新型冠状病毒肺炎危重型患者临床特征变化及心肺病理改变

Clinical feature changes of a COVID-19 patient from mild to critical condition and cardiopulmonary pathological results

目的分析新型冠状病毒肺炎(COVID-19)危重型患者的临床资料和心肺病理特征,为类似病例的临床救治提供借鉴。方法回顾性分析1例COVID-19患者从发病到危重型快速进展过程中的临床指标、实验室检查、支气管镜及超声心动图结果的动态变化和心肺病理解剖结果。结果该例患者在2019新型冠状病毒(2019-nCoV)感染后第9天入院。患者起病后从轻症到重症,再到危重症分别经历了12和18 d,在第28至45天期间接受了体外膜肺氧合(ECMO)联合连续性肾脏替代疗法(CRRT)以及心肺联合移植术,术后第2天死亡。患者有8年高血压病史。早期症状轻,炎症指标升高、淋巴细胞减少。治疗效果差,病情进展迅速,多次病毒核酸检测转阴之后病情仍加重,并逐渐发展为肺出血和实变,大量分泌物和肺内出血导致肺功能丧失、肺动脉高压、右心衰竭、恶性心律失常及肝功能异常。予右肺移植和原位心脏移植术后不能维持循环稳定而死亡。肺病理检查可见气管及支气管内存在大量黏液、暗红色分泌物和血块,病理改变主要为肺组织出血坏死、肺泡炎、纤维素性渗出和小血管病变,心肌细胞水肿和少量炎症细胞浸润。结论COVID-19危重型患者从轻症到危重症、死亡进展快速,危重症阶段发生肺、心和肝脏损伤。

ObjectiveTo analyse the clinical history,laboratory tests and pathological data of a patient who suffered from novel coronavirus pneumonia(COVID-19)and provide reference for the clinical treatment of similar cases.MethodsData of clinical manifestation,laboratory examination,bronchoscopy,echocardiography and cardiopulmonary pathological results were retrospectively reviewed in a case of COVID-19 with rapid exacerbation from mild to critical condition.ResultsThis patient hospitalized at day 9 post 2019 novel coronavirus(2019-nCoV)infection,experienced progressive deterioration from mild to severe at day 12,severe to critical at day 18 and underwent extracorporeal membrane oxygenation(ECMO)and continuous renal replacement therapy(CRRT)as well as heart lung transplantation during day 28-45 post infection,and died at the second day post heart and lung transplantation.The patient had suffered from hypertension for 8 years.At the early stage of the disease,his symptoms were mild and the inflammatory indices increased and the lymphocyte count decreased continuously.The patient′s condition exacerbated rapidly with multi-organ infections,and eventually developed pulmonary hemorrhage and consolidation,pulmonary hypertension,right heart failure,malignant ventricular arrhythmias,liver dysfunction,etc.His clinical manifestations could not be improved despite viral RNAs test results became negative.The patient underwent lung and heart transplantation and finally died of multi organ failure at the second day post lung and heart transplantation.Pathological examination indicated massive mucus,dark red secretions and blood clots in bronchus.The pathological changes were mainly diffused pulmonary hemorrhagic injuries and necrosis,fibrosis,small vessel disease with cardiac edema and lymphocyte infiltration.ConclusionsThe clinical course of severe COVID-19 can exacerbate rapidly from mild to critical with lung,liver and heart injuries.