发热、腹部感染、ARDS

发热 肺部感染 ARDS发热、肺部感染、ARDS 首 都 医 科 大 学 急 诊 医 学 系 首都医科大学附属北京朝阳医院急诊科首都医科大学附属北京朝阳医院急诊科 何新华 2011-08-28 一般情况 † 男性，27岁 † 发热10天 咳嗽 咳痰伴左侧胸痛5天† 发热10天，咳嗽、咳痰伴左侧胸痛5天 † 血气：PH 7.531，PCO2 23.3mmHg，PO2 气： H 7.53 ， O2 3.3mmHg， O2 54.5mmHg（文丘里吸氧10l/min，FiO2 50%) † 血常规 WBC 4 39×109/L N 80 1%† 血常规：WBC 4.39×109/L，N 80.1%， HGB 134g/L，PLT254×109/L。 2011-05-03HRCT（入院第1天） 2011-05-03HRCT（入院第1天） 诊治经过 † 肺部CT和化验检查，考虑患者重症肺炎 泰能 斯沃 利福平 希舒美† 泰能+斯沃+利福平+希舒美 † 初期治疗 症状进一步加重† 初期治疗，症状进 步加重 † 气管插管接呼吸机辅助通气 † FiO2100%，SpO2 82%，PaO2 55mmHg 诊治经过 PCT 0 26 ng/mlPCT 0.26 ng/ml 诊治经过 临床考虑：非细菌感染 † 痰病毒核酸检验：腺病毒（+） † 血清病毒核酸：腺病毒（+） † 血清G试验（-）† 血清G试验（ ） 诊断：腺病毒肺炎诊断：腺病毒肺炎 诊治经过 † 给予更昔洛韦抗病毒治疗给予更昔洛韦抗病毒治疗 † 应用丙种球蛋白、胸腺肽免疫调节† 应用丙种球蛋白、胸腺肽免疫调节 † 联合应用中药抗病毒治疗† 联合应用中药抗病毒治疗 诊治经过诊治经过 入院2天 入院6天 诊治经过诊治经过 入院8天 入院11天 2011-05-18HRCT（入院第16天） 2011-05-18HRCT（入院第16天） 2011-05-28HRCT（入院第26天） 2011-05-28HRCT（入院第26天） 出院前 From Canada 方式与方法 † 时间：2004-2006 † 地点 5家医院 前瞻性临床研究† 地点：5家医院，前瞻性临床研究 † 方法：细菌学培养、血清学检查、咽试子实 验 † 流感病毒、人变性肺病毒、呼吸道合孢病毒、† 流感病毒、人变性肺病毒、呼吸道合孢病毒、 鼻病毒、副流感病毒、冠状病毒和腺病毒。 结果 † 193人入选，平均71岁，51%男性，47%SCAP。 † 75（39%）病源学。其中病毒29例（15%），细† 75（39%）病源学。其中病毒29例（15%），细 菌38例（20%），8例混合感染（4%）。 † 流感7，人变性肺病毒7，呼吸道合孢3，腺病毒2† 流感7，人变性肺病毒7，呼吸道合孢3，腺病毒2 † 肺链37% † 与细菌感染相比 病毒感染者年龄更大（76 vs † 与细菌感染相比，病毒感染者年龄更大（76 vs 64，p=0.01），同时合并基础疾病（66% vs 32%，p=0 02）32%，p=0.02） † 细菌和病毒感染在临床表现和预后方面没有差异。 结论 † 在CAP住院病人中呼吸道病毒感染是常见的。 病源学明确的患者中占39%，在所有观察病源学明确的患者中占39%，在所有观察 病人中占15%。 † 流感病毒 人变性肺病毒和呼吸道合孢病毒† 流感病毒、人变性肺病毒和呼吸道合孢病毒 最为常见。 † 鉴别是否感染病毒仍然很困难。 † 建议此类病人常规行病毒学检查。† 建议此类病人常规行病毒学检查。 From New ZealandThorax 2008; 63: 42-48 From New Zealandhorax 008; 63 8 Methods † Adults admitted to Christchurch Hospital over a 1-year period with CAP were included in the y p study. † Blood and sputum cultures urinary antigen † Blood and sputum cultures, urinary antigen testing for Streptococcus pneumoniae and Legionella pneumophila, antibody detection in Legionella pneumophila, antibody detection in paired sera and detection of respiratory viruses in nasopharyngeal swabs by p y g y immunofluorescence, culture and PCR. Results † 304 patients with CAP, a viral diagnosis was made in 88 (29%), with rhinoviruses and influenza A being the most common. † Two or more pathogens were detected in 49 (16%) patients, 45 of whom had mixed viral and bacterial infections. infections. † There were no reliable clinical predictors of viral pneumonia, although several variables were independently associated with some aetiologies The presence of myalgiaassociated with some aetiologies. The presence of myalgia was associated with pneumonia caused by any respiratory virus (OR 3.62, 95% CI 1.29 to 10.12) and influenza pneumonia (OR 190.72, 95% CI 3.68 to 9891.91).p ( , ) † Mixed rhinovirus/pneumococcal infection was associated with severe disease. Conclusions † Virus-associated CAP is common in adults† Virus-associated CAP is common in adults. † Polymicrobial infections involving † Polymicrobial infections involving bacterial and viral pathogens are f t d b i t d ith frequent and may be associated with severe pneumonia. From ChinaFrom h na Conclusion † M. pneumoniae and respiratory viruses (IFVA PIV AdV hMPV) were the most (IFVA, PIV, AdV, hMPV) were the most frequent pathogens found in ambulatory adult CAP patients adult CAP patients. † Quinolones were better than β-lactams, Q β macrolides, or β-lactams + macrolides in the resolution of fever of M. pneumoniae th r ut n f f r f M. pn um n a pneumonia. Current Opinion in Infectious Diseases 2009; 22: 143-147p ; From SpainFrom Spa n Recent Finding † Better quality diagnostic tests, such as nucleic acid amplification techniques, have markedly improved our ability to detect multiple viral improved our ability to detect multiple viral pathogens. † With these diagnostic tools a viral cause can † With these diagnostic tools, a viral cause can be established in more than half of patients with CAP. † Influenza A and RSVs are the most frequent causes of viral pneumonia followed by adenovirus parainfluenza virus types 1 2 and 3 adenovirus, parainfluenza virus types 1, 2, and 3, and influenza. † Although some clinical findings have been more frequent with viral infection,no clear-cut clinical signs have been shown to be predictive clinical signs have been shown to be predictive of specific cause. † Of more interest is the association of mixed † Of more interest is the association of mixed virus–bacteria infection with poorer severity scores found in some studies. † Unfortunately, there are no other licensed antivirals or vaccines against the large variety of clinically important respiratory viruses with of clinically important respiratory viruses with the notable exception of influenza. Summary † Given the high rate of viral infection in CAP and its probable association with p poorer prognosis in mixed virus–bacteria infection, an extensive evaluation for virus in some populations seems appropriate. † These findings can be useful for a more appropriate management of these appropriate management of these patients. 小结 † 病毒感染在CAP占有较高的发病率。 临床症状 体征 X线无特异性† 临床症状、体征、X线无特异性。 † 特异性病毒学检查可明确诊断† 特异性病毒学检查可明确诊断。 † 无特异性治疗药物无特 性 疗药物 † 混合感染预后差。 † 老年人更易合并病毒感染。 发 热发 热 肺部感染 病毒感染 ARDS