首发肝外表现的药物性肝损伤致肝纤维化临床特征及误诊分析

Clinical Characteristics and Misdiagnosis Analysis of Hepatic Fibrosis Caused by Drug-Induced Liver Injury with Initial Extrahepatic Manifestations

目的探讨药物性肝损伤(DILI)致肝纤维化的误诊原因及防范措施。方法回顾性分析2020年5月至2022年12月收治的DILI致肝纤维化误诊患者15例的临床资料。结果15例中,发热伴咳嗽1例,发热伴尿频、尿急、尿痛2例;皮肤瘙痒、荨麻疹3例;肌肉酸痛、关节疼痛2例;食欲减退、乏力、恶心、腹泻、上腹部不适7例。4例轻度巩膜黄染;1例触及左侧颌下增大淋巴结,与周围组织无粘连,轻度压痛;1例听诊呼吸音减弱,未闻及明显湿啰音;7例上腹部轻中度压痛;1例晨起关节疼痛伴僵硬;1例腰部和髋关节活动受限。初步诊断肺部感染、类风湿关节炎、强直性脊柱炎各1例,尿路感染2例,过敏性皮疹3例,胃肠炎7例。15例完善相关检查提示肝纤维化,明确用药史后确诊为DILI致肝纤维化。误诊时间为2~7 d。确诊后立即停用可疑药物,积极给予对症及生物红外治疗仪治疗,患者症状缓解。随访6个月,肝纤维化程度改善。结论DILI起病隐匿,临床表现呈现多样性且缺乏特异性,易误诊。临床医师应提高对DILI的临床辨识能力,以减少或避免误诊。

Objective To investigate the causes of misdiagnosis and preventive measures of hepatic fibrosis caused by drug-induced liver injury(DILI).Methods The clinical data of 15 misdiagnosed patients with DILI-induced liver fibrosis admitted from May 2020 to December 2022 were retrospectively analyzed.Results Among the 15 patients,there was fever accompanied by cough in 1 patient,fever accompanied by frequent urination,urgent urination and pain in 2 patients,skin pruritus and urticaria in 3 patients,muscle soreness and joint pain in 2 patients,loss of appetite,fatigue,nausea,diarrhea,and upper abdominal discomfort in 7 patients.There was slight scleral yellow staining in 4 patients,the enlarged lymph nodes palpated on the left submaxillary side without adhesion to the surrounding tissues and mild tenderness in 1 patient.On auscultation,there was 1 patient with reduced respiratory sound,and no obvious moist rales were heard.There was mild to moderate tenderness in upper abdomen in 7 patients,joint pain with stiffness in the morning in 1 patient,and limited mobility of the waist and hip joints in 1 patient.The preliminary diagnosis was pulmonary infection(n=1),rheumatoid arthritis(n=1),ankylosing spondylitis(n=1),urinary tract infection(n=2),allergic rash(n=3)and gastroenteritis(n=7).All 15 patients were diagnosed as liver fibrosis caused by DILI after completing relevant examination and confirming the history of medication.The misdiagnosis lasted 2-7 d.After diagnosis,the suspected drugs were withdrawn immediately,and aggressive symptomatic and biological infrared therapy was given,and the symptoms of the patient were relieved.At 6 months after follow-up,the degree of liver fibrosis improved.Conclusion The onset of DILI is occult,and its clinical manifestations are diverse and lack of specificity,which are more likely to lead to misdiagnosis.Clinicians should improve their ability of clinical identification of DILI to reduce or avoid misdiagnosis.