劑量的抗凝血劑,但是經過影像學上的追蹤,發現血栓並無溶解的跡象,同時肺部引起壞死和繼發性感染,形成肺膿瘍。
本病例為少見的肺栓塞的併發症。在文獻上Pulmonary
infarct佔所有肺栓塞病例之10%, Cavitary pulmonary infarct只佔所有pulmonary
infarct
病例之4-5%。在輔以外科手術的方法,將肺膿瘍及右肺動脈內的血栓清除,此病患於術後順利出院,沒有留下明顯的後遺症,為一成功治療之典範。
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