This article is adapted from a real case On duty, on duty, on duty, it is also a night shift before emergency. At 8:00 pm, I had already seen five critically ill patients, and was pulled by the head nurse to rush to repair the old electrocardiograph in the observation room. I just got down now and ate the pancake fruit that Brother Kouhao sent. Just after eating, the door of the clinic was knocked again. The one who pushed the door and walked in was a thin old woman. I recognize her—Aunt Gui who sells pancakes and fruits in front of the hospital. After a brief consultation, I learned that she started experiencing night sweats and hot flashes four months ago, but she had no symptoms. Substantial fever and no other obvious discomfort. Here, I thought this was a case of insomnia caused by psychological factors. However, the subsequent progression and diagnosis of the disease exceeded all expectations…

01. strong>

This patient is an old acquaintance of ours for ten years Before, I started a stall in front of the hospital, specializing in pancakes and fruits. As a 78 year old female patient, her health is not too bad. I glanced at past medical records: type 2 diabetes, controlled with medication, well controlled; hypertension, controlled with medication, well controlled; history of atrial fibrillation, currently controlled with medication. It seems that these chronic diseases have little to do with insomnia. Based on past experience, this is a bit like typical perimenopausal symptoms. But she is 78 years old and has long been here, so these symptoms are obviously not caused by hormonal changes. I then asked the patient if he had experienced other long-term discomforts. After all, the 4-month course of the disease does not seem like a trivial matter. At this point, the patient adds, there has been some recent weight loss. “How to lose weight? How much lighter in a month?” “I started losing weight two months ago, I didn’t eat too much, and I didn’t exercise much, but I lost a little weight every day, and today, I have lost almost ten kilograms.” Older women , without obvious incentives, poor sleep, hot flashes, night sweats, and rapid weight loss, I couldn’t help but feel a little bit in my heart. I performed a general physical examination on the patient first, and found no abnormality. But if it is as I thought, this is obviously not a problem that can be solved by the night shift before the emergency. I ordered a blood cell routine and a full set of blood biochemistry, and asked her to come back to the internal medicine clinic tomorrow to see me with the results. Pancake fruit stall (photo source: author) The next afternoon, the patient came as scheduled outpatient clinic. I looked at the test prescribed yesterday: Burea nitrogen 18.8mmol/L↑(1.8～7.1mmol/L), creatinine 388mmol/L↑(44～133mmol/L) span>, the blood count also suggested a moderate anemia. Obviously, there are some problems with the patient’s kidneys: normal glomerular filtration is the main way of excretion of metabolites, and nitrogen-containing wastes such as urea and creatinine are This filtration, and her glomerular filtration function was significantly impaired. Afterwards, her 24-hour urine protein quantification indicated “urine protein++++” 40 times the upper limit of normal. I flipped through the stack of lists she handed over. It was obvious that the physical examination report 2 months ago only suggested a mild anemia, and both blood urea nitrogen and creatinine were still normal. scope. Too fast, too fast for kidney failure. At this time, I remembered that the patient’s underlying disease, diabetes, long-term hyperglycemia and exacerbated inflammatory response may cause kidney damage. But this doesn’t make sense, because the progression of diabetic nephropathy is apparently not so fast. After several discussions in the department, we decided to perform a renal biopsy to confirm the diagnosis. At the same time, in the process of waiting for the pathological results, we also need to rule out the most terrible suspicion: malignant tumor. Therefore, we prescribe tumor markers, CT images, blood protein tests, etc. to patients. A few days later, the results came in. All tests indicated that this patient did not have any solid organ tumors and she did not have cancer. Because of the relationship between the province and other places to seek medical treatment, patientshave to pay the high cost of treatment first, so is basically excluded. After dire options, she insisted on being discharged. So, we had to let her sign and leave the hospital first, and come back in 2 weeks for a kidney biopsy.    

02.

