对乙酰氨基酚致药物性肝损伤临床误诊分析

Analysis of Clinical Misdiagnosis of Drug⁃induced Liver Injury Induced by Acetaminophen

目的探讨对乙酰氨基酚(APAP)致药物性肝损伤(DILI)的临床特点和误诊原因。方法回顾分析2020年10月—2021年10月收治的因APAP致DILI误诊患者9例的临床资料。结果9例半个月前因流涕、咳嗽、发热就诊当地社区卫生院予APAP等治疗后因仍间断发热及血白细胞计数、中性粒细胞百分比均升高入我院,行X线检查示肺纹理增粗紊乱,初步诊断为肺炎。后查房发现患者出现黄疸、肝区不适,行肝功能检查异常,肝脏B超示:肝实质点状高回声、回声衰减,肝内脉管显示不清;4例肝实质光点增亮、增粗、分布不均。追问病史得知患者在流行性上呼吸道感染治疗期间有APAP过量服用史,遂确诊为APAP致DILI。误诊时间1~2 d。9例立即停用APAP,并予还原型谷胱甘肽等保肝、解毒、降酶对症治疗,肝功能指标逐步恢复正常,复查肝脏B超示肝脏病变明显好转,1个月后出院。结论DILI表现多种多样,无特异性,部分患者早期可无黄疸、肝区不适等典型症状,易引起误诊;加强接诊医生对DILI的了解,提高警惕性,熟知引起肝毒性的药物,仔细询问患者用药史,治疗过程中仔细观察有无黄疸、肝区不适等典型症状,及早行肝功能及肝脏超声检查,有利于早期确诊。

Objective To investigate the clinical characteristics and causes of misdiagnosis of drug⁃induced liver in⁃jury(DILI)induced by acetaminophen(APAP).Methods The clinical data of 9 patients with DILI misdiagnosed due to APAP admitted from October 2020 to October 2021 were retrospectively analyzed.Results Nine patients with runny nose,cough and fever presented to the local community health center half a month ago and treated with APAP.However,they were admitted to our hospital due to intermittent fever,increased blood white blood cell(WBC)count and neutrophil percentage.X⁃ray showed thickening and disorder of lung markings,and the initial diagnosis was pneumonia.After ward round,it was found that the patient developed jaundice and discomfort in the liver area,and liver function test showed abnormality.B⁃ultra⁃sound of the liver showed spot⁃like hyperechogenicity of liver parenchyma,attenuation of echo signal,and unclear intrahepatic vasculature.The liver parenchymal area was brightened,thickened and unevenly distributed in 4 cases.Inquiry about medical history revealed that the patient had a history of APAP overdose during an epidemic of upper respiratory tract infections,so the patient was diagnosed as APAP⁃induced DILI.The duration of misdiagnosis was 1⁃2 d.The 9 cases stopped APAP immediately and received symptomatic treatment of liver protection,detoxification and enzyme reduction,including reduced glutathione.Liver function indexes gradually returned to normal,and liver lesions were significantly improved after reexamination by liver B⁃ultrasound.They were discharged from hospital one month later.Conclusion The manifestations of DILI are varied and non⁃specific.Some patients may not have typical symptoms such as jaundice and liver discomfort in the early stage,which is more likely to cause misdiagnosis.It is beneficial to strengthen the understanding of the receiving doctors about DILI,enhance their vigilance,be familiar with the drugs causing liver toxicity,carefully inquire about the patient's history of drug use histo⁃ry,carefully observe whether there is jaundice,liver discomfort and other typical symptoms during treatment,and perform liv⁃er function and liver ultrasound examination as early as possible,which is conducive to early diagnosis.