MODS并肾上腺危象漏诊患者1例并文献复习

One case of missed diagnosis of multiple organ dysfunction syndrome complicated with adrenal crisis and literature review

目的探讨多器官功能障碍综合征(multiple organ dysfunction syndrome,MODS)合并肾上腺危象(adrenocortical crisis,AC)的临床特征、诊疗要点及误诊漏诊原因。方法对MODS合并AC漏诊患者的1例病历资料进行回顾性分析。结果患者为48岁中年男性,因呕吐、腹泻2 d,嗜睡1 d,意识丧失10 min入院。因高热,低血压,降钙素原及乳酸高,合并肝肾功能、凝血功能异常,诊断为肠道感染并脓毒性休克、MODS,积极给予抗感染、脏器支持、维持内环境稳定等对症支持治疗,但患者休克及意识障碍程度较入院时无明显改善。反复追问病史,患者家属诉既往体健,重新给予患者体格检查,发现患者全身皮肤黝黑,除外患者工作原因,考虑为内分泌系统疾病所致,给予患者检查激素水平后明确诊断为AC,给予醋酸泼尼龙2.5 mg,1次/d口服,根据复查激素水平调整醋酸泼尼松剂量,症状很快纠正。结论对于无基础病的健康群体,AC的早期临床表现往往表现为呼吸道、消化道、神经系统等症状,易漏诊、误诊。医生应加强对本疾病的认识,早期给予糖皮质激素治疗并寻找导致AC的病因,积极给予治疗。

Objective To discuss the clinical features,diagnosis and treatment points,and causes of misdiagnosis and missed diagnosis of multiple organ dysfunction syndrome(MODS)complicated with adrenal crisis(AC).Methods A retrospective analysis was conducted on the medical records of one case of missed diagnosis of MODS complicated with AC.Results A 48-year-old male patient was admitted to hospital with vomiting and diarrhea for 2 days,drowsiness for 1 day and loss of consciousness for 10 minutes.Due to high fever,low blood pressure,high pro-calcitonin and lactic acid,combined with abnormal liver and kidney function and coagulation function,the patient was diagnosed as intestinal infection with septic shock and MODS.Symptomatic supportive treatment including anti-infection,organ support,and maintaining internal environment stability was actively given.However,there was no significant improvement in the degree of shock and consciousness disorder compared with admission.After repeatedly asking about the medical history,the family members complained that the patient was in good health in the past,and then a physical examination was given again.It was found that the patient's whole body skin was dark,except for work reasons,it was considered that this situation was caused by endocrine system diseases.After examining the hormone levels,the patient was diagnosed as AC,and 2.5 mg of prednisolone acetate was given orally once a day.The dosage of prednisolone acetate was adjusted based on the rechecked hormone levels,and the symptoms were quickly corrected.Conclusion For healthy population without underlying diseases,the early clinical features of AC are often manifested as respiratory tract,digestive tract and neurological symptoms,which are prone to miss diagnosis and misdiagnosis.Doctors should strengthen the understanding of this disease,provide early treatment with glucocorticoid,identify the cause of AC,and give active treatment.