One morning a dozen days later, I took the pancakes I bought from Aunt Gui and printed out a few Fang table, went to the nurse station to take a look at the pathology report sent by the pathology department, the first one was her report. I don’t know if I don’t see it, I’m startled when I see it. From the report, she has focal capillary loop sclerosis in her kidneys with massive dense deposits, and her immune system has apparently been a problem for some time strong>. Kidney pathological section (source: provided by the doctor of the original case)she may be the first one There is a long-term chronic infection; the second possibility is that she has an autoimmune disease. For the first possibility, we cannot rule out chronic infection, but long-term blood tests do not suggest this problem; for the second possibility, although the patient does not have lupus , arthritis, etc., we are still not sure. I scratched my head, ran back to the office to turn on the HIS system, called out the patient’s disease course and read it carefully. They notified her of readmission. At this point, we still don’t know the cause, but what we do know is that the patient’s kidney function deteriorated again — hospital Over the next 24 hours, we collected more than 10 g of protein from the patient’s urine, and she had severe kidney damage. In any case, her immune system seemed overactive, and the director immediately instructed her to use hormones. But things are getting worse. one week Later, on the eve of my emergency department, I encountered this patient again. This time, she was supported by her daughter. Triage temperature 38.9 °C, chills, nausea, vomiting with severe diarrhea. Her daughter added emotionally: “Doctor, my mother’s urine was pink twice, why did she not take medicine well, and people kept getting worse. Worse?” —hematuria. I am afraid that the patient’s renal function has deteriorated again, and there is a high probability of acute infection. Although the current thinking is not clear, I will give her quickly Routine hematuria and biochemical tests were prescribed. At this time, the patient’s daughter began to keep complaining in her ears: “This is not the first time that the disorder has been messed up. I don’t listen.. In the past two days, the old woman has to go to her pancake stand again, tell her not to go, no one listens, she has to go, it’s okay now , it’s like this again.”  Wait a minute, pancake fruit… Pancake Fruit! Suddenly a string was taut in my mind. If I remember correctly, the reason why the patient’s pancakes are so popular is the taste. The patient once told me that her batter is different from other companies, and she will beat a lot of raw eggs into it and mix it. “The secret,Take a few bites of cold batter every day to see what today’s pancake crust tastes like. ” Cold batter, raw eggs, gastrointestinal symptoms—could it be Salmonella Enteritidis infection? Salmonella pathogenic bacteria on agar plates (source: Salmonella enterspandis) Wikipedia It is a genus of Enterobacteriaceae, gram-negative, including two species of Salmonella enterica and Salmonella Bongo, of which there are 6 subspecies and more than 2600 serotypes under Salmonella enterica. This kind of bacteria can not only cause serious economic losses of poultry disease and death, but those contaminated poultry products, as carriers of Salmonella Enteritidis, will also seriously endanger human health. Subsequent examinations confirmed my suspicion. Both Salmonella Enteritidis were isolated – an acute Salmonella Enteritidis infection. The patient may have had a long-standing chronic infection that did not show up on blood tests. This time, because of the recent oral prednisolone, an acute infection was caused. Hormone and infection are two weights in the same balance. Although hormones have powerful therapeutic effects, a large amount of cortisol hormone will inevitably increase the risk of infection. So, after cutting back on oral prednisolone and starting antibiotics, the fever went down quickly. As the infection clears, the patient’s bloodUrine cultures were all negative for bacteria, and she was told she could be discharged but could no longer eat any raw food. Colleagues in the gastroenterology department also prescribed 4 weeks of antibiotics to her and asked her to follow up in a month. At this point, all of us thought the diagnosis and treatment of the disease had finally come to an end.   It wasn’t long before she came to the emergency room again…  03. Yes, two weeks have passed and this patient is back. This time, her symptoms were even more special: a large rash on her back was accompanied by a comeback of fever, nausea, and vomiting. I’m on duty again. I looked at the patient’s new rash, and found plaques and scaly scales, not like an antibiotic allergy rash. I think there must be other reasons behind this. The facts proved my speculation, the patient’s daughter told me: “It shouldn’t be an allergy, because my mother stopped taking that antibiotic a long time ago. She feels better, so she doesn’t need to take it. Medicine.” Meeting such a patient who didn’t follow the doctor’s orders, my eyes were darkened, and my brain was already buzzing. The examinations that can be done in the emergency department are really limited, I had to say to the mother and daughter: “Well, I’d better open the examinations for you first, and do the emergency examinations first. “The patient pouted, took the form and went out. After a few seconds, there was a commotion outside the door. Hearing the patient’s daughter shouting, I rushed out the door. The person lying on the ground in sight is the patient who just left my clinic. I called at the speed of light to Brother Hao from the surgical clinic next door, and then ran over to briefly confirm the patient’s consciousness: still clear. Looks like a normal slip. “Fortunately in the emergency room,” I thought to myself. 15 minutes later, the patient’s imaging findings came back: Linear fracture of the right tibia with multiple old bone lesions; The gap was blurred, dense striae appeared in the subcutaneous fat layer, and soft tissue hyperemia and edema. Brother Hao from the surgical clinic next door asked me, “What’s wrong with this old lady? The film is not simple, and it looks a bit like acute osteomyelitis.” “The previous diagnosis was a Salmonella Enteritidis infection, and I went back after it turned negative.” I wondered in my heart: “Isn’t it possible, I’ve never seen it before. Salmonella Enteritidis infection can also invade the bone marrow.” With a rigorous attitude, the surgery decided to make a bone tissue for her Biopsy, and subsequently discoveredthe culprit of osteomyelitis: Salmonella Enteritidis. Salmonella found in blood cultures confirms this again, This shows that in just a few weeks, the batter can be The exact same bacteria infect her again. I was even more confused: “How is this possible?”Mysterious kidney damage, mysterious rash, mysterious We both fell into contemplation at the same time after re-prescribing antibiotics for our patients.    

