Believe you, not ordinary people~
01
Opening
Case: A 72-year-old female with previous diabetes who was admitted to hospital for breathing difficulties after activity.
Imaging tests are shown in Figures A and B. What disease to consider?
图A、B
Diffuse frosted glass shading of both lungs, first considered infection, viral pneumonia may be;
But this flaky ground glass is a bit like a pig's head cheese sign, followed by interstitial lung disease;
The likelihood of tumors is very small, although lymphoma, etc. can also manifest as diffuse ground glass shadows!
02
The following detective case officially begins
The patient is a 72-year-old Japanese housewife.
It was 5 days before admission, and dyspnea after activity began to occur 3 days ago.
Have type 2 diabetes and high blood pressure.
A few years ago she had herpes on her lips.
Nothing else is special.
Physical examination:
Body temperature 37.6 °C, oxygen inhalation 3 L/min, blood oxygen saturation of 93%, no rash on the lips and genitals, auscultation of diffuse fine wet rales in both lungs, no edema of the limbs.
Auxiliary tests:
Blood count showed 8.8 × 109/L (neutrophils 72.5%, lymphocytes 17.9%, monocytes 4.9%, eosinophils 4.9%).
Lactate dehydrogenase (LDH) 577 IU/L, C-reactive protein 6.8 mg/dL, glycosylated hemoglobin 7.1%.
Immunoglobulin levels are in the normal range.
HIV antibodies and influenza rapid diagnostic tests are negative.
03
Diagnosis and treatment process
So many lesions, lung infection should cough and cough up sputum, but patients do not have symptoms of upper respiratory tract infection, consider acute interstitial pneumonia, give prednisone 50 mgqd treatment.
Community-acquired pneumonia caused by atypical pathogens such as Mycoplasma cannot be completely excluded, and azithromycin is given 2 g on the first day of admission.
The azithromycin instructions are 0.5 g qd, so it is difficult for this doctor in a Chinese hospital to survive the first 3 episodes.
Sorry, it is estimated that it is difficult to survive episode 3, because he exceeded the instructions for 1 day to give the patient 2 g of azithromycin, and his condition worsened.
On the third day of hospitalization, the number of re-examination imaging lesions increased.
What about swelling?
Don't worry, Tarzan pressed the top face without fear, and showed my general style.
Isn't it interstitial pneumonia, methylprednisolone shock treatment: 1000 mg× 3 days!
Result: Ankylos thysmus shock treatment, the patient was really shocked, and the breathing difficulty was more serious!
I was hit in the waist by youth, and you were hit by a strong dragon!
What's next?
The next step is to test the comprehensive strength of the hospital!
The laboratory department actually found inclusion bodies (sputum cytology) in the sputum, and clinicians began to suspect viral pneumonia.
The impact of methylpryloid is indeed very good, the patient is shaken by the impact, respiratory failure worsens, immediate endotracheal intubation, ventilator treatment.
Immediate bedside bronchoscopy and upper right lobe bronchoscopy.
Conduct pathogen screening of bronchial irrigation fluids!
Cultures of bacteria, fungi, and mycobacteria are negative.
Herpes simplex virus type 2 (HSV2), varicella zoster virus, influenza viruses A and B, respiratory syncytial virus, parainfluenza virus types 1-4, human coronavirus, human adenovirus, human partial pneumovirus, enterovirus, human rhinovirus, and human Boca virus PCR are negative. There were no significant increases in specific IgG antibodies against Legionella, Mycoplasma pneumoniae, Chlamydia pneumoniae, Chlamydia psittacosis, and influenza viruses.
Viral inclusions were found in bronchial irrigation fluid, herpes simplex virus type 1 (HSV1) immunoperoxidase staining was positive, PCR was positive, and viral loads as high as 14×106/mL.
Figure 2
Starting from the 11th day of hospitalization, acyclovir 15 mg/kg/day was given for 16 days, and the shadow of the lungs was re-examined and absorbed earlier, and the hospital was finally discharged after more than 60 days of hospitalization.
Well, it is estimated that I wrote 2 30-day rounds, and reported 2 times that I was hospitalized for more than 30 days!
05
Final diagnosis
Viral pneumonia (herpes simplex virus type 1).
Postscript: Viral pneumonia
Influenza viral pneumonia, coronavirus pneumonia, cytomegalovirus pneumonia, adenovirus pneumonia, etc., many people know, but herpes simplex virus pneumonia, very rare, the vast majority of doctors can not encounter in a lifetime!
At present, there are only more than 10 confirmed cases reported abroad.
This article adds additional evidence for the existence of herpes simplex virus pneumonia.
But, be careful! HSV can be cultured from the oral cavity of 1% to 5% of asymptomatic adults, and cultured from sputum to HSV has limited value because it is difficult to determine whether HSV is a pathogen of pneumonia.
Bronchial irrigation fluid is positive for herpes simplex virus PCR, combined with histology, cytology and other tests (finding viral inclusions), comprehensive analysis, can be diagnosed.
HSV can not be easily diagnosed herpes simplex virus pneumonia, especially NGS (second-generation gene sequencing), can be widely found a variety of strange microorganisms, sensitivity is greatly improved, but the specificity requires comprehensive analysis by clinicians, can not just look at the test sheet, after all, this disease is too rare.
In patients with herpes simplex virus pneumonia, many of them have no immunity, and treatment is generally acyclovir, and patients without antivirals may also self-heal.
bibliography:
[1] Yuri Baba, MD; Takashi Ishiguro, MD, PhD; Mina Gochi, MD, PhD; Yoshihiko Shimizu, MD, PhD; and Noboru Takayanagi, MD, PhD.A 72-Year-Old Woman With Respiratory Failure and Bilateral Ground-Glass Opacities.CHEST 2020; 158(1):e41-e45.
This article was first published: Respiratory Channel of the Medical Profession
The author of this article is Sun Danxiong, a court of Yunnan Province
Editor-in-Charge: Sun Ying
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