1例恶性疟可能诱发纵隔淋巴结结核病例分析及文献复习

A case analysis and literature review of falciparum malaria that may induce mediastinal lymph node tuberculosis

通过报道1例恶性疟可能诱发纵膈淋巴结结核病例的诊断过程,为不明原因发热的诊断提供新经验。患者男性,48岁,3 d前从塞拉利昂回国,既往体健。本次因"高热、寒战3 d"入院,体查可见球结膜轻度水肿,外周血涂片镜检及抗原鉴定为恶性疟原虫,予蒿甲醚抗疟及激素减轻可疑脑水肿治疗后外周血涂片转阴,但仍反复高热。予小剂量激素及头孢唑肟治疗无效。多次血培养阴性,胸部CT(computerized tomography)提示双肺气肿并多发肺大疱,心脏彩超未见异常。为排除肿瘤及自身免疫病,完善骨髓穿刺与自身抗体检查,均未见异常。为排除药物热,停用所有药物观察,但仍高热不退,经验性予多西环素抗立克次体治疗无效。其胸部增强CT可见纵隔内多发淋巴结,同时外周血结核干扰素释放试验阳性。遂取纵膈淋巴结活检,发现抗酸染色阳性,诊断为"纵膈淋巴结结核",予抗痨治疗后退热出院。其发病考虑疟疾感染、激素使用、旅行导致潜伏结核激活,提示医师在临床工作中应重视不典型病灶。

Through the report of a case be diagnosed with mediastinal lymph node tuberculosis which may be induced by falciparum malaria, we provide a new experience for the diagnosis of fever of unknown origin. A middle-aged previously healthy male, who returned from Sierra Leone 3 days ago, was admitted to the hospital with a 3 days history of high fever and chills. Physical examination showed mild bulbar conjunctiva edema. Peripheral blood smear microscopic examination and antigen identification showed Plasmodium falciparum. After treatment with artemether and glucocorticoid, the glucocorticoid was used to reduce suspected brain edema, the peripheral blood smear turned negative, but the patient still had high fever.Sequential treatment with glucocorticoid of low dose and cefazoxime was ineffective. Multiple blood cultures were negative,computerized tomography(CT) indicated double emphysema and multiple pulmonary bullias, and echocardiography was normal. In order to exclude tumor and autoimmune diseases, bone marrow puncture and autoantibody tests were completed, but no abnormalities were found. In order to eliminate drug fever, all drugs were stopped for observation, but the high fever persisted. Empirical use of anti-rickettsial medicine doxycycline was ineffective. Contrast chest CT scan showed multiple lymph nodes in the mediastinum, meanwhile the peripheral blood interferon-γ release assay was positive. The mediastinal lymph node biopsy was taken, and positive acid-fast staining bacilli were found. Thus, the patient was diagnosed as mediastinal lymph node tuberculosis. After antituberculosis treatment, the patient was discharged from hospital without fever. Malaria, use of glucocorticoid and travel may lead to the activation of latent tuberculosis, suggesting that doctors should pay attention to atypical lesions in clinical work.