原发性肺鼠疫五例患者的临床特点及诊治经验

Clinical features, diagnosis and treatment of 5 cases of primary pneumonic plague in Tibet in 2010

目的了解肺鼠疫患者的临床表现、胸部影像学特点及其预后，探讨重症肺鼠疫患者的临床救治经验。方法分析5例原发性肺鼠疫患者的临床救治资料，观察患者的病情演变、胸部影像学表现、抗菌药物的使用、呼吸支持治疗及预后。结果5例均表现为高热、咳血痰，早期出现呼吸困难。胸部X线胸片表现为以肺段为中心的出血坏死性炎症，可累及多个肺叶（段），为团块样病灶，可融合成片，甚至呈“白肺”。3例出现低氧血症。发病第2天痰标本反相间接血凝试验检测鼠疫特异性Fl抗原均阳性。经抗菌药物等综合治疗后，5例均痊愈，但肺部病灶吸收缓慢。结论原发性肺鼠疫发病急，临床表现为高热、咳血痰，肺部损害重。发病早期反相间接血凝试验阳性结果可作为早期鼠疫的诊断依据。链霉素仍应作为首选治疗药物，但剂量需要进一步确定；氟喹诺酮类可作为联合使用药物。在应用有效的抗菌药物的同时，应加强对鼠疫患者的病情监测、对症治疗和营养支持，及时给予无创或有创机械通气。

Objective To explore the clinical manifestations, the feature of chest X-ray, the clinical outcome, and the clinical treatments of severe pneumonic plague. Methods We observed the clinical course of primary pneumonie plague in 5 patients, who infected Yersinia pestis in Tibet during September 2010, including manifestations of chest X-ray, the antibiotic therapy, respiratory support and the prognosis. Results All of the 5 patients presented with high fever,bloody sputum and difficulty breathing. The chest X-ray showed signs consistent with neerotizing inflammation with multiple lobar involvement. Mass-like lesions might coalesce, and the ＂white lung＂ sign might appear. Three out of the 5 patient spresented with hypoxemia. The results of reverse indirect hemagglutination assay （RII-IA） in these patients were positive on the second day of the illness onset. All of these patients recovered after antibiotic therapy and other treatments. However, the absorption of lung lesions was very slow. Conclusions Patients infected with primary pneumonic plague presented with rapid onset high fever and hemoptysis, and the lung injury was very severe. The positive result of RIHA was useful for early diagnosis of plague. Streptomycin should be the first choice for Yersinia pestis infection, but its optimal dose needed further study. Fluoroquinolones can be used as combination with Streptomycin. Nutritional support and symptomatic treatment, as well as non-invasive or invasive mechanical ventilation when needed, were important for the management of the disease.