以呼吸系统症状为首发表现的恙虫病16例误诊分析

Misdiagnosis analysis on 16 cases of patients with Tsutsugamushi disease showing respiratory symptoms as first complaint

目的探讨以呼吸系统症状为首发表现的恙虫病的临床特点和误诊原因,并提出防范措施。方法回顾性分析16例被误诊的恙虫病的发病时间、接触史、首发表现、主要症状、误诊情况、体征、外斐试验、影像学表现及治疗经过。结果发病时间主要集中于7～9月,16例均有野外活动或草地接触史,出现不同程度的发热;入院时误诊为细菌性肺炎8例(50.0%),支气管炎3例(18.8%),上呼吸道感染4例(25.0%),结核性胸腔积液1例(6.2%);误诊时间为5～21天。所有病例有焦痂或溃疡,血清变形杆菌OXk凝聚效价1∶160～1∶640阳性13例(81.2%)。影像学表现:肺部炎性渗出性病变13例(81.2%),肺间质炎性改变8例(50.0%),胸膜病变6例(37.5%)。确诊后治疗:首选盐酸多西环素0.2g/次或阿奇霉素0.5g/次,每日1次;疗程5～7天。退热时间为1～4天,平均(1.7±0.2)天;住院时间为3～12天,平均(5.3±1.6)天,均痊愈出院。结论恙虫病临床症状无特异性,容易误诊;详细询问病史、全面的体格检查、寻找特征性焦痂和进行外斐试验有助于诊断。

Objective To evaluate the clinical features and misdiagnosis of patients with Tsutsugamushi disease showing respiratory symptoms as the first complaint, and to offer some advice on prevention. Methods Retrospective analysis of 16 misdiagnosis patients with Tsutsugamushi disease in aspects of predilection month,initial presentation, chief complaint, misdiagnosis, clinical sign, Weil-Felix test, imaging presentations and treatment. Results Morbidity time of 16 Tsutsugamushi cases ranged from July to September. All patients had a history of field activity and followed by fever. Of these patients,8 cases（50.0%） were misdiagnosed as bacterial pneumonia,3 cases（18.8%） as bronchitis, 4 cases （25.0%） as common cold, and 1 case（6.2%） as tuberculous pleural effusion. The duration of misdiagnosis ranged from 5 to 21 days. All patients showed eschar or ulcer on skin. Test on serum bacillus proteus OXk agglutination was positive in 13 patients（81.2%）, and the titer ranged from 1 ： 160 to 1 ： 640. Imaging presentations included： pulmonary inflammatory exudation in 13 patients （81.2%）, pulmonary interstitial inflammation in 8 patients （50.0%）, pleural abnormality in 6 patients （37.5%）. Patients were prescribed doxycycline 0.2 g, once daily and azithromycin 0.5 g,once daily for 5-7 days,and it took 1-4 days, average （1.7±0.2） days for the temperature to become normal. Duration of admission ranged from 3 to 12 days,average （5.3±1.6） days. All patients were completely recovered. Conclusion Clinical symptoms of Tsutsugamushi disease are not specific,which often leads to misdiagnosis. Detailed illness history,careful physical examination, typical eschar and Well-Felix test are helpful to diagnosis.