<Case
Presentation>
A 79 year-old man presented
with aggravated cough, shortness of breathing and left-sided chest
pain for 2 weeks.
This patient had been a coal miner
for 30 years. He was a case of diabetes using oral
hypoglycemic agents for more than 10 years with a poor
compliance. He had had pulmonary tuberculosis about 8 years
ago, which was treated with a complete course of
anti-tuberculosis medication for 2 years.
He was
brought to this hospital because of exacerbated respiratory
condition even after taking oral antibiotics from another
hospital. On admission, the temperature was 39.8°C, the pulse
was 95, and the respiration was 26. The blood pressure was
145/ 67 mmHg. After admission, intravenous amoxicillin/
clavulanic acid and gentamicin was given. However, severe
left-sided chest pain occurred 2 days after admission.
Auscultation showed total absence of respiratory sound of the
left lower lung region. Chest X-ray (Fig.1
) revealed accumulation of
left-sided pleural effusion. Under echographic guidance, turbid
pleural effusion was aspirated and the laboratory analysis of
pleural effusion was as following:
WBC 27,000/μl, RBC 30/μl, Lymphocyte/ Neutrophil/
Histiocyte: 0/ 82/ 18 Acid-fast stain (-), Gram’s stain: Gram
(-) bacilli,
Glucose 261 mg/dl, Total protein 4 g/dl, LDH 1916 U/L,
cytology shows polymorphonuclear cells only.
Culture of pleural effusion yielded Klebsiella pneumonia
that was resistant to ampicillin only.
Left lower lobe, B6 segment abscess
formation was noticed but resolved gradually under antibiotic
treatment with pipracillin and tazobactem. Chest tube drainage
of the empyema was performed under antibiotic coverage. His
general condition improved after above treatment, and the
chest x-ray revealed resolution of the pneumonic patch (Fig. 2
).
<Laboratory
Data>
Table
1. Hematologic laboratory values
|
WBC /μL |
Hb g/dL |
MCV fL |
Plt k/μL |
Neu % |
Lym % |
On admission |
5500 |
9.2 |
92.2 |
362 |
66.9 |
16 |
7th day of admission |
6500 |
8.5 |
94 |
391 |
68.6 |
16 |
12th day of admission |
8300 |
9.9 |
91.6 |
383 |
77.7 |
13.4
|
Table 2. Blood chemical values
|
Glusos e mg/dL |
Bilirub in mg/dL |
AST/AL T U/L |
BUN mg/d L |
Creatini ne mg/dL |
Na mM |
K mM |
On admission |
213 |
0.4/0.2 |
13/22 |
12 |
0.8 |
137 |
4.3 |
12th day of admission |
158 |
|
19/ |
11 |
1.1 |
141 |
4.0 |
Fe 28, TIBC 174, HbA1C
12.4%.
<病案分析>
本病例為控制不佳之糖尿病患者,發生Klebsiella
pneumonia之肺炎感染,在台灣本土是相當常見的糖尿病相關併發症。第二型糖尿病患者的長期追蹤,可檢查病人的糖化血色素。若糖化血色素超過8%,代表病人最近兩三個月平均血糖值約在180
mg/dL以上。也就是說,血糖控制相當的差!此時必須考慮增加原有的藥量,或者是改成其他的藥物來治療。本病例之糖化血色素高達12%,在臨床上,若遇到這樣的病患,一定要特別注意,因為血糖200
mg/dL以上就會影響到人體的細胞型免疫力(cellular
immunity)及白血球的吞噬能力,使病患容易發生嚴重的感染。
|