04.

After this, the patient was transferred to the next department for treatment. I did not follow up on this case very much in the teaching task above. Until later, I met Brother Hao from surgery on the night shift before an emergency. Brother Hao asked me: “Guess what happened to the old grandma who was infected with salmonella last time?” “Isn’t it a recurrence of infection caused by improper use of antibiotics?” “Xiao Wang, I didn’t say you, taking antibiotics and banning raw food, how easy it is to relapse ?” Brother Hao is right, usually, recurrent Salmonella bacteremia only occurs when the immune system is weakened . For example, in organ transplantation, in order to reduce transplant rejection, it is necessary to moderately suppress the recipient’s immune response, and such patients are prone to such a course of disease. “Do you remember what the patient’s daughter said, it’s not the first time that the problem of “messiness” is gone< /span>.”“I said that, I have a little impression.”“We found that the patient’s fracture had an old injury. When we asked, her daughter said that the patient had a fracture ten years ago. At that time, the doctor found that there was a Reactive sclerosis, but she doesn’t take it seriously.Combined with the previous medical history, we highly suspect that this may be…” “Wait a minute! I get it, she’s already immunocompromised!” I hurried to answer, with a new answer in my mind:  < span>——Acquired Immune Deficiency Disorder, also known as AIDS! Brother Hao confirmed my guess: “That’s right! We tested her for HIV antibodies, and it turned out to be positive. Every milliliter of her There are 550,000 viruses in the blood, and after checking for CD4 T cells, she has every milliliter of bloodThere are only 60 left. ”(Note: This article is adapted from a foreign case, and there is no mandatory requirement for preoperative HIV testing such as renal puncture.) As for the cause, the patient insists that he has only 40 years of A husband, who denies a history of blood transfusions, has been to the village dental clinic several times. Too much time has passed, and there is currently no way to prove the real cause of her AIDS infection. Image source: Image Worm Creative  At that moment, it dawned on me that everything made sense. My memory suddenly began to flash back: AIDS patients will have kidney damage in the late stage, which is manifested by massive proteinuria and rapidly worsening kidney disease. The typical symptom of AIDS-related nephropathy is the collapse of focal stage glomerulosclerosis with interstitial inflammation! The raw batter that patients eat every day is a source of Salmonella Enteritidis. We know that in normal people with strong immunity, it is not easy to get this bacteria from uncooked eggs or untreated poultry, and even if it is infected, it is not easy to relapse.< strong>It will not be as serious as her, directly infringing on the bone marrow. Similarly, rashes are common in AIDS. “Actually, such high doses of hormones should not be given to AIDS patients like Aunt Gui, because it will increase the risk of infection.” Brother Hao warned. Brother Hao also told me that the patient is now receiving triple antiretroviral therapy and his health is improving. Listening, I can’t help but ponder. Faced with a 78-year-old man, we always think of diabetes, heart disease, or cancer first, but not at all. All of us are led by the disease and treated symptomatically, but we fail to be alert to the special diagnosis of the disease earlier. Since then, I have always raised multiple alarm bells when I see a doctor, I encounter some strange infection symptoms, no matter what age group I have span>I will keep a few more minds. Author: carolleroPlanning: MetforminProducer: gyouzaThanks to Bernard Hsu (@Chubbyemu), University of Illinois for providing and licensing this case Acknowledgments: This article was written by Li Tongzeng, Chief Physician, Department of Infectious Diseases, Beijing You’an Hospital Affiliated to Capital Medical University、Chen Yan, Chief Physician of the Department of Gastroenterology, The Second Affiliated Hospital of Zhejiang University, Lin Wanbing, Chief Physician of the Department of Nephrology, The Second Affiliated Hospital of Zhejiang University Professional review

