50例误诊为肺炎的肺栓塞患者的临床特点分析

Clinical Features of 50 Pulmonary Embolism Patients Misdiagnosed as Pneumonia

目的分析50例误诊为肺炎的肺栓塞(PE)患者的临床特点,以提高临床对PE与肺炎的鉴别诊断能力。方法收集2011年10月—2015年10月广州医科大学附属第一医院收治的误诊为肺炎的PE患者50例,回顾性分析其临床资料,包括临床症状和体征、实验室检查结果、PE的临床可能性分级、危险因素及临床转归。结果临床症状:气促42例(84%)、咳嗽41例(82%)、胸闷28例(56%)、胸痛21例(42%)、发热21例(42%)、咯血19例(38%)、咳脓痰14例(28%);临床体征:心动过速30例(60%)、发绀15例(30%)、肺部干湿啰音14例(28%)、胸腔积液11例(22%)、P2亢进10例(20%)、下肢水肿10例(20%)。实验室检查结果:D-二聚体升高者50例(100%),降钙素原升高者11例(22%),脑钠肽升高者4例(8%);血气分析:动脉血氧分压<60 mm Hg者35例(70%),动脉血二氧化碳分压<35 mm Hg者25例(50%);血常规:白细胞计数升高者29例(58%);CT肺动脉造影(CTPA):多肺叶病灶42例(84%),胸膜下病灶40例(80%),胸腔积液11例(22%),楔形阴影2例(4%),肺纹理稀疏/纤细0例;静脉超声:深静脉血栓形成(DVT)25例(50%)。修正Wells评分:低度可能0例,中度可能25例(50%),高度可能25例(50%);修正Geneva评分:低度可能0例,中度可能30例(60%),高度可能20例(40%)。危险因素:下肢DVT 20例(40%),慢性肺疾病10例(20%),手术10例(20%),肿瘤2例(4%)。临床转归:治疗有效45例(90%),死亡5例(10%)。结论 PE无特异性临床症状和体征,修正Wells评分和修正Geneva评分联合D-二聚体检测或CTPA有助于鉴别PE和肺炎,同时要考虑PE的危险因素。

Objective To analyze the clinical features Of 50 pulmonary embolism patients misdiagnosed as pneumonia, to improve the differential diagnosis ability between pulmonary embolism and pneumonia. Methods A total of 50 pulmonary embolism patients misdiagnosed as pneumonia were selected in the First Affiliated Hospital of Guangzhou Medical College from October 2011 to October 2015, their clinical data was retrospectively analyzed, including clinical symptoms and signs, laboratory examination results, possibility of clinical grading for pulmonary embolism, risk factors and clinical outcome. Results Clinical symptoms： 42 cases performed as anhelation （accounting for 84% ）, 41 cases performed as cough （accounting for 82% ）, 28 cases performed as chest distress （ accounting for 56% ）, 21 cases performed as chest pain （ accounting for 42% ）, 21 cases performed as fever （accounting for 42% ）, 19 cases performed as hemoptysis （accounting for 38% ）, 14 cases performed as tussis of purulent sputum （accounting for 28% ） ; clinical signs： 30 cases occurred tachycardia （accounting for 60% ）, 15 cases occurred cyanosis （ accounting for 30% ）, 14 cases occurred dry or wet rale （ accounting for 28% ）, 11 cases occurred pleural effusion （ accounting for 22% ）, 10 cases occurred accentuation of second cardiac sound in pulmonic area （ accounting for 20% ）, 10 cases occurred edema of lower extremity （ accounting for 20% ）. Laboratory examination results： all of the 50 cases with elevation of D - dimer （ accounting for 100% ）, 11 cases with elevation of procalcitonin （ accounting for 22% ）, 4 cases with elevation of BNP （accounting for 8% ） ; blood -gas analysis results： 35 cases with PaO2 less than 60 mm Hg （ accounting for 70% ）, 25 cases with PaCO2 less than 35 mm Hg （accounting for 50% ） ; blood routine examination results found 29 cases with elevation of white blood cell cuunt （accounting for 58% ） ; CT pulmonary angiography examination results： 42 cases performed as multiple pulmonary lobe lesions （accounting for 84% ）, 40 cases performed as subplem-al lesions （accounting for 80% ）, ll cases performed as pleural effusion （accounting for 22% ）, 2 cases performed as wedge shadow （accounting for 4% ）, no one found sparse or slender lung texture; intravenous ultrasound examination results found 25 cases with deep venous thrombosis （accounting for 50% ）. Modified Wells score evaluation results： no one belonged to low possibility, 25 cases belonged to moderate possibility （ accounting for 50% ）, 25 cases belonged to high possibility （accounting for 50% ）; modified Geneva score evaluation results： no one belonged to low possibility, 30 cases belonged to moderate possibility （ accounting for 60% ）, 20 cases belonged to high possibility （ accounting for 40% ）. Distribution of risk factors ： 20 cases complicated with deep venous thrombosis of lower extremity （accounting for 40% ） , 10 cases complicated with chronic pulmonary disease （ accounting for 20% ）, 10 cases received operative treatment （ accounting for 20% ）, 2 cases complicated with turnout （ accounting for 4% ）. Clinical outcome ： 45 cases got effective treatment （ accounting for 90% ）, 5 cases died （ accounting for 10% ）. Conclusion Pulmonary embolism lacks specific clinical symptoms or signs, modified Wells score and modified Geneva score combined with detection of D - dimer or CT pulmonary angiography are helpful to identify pulmonary embolism and pneumonia, meanwhile the risk factors of pulmonary embolism should be consider.