[Note]

Li Tongzeng, Chief Physician, Department of Infectious Diseases, Beijing You’an Hospital Affiliated to Capital Medical University Review comments:

The infection of immunocompromised people is relatively complex, and the pathogen spectrum of infection is quite different from that of people with normal immune function. Even if the same pathogen has different clinical manifestations, Therefore, when encountering an infection that is difficult to explain by routine, it is first necessary to evaluate whether the patient’s immune function is normal.

Clinicians are indeed easy to ignore the HIV infection in the elderly. In this case, the infected person is 78 years old. According to the incubation period, The time of HIV infection in patients should be after the age of 60.

In fact, the HIV infection rate among the elderly has been on the rise in recent years, and the self-protection awareness of the elderly is relatively poor. It may be easier to go to some informal medical institutions for invasive operations, such as oral disease diagnosis, eyebrow tattooing, lip tattooing, tattooing and other medical and aesthetic projects. There are also some elderly people who may be infected by sexual transmission. On the one hand, most of the elderly still have sexual needs, and on the other hand, the elderly have relatively lack of knowledge about sexually transmitted diseases.

Therefore, when encountering patients with infectious diseases that cannot be explained by common sense, do not Forget screening for HIV and other STDs.

Chen Yan, Chief Physician, Department of Gastroenterology, The Second Affiliated Hospital of Zhejiang University Review comments:

Salmonella is a common food-borne pathogen and a common bacterium in acute gastrointestinal infections. Most patients can get better quickly, but the elderly, young, and immunocompromised (such as AIDS) patients are prone to severe disease.

Department of Nephrology, The Second Affiliated Hospital of Zhejiang University Attending physician Lin Wanbing Review opinion: different from this case, generally speaking, domestic treatment Before renal puncture, it is routine to determine whether the patient has infection and tumor. Under this premise, if there is viral infection such as HIV or hepatitis B, the pathological examination will generally be added to the corresponding etiological examination. The source of the title image: photographed by the authorReferences:[1 ].@Chubbyemu YouTube videoFrequency, details provided by Chubbyemu myself via email[2].People’s Health Publishing HouseInternal Medicine< /span>Lilac Garden RecruitmentJob Name: New Media Operation (Lilac Garden)Complete original content planning independentlyAssist in the operation of Lilac Garden official account WeiboWork location: HangzhouClick here Send your resume directlyYou can also send your resume to the mailbox< span>[email protected]Mail Title: Post Name